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Management of the visual field in endoscopic sinus surgery

With the introduction of hypotensive, total intravenous anesthesia (TIVA) and the use of topical 1:1000 epinephrine, intraoperative bleeding during sinonasal surgery has been significantly curtailed, and the operative field markedly improved, allowing for much more meticulous surgical procedures with excellent visualization. However, increasingly, procedures are being performed in the office, and therefore understanding potential hemodynamic changes associated with anesthesia becomes even more critical than in a closely monitored operating room. Accordingly, the issues of anesthesia and vasoconstriction in intranasal surgery continue to be an important area for clinical research, and this is highlighted in several articles in this issue of the International Forum of Allergy and Rhinology (IFAR). Ahmed et al.1 performed a prospective study of the hemodynamic changes occurring following local infiltration of either 1:100,000 or 1:200,000 epinephrine utilizing arterial line monitoring. Although there was some blood pressure elevation, there was no significant difference between the 2 dosages. However, following the local infiltration, they also evaluated the hemodynamic effects of topical 1:1000 epinephrine-soaked pledgets and noted that in a subset of patients (2/28) there was a significantly more marked (>75 mmHg) rise in blood pressure. Although prior studies have shown no adverse effects from the routine use of 1:1000 epinephrine topically, this study identifies the need for broader evaluation. Additionally, because the topical epinephrine was applied following local vasoconstriction by infiltration, it is possible that in the absence of the local infiltration, the absorption and hemodynamic effects would have been even greater. Tangbumrungtham et al.,2 in a double-blind study, evaluated whether, when using 1:1000 topical epinephrine for vasoconstriction, the addition of 1% lidocaine with 1:100,000 epinephrine provided a surgical field advantage. They found that the local infiltration did not provide any advantage over saline injection in terms of operative field visualization. However, they did not monitor hemodynamic changes as in the Ahmed et al.1 study, or whether