Comparison of Tranexamic Acid and Dexmedetomidine on Bleeding in Endoscopic Sinus Surgery.

Introduction: The quality of the surgical field during the surgery is impaired when bleeding occurs. This study compared the effect of tranexamic acid and dexmedetomidine on the rate of bleeding during endoscopic sinus surgery (ESS). Materials and Methods: In this one-blind clinical trial, 72 patients with chronic rhinosinusitis who were candidates for ESS at Be'sat Hospital in Hamedan were randomly assigned to two groups. Group A received dexmedetomidine at a dose of 1µg/kg, and group B received tranexamic acid at a dose of 10mg/kg immediately after induction of anesthesia intravenously within 15 minutes. The two groups were evaluated and compared regarding the quality of the surgery field with the Boezaart scale, volume of intraoperative bleeding, hemodynamic changes, and complications up to 90 minutes after the beginning of surgery. Results: The mean volume of intraoperative bleeding in group A (181.67±86.66) was significantly higher than in group B (110.28±61.23) (P =0.000). At 15, 30, and 60 minutes, the quality of the surgical field in group B was better than group A (P =0.038), while at 90 minutes, there was no statistically significant difference (P =0.450). The mean arterial pressure in group A at 15 minutes was higher than in group B (P=0.003); at 60 and 90 minutes, it was lower, and the difference was statistically significant (P =0.01). On the other hand, in 30 minutes, the mean arterial pressure in group A was higher than in group B, without a significant difference (P =0.07). Moreover, there was no statistically significant difference between the average surgery time (P = 0.25) and the frequency of complications (P =0.405). Conclusions: Based on the results, tranexamic acid is preferable to injectable dexmedetomidine to control and reduce bleeding during ESS.

Effect of Topical Furosemide Efficacy on Reducing Bleeding and Quality of Surgical Field During Endoscopic Sinus Surgery in Patients with Chronic Rhinosinusitis.

Introduction: Bleeding during endoscopic sinus surgery has an unfavorable effect on the surgical field and prolongs the time of surgery. In this study, we assessed the efficacy of topical furosemide on bleeding and the quality of the surgical field during endoscopic sinus surgery. Materials and Methods: In this clinical trial, 76 patients with chronic rhinosinusitis were selected for endoscopic sinus surgery and randomly assigned to two groups, topical furosemide (intervention) and normal saline (control). The intervention group received 20 micrograms of intranasal spray twice daily, and the control group received regular intranasal saline spray, similar to the intervention group. In addition, the quality of the surgical field (scoring by the BOEZAART grading system) and the amount of bleeding during surgeries were measured. All data were analyzed. Results: In the intervention and control groups, the mean surgical bleeding volume was 187.70± 24.79 and 229.21± 28.18 ml (P <0.001), the mean of Boezaart scale 2 and 3 (P <0.001) and the mean of surgical time were 106.53±14.67 and 126.63 ± 15.42 minutes (P <0.001), respectively. In patients of the intervention group with and without polyps, the mean surgery time was 99.56± 12.15 and 118.84 ±10.03 minutes (P <0.001), and the mean bleeding volume during endoscopic sinus surgery was 176.46 ± 22.58, 208.46 ±12.14 ml (P <0.001) respectively. Conclusions: Our findings showed that nasal, topical furosemide spray significantly reduced the amount of bleeding during endoscopic sinus surgery and time of the surgery and improved the quality of the surgical field.

Effects of Vitamin D Supplementation on Recurrence of Nasal Polyposis after Endoscopic Sinus Surgery.

