Hot Saline Irrigation vs Room Temperature Saline Irrigation in the Control of Intraoperative Bleeding During Functional Endoscopic Sinus Surgery (FESS)

Background and Significance:

Functional endoscopic sinus surgery (FESS) is a minimally invasive surgery to relieve obstruction and to facilitate drainage and ventilation of the paranasal sinuses. It is a common rhinologic procedure that is safe, comfortable and allows quick patient recovery. As the paranasal sinuses have complex anatomy and are surrounded by important structures, there are risks of serious orbital and intracranial injuries. These risks are increased if visualization during surgery is impaired with bleeding. The endoscopically magnified operative field in sinus surgery makes even a small amount of bleeding a potentially significant hindrance. Hence, numerous methods to reduce intraoperative bleeding during FESS have been described. These include the use of preoperative nasal decongestion (such as topical oxymetazoline, cocaine and adrenaline), preoperative oral tranexamic acid, intraoperative injection of the lateral nasal wall with lidocaine and adrenaline and intraoperative controlled hypotension (using total intravenous anaesthesia and B-blockers) as well as the head up position during surgery. The success rates of these methods have been variable and some of these techniques are associated with adverse cardiopulmonary events.1-7 Visual compromise secondary to bleeding remains a problem during FESS and the ideal method to reduce intraoperative bleeding remains elusive.

Hot water irrigation (HWI) was first used by obstetricians in controlling postpartum bleeding over a hundred years ago.8 Its use in the control of intractable epistaxis was first described by Guice in 1878.9 In a histological study of nasal mucosa of rabbits irrigated with hot water, Stangerup and Thomsen found that temperatures of up to 50 degrees Celsius produces vasodilation and edema of the nasal mucosa without necrosis. They postulated that mucosal edema leads to compression of the bleeding vessels and may trigger and accelerate the clotting cascade.10 Stangerup et al found that in their series of 122 patients, posterior epistaxis was controlled in 55% of patients treated with HWI compared to 44% in the group treated with nasal packing.11 Novoa and Schlegel-Wagner subsequently showed that 82% of patients with intractable posterior epistaxis can be arrested with HWI.12 HWI has also led to reduced hospital stay, reduced number of surgical procedures, less pain and less nasal trauma. As continuous exposure of the nasal mucosa to pure water for 30 minutes has been shown by an in-vitro study to cause severe damage to the epithelial cells, we have decided to use hot normal saline in our study.13 Although hot saline irrigation (HSI) has been used in FESS and endoscopic skull base surgery, there are currently no reports in the English literature on its effectiveness.

Aim:

To assess the effectiveness of hot saline irrigation (HSI) compared to room temperature saline irrigation (RTSI) in the control of intraoperative bleeding during FESS.