INTRODUCTION: Chronic rhinosinusitis with nasal polyposis (CRSwNP) is a relatively common disease with serious impacts on patient quality of life. Recurrence of polyps after functional endoscopic sinus surgery (FESS) is a dilemma. Vitamin D3 (VD3) is known to inhibit the proliferation of nasal polyp-derived fibroblasts. The present study aimed to investigate the effects of oral VD3 on the recurrence of polyposis after FESS. MATERIALS AND METHODS: This triple-blind placebo-controlled clinical trial was conducted on 40 patients with CRSwNP who did not respond to medical treatment and were candidates for FESS. In addition, the patients had VD3 insufficiency. Following the surgery, all the patients received routine treatment (i.e., fluticasone spray, irrigation, cefixime 400 mg daily for 10 days, and montelukast for a month). Moreover, the case group received oral VD3 tablets 4000 IU (single daily dose) for a month, and the control group received placebo in the same manner. The Sino-Nasal Outcome Test (SNOT-22) and Meltzer endoscopic grading scores were recorded at months 1, 3, and 6 after the study. RESULTS: In this study, 6 months following the intervention, the severity of polyposis was reported to be significantly lower in the VD3 group compared to the placebo group based on SNOT-22 (16.25±10.16 in the VD3 group vs. 47.45±13.55 in the placebo group; P<0.001) and Meltzer scores (0.50±0.60 in the VD3 group vs. 2.65±0.93 in the placebo group; P<0.001). No adverse effects were observed in the case group. CONCLUSION: This study showed the efficacy and safety of vitamin D supplementation in the reduction of polyposis recurrence after FESS in patients with CRSwNP.

Correction of Severe Deviated Nose by Intermediate Short Osteotomy.

BACKGROUND: The deviated nose is a common deformity encountered in rhinoplasty, and yet it is the most challenging pathology to treat, because multiple internal and external structures have deformity, so there is a need to be corrected. METHODES: The intermediate short osteotomy has been applied as a technique to correct severe nasal bony deviations. Eleven patients with severe deviated nose who had been operated by the senior author from 2013 through 2016 were included in the study (follow-up period of 6-24 month). Intermediate short osteotomy was performed after medial and before lateral osteotomy. Surgical outcomes were assessed by another otolaryngologist based on review of pre- and post-operative (6 to 24 months after surgery) photographs. The post-operative outcome in terms of deviation correction was classified as excellent, good, fair, or no change. RESULTS: Of all 11 cases, 6 (54.5%) were accepted as excellent, 4 (36.4%) as good, and 1 (9%) as no change. CONCLUSION: Intermediate short osteotomy can be considered as a modification of intermediate osteotomy that eliminates nasal dorsal deviation more completely. This osteotomy is very simple and need only 1 to 2 minutes and use of this method is recommended for correction of severe deviated bony noses.

Effect of local desmopressin administration on intraoperative blood loss and quality of the surgical field during functional endoscopic sinus surgery in patients with chronic rhinosinusitis: a triple-blinded clinical trial.

BACKGROUND: Bleeding during functional endoscopic sinus surgery always been a challenge for the quality of surgical field for surgeons. This study aimed to evaluate the effect of local nasal desmopressin premedication on blood loss and the quality of surgical field in functional endoscopic sinus surgery. METHODS: This study was conducted on 90 patients with chronic rhinosinusitis who were candidate for endoscopic sinus surgery. They were randomly assigned to two study groups. One group received a single puff of local desmopressin (10 µg) in each side of nasal cavity 30 min before the surgery and the other received normal saline instead. Blood loss and the quality surgical field were determined in 15, 30, 60 and 90 min during the surgery (scoring by BOEZAART grading system). All data were analyzed. RESULTS: Blood loss was significantly lesser in the desmopressin group (mean ± SD, 16.289 ± 5.605 ml) than in the control group (24.289 ± 5.2722 ml, P < 0.001).Surgeons were more satisfied with the surgical field in the desmopressin group than control group in all cutoff points (15, 30, 60, and 90 min during the surgery, P < 0.001). No side effects were observed using local desmopressin. CONCLUSIONS: Premedication with local desmopressin can reduce bleeding effectively and clear the surgical field during functional endoscopic sinus surgery.

Comparing the Efficacy of Temperature-Controlled Radiofrequency Tonsil Ablation versus CO2-Laser Cryptolysis in the Treatment of Halitosis.

INTRODUCTION: Halitosis and foreign body sensation are two common and disturbing symptoms of chronic caseous tonsillitis (CCT). The aim of this study was to compare the efficacy and safety of temperature-controlled radiofrequency (TC-RF) tonsil ablation with CO2-laser cryptolysis (CO2-LC) in the treatment of patients with halitosis caused by CCT. MATERIALS AND METHODS: Sixty-two patients who suffered from halitosis and/or foreign body sensation due to CCT were enrolled in the present randomized clinical trial, and were randomly assigned into two groups. Group A underwent TC-RF tonsil ablation and Group B received CO2-LC. The severity of symptoms including halitosis and foreign body sensation was reported 7 days, 1 month, and 6 months after the procedure. Patient pain levels and amount of bleeding were evaluated as safety outcome measures. Pain levels were evaluated during the intervention, and at Day 1, 3, and 7 following the procedure using a visual analog scale (VAS). RESULTS: Mean rank of pain score in the RF tonsil ablation group was found to be higher than in the CO2-LC group at all measured timepoints following the procedure. The amount of bleeding in the LC group was found to be significantly less than in the RF group (P<0.05). No significant difference was found between the groups regarding duration of procedure (P=0.157). CONCLUSION: Both procedures were found to be effective and safe in the treatment of CT-associated halitosis. However, LC showed better results based on lower pain levels, lower incidence of bleeding, and faster progression to a routine diet.

Effect of Topical Furosemide on Rhinosinusal Polyposis Relapse After Endoscopic Sinus Surgery: A Randomized Clinical Trial.

Importance: Evidence from previous studies suggests that furosemide may be effective in reducing the recurrence of polyps after sinus surgery. However, the evidence is limited and insufficient, and further investigations are required. Objective: To assess the effect of topical furosemide on recurrence rate of rhinosinusal polyposis after endoscopic sinus surgery. Design, Setting, and Participants: Triple-blind randomized clinical trial of patients aged 18 to 60 years with chronic rhinosinusitis associated with polyposis who did not respond to medical treatment and were candidates for endoscopic sinus surgery at Besat Hospital, Hamadan University of Medical Sciences, from April 2014 to June 2015. Interventions: Patients were randomly assigned to receive postoperative nasal spray, 2 puffs twice a day for 2 months, either 300 µg of furosemide per day or placebo. Main Outcomes and Measures: Six months after surgery, the patients were examined for nasal and paranasal sinus polyposis using Meltzer endoscopic grading, computed tomographic (CT) scan of paranasal sinuses (PNS) scoring, Sino-Nasal Outcome Test (SNOT-22) scoring, and visual analog scale (VAS). Results: Of 110 patients enrolled, 84 patients remained for analysis (53 men and 31 women; mean age in the furosemide group, 37.02 years, range, 18-58 years; mean age in the placebo group, 36.30 years, range, 18-60 years). Six months after the intervention, the grade of polyposis decreased in both groups, but this reduction was substantial in the furosemide group vs the placebo group. The severity of polyposis was significantly lower in the furosemide group vs the placebo group based on SNOT-22 scoring (difference, 8.05; 95% CI, 3.24-12.85) and VAS (difference, 0.81; 95% CI, 0.22-1.39) but not significantly different based on CT scan of PNS scoring (difference, 2.52; 95% CI, -0.35 to 5.39). The incidence of adverse effects (nasal irritation, headache, and constipation) were not significantly different between the 2 groups. Conclusions and Relevance: These findings indicate that topical furosemide is a safe drug, with no important adverse effects, that can substantially reduce the severity of polyposis after endoscopic sinus surgery. Trial Registration: Iranian Registry of Clinical Trials registration number: IRCT201403143186N5.

Clinical effects of topical antifungal therapy in chronic rhinosinusitis: a randomized, double-blind, placebo-controlled trial of intranasal fluconazole.

Several studies have been in favor of fungi as a possible pathogenesis of chronic rhinosinusitis (CRS); however, to date, there is no scientific consensus about the use of antifungal agents in disease management. The aim of the present study was to investigate the efficacy of intranasal fluconazole in improving disease symptoms and objective outcomes of patients with CRS. A randomized, double-blind, placebo-controlled study was conducted on 54 patients who were diagnosed with CRS and had not been responsive to routine medical treatments. They were randomly assigned to receive either fluconazole nasal drop 0.2 % or placebo in addition to the standard regimen for a duration of 8 weeks. Patients' outcomes were evaluated according to Sino-Nasal Outcome Test 20 (SNOT-20), endoscopic scores, and Computed Tomography (CT) scores. No statistically significant difference was found in SNOT-20 (p = 0.201), endoscopic (p = 0.283), and CT scores (p = 0.212) of the patients at baseline and after 8-week course of treatment between drug and placebo group. Similar to many studies, the use of topical antifungal treatment for patients with CRS was not shown to be significantly effective. However, further studies are needed to obtain high levels of consistent evidence in order to arrive at a decision whether antifungal therapy is effective in management of CRS or not.

The effect of thyme honey nasal spray on chronic rhinosinusitis: a double-blind randomized controlled clinical trial.

Chronic rhinosinusitis is a common disease which causes persisting inflammatory conditions of one or more sinuses. This study was designed to evaluate the effect of thyme honey nasal spray as an adjunctive medication on chronic rhinosinusitis after functional endoscopic sinus surgery. This was a randomized, placebo controlled, double-blind clinical study. 64 patients with chronic rhinosinusitis undergoing functional endoscopic sinus surgery were enrolled in this study. Patients were randomized and blinded to receive either placebo or thyme honey nasal spray in addition to the standard regimen postoperatively. Patients were visited on postoperative days 7, 30 and 60. The sino-nasal outcome test, endoscopic grading system and sinus CT-scan were scored before operation and on the day 60 after surgery. 54 patients completed the study. Significant improvement was observed in both treatment groups. There were no significant changes in SNOT-22, endoscopy and CT-scan scores between the two study groups. However, a greater reduction in endoscopic scores was shown in thyme honey group. The incidence of adverse effects was not significantly different between the groups, but synechiae formation and epistaxis were lower in treatment group. Thyme honey nasal spray seems to be a low-priced potential adjuvant remedy with excellent safety profile, to reduce inflammation and polyp formation and also fostering mucosal healing for patients suffering from chronic rhinosinusitis. However, further studies are recommended.

Effect of topical tranexamic acid on bleeding and quality of surgical field during functional endoscopic sinus surgery in patients with chronic rhinosinusitis: a triple blind randomized clinical trial.

BACKGROUND: The effect of tranexamic acid (TXA) on bleeding and improvement of surgical field during functional endoscopic sinus surgery (FESS) is not clear yet. This study was conducted to answer this question. METHODS: This trial was conducted on 60 patients with chronic sinusitis at Beasat Hospital, Hamadan, Iran, from April to November 2013. Thirty patients in the intervention group received three pledgets soaked with TXA 5% and phenylephrine 0.5% for 10 minutes in each nasal cavity before surgery. Thirty patients in the control group received phenylephrine 0.5% with the same way. The amount of bleeding and the quality of surgical field were evaluated at 15, 30, and 45 minutes after the start of surgery using Boezaart grading. RESULTS: The quality of the surgical field in the intervention group compared to the control group was significantly better in the first quarter (P = 0.002) and the second quarter (P = 0.003) but not in the third quarter (P = 0.163). Furthermore, the amount of bleeding was much less during all periods in the intervention group than in the control group (P = 0.001). CONCLUSION: Topical TXA can efficiently reduce bleeding and improve the surgical field in FESS in patients with rhinosinusitis. Based on these findings, topical TXA may be a useful method for providing a suitable surgical field during the first 30 minutes after use. TRIAL REGISTRATION: Iranian Registry of Clinical Trials IRCT201212139014N15.

Effect of topical sucralfate vs clindamycin on posttonsillectomy pain in children aged 6 to 12 years: a triple-blind randomized clinical trial.

IMPORTANCE: Postoperative sore throat is one of the most common problems after tonsillectomy. Antibiotics remove the local flora and reduce inflammation and thus may reduce postoperative pain after tonsillectomy. OBJECTIVE: To assess the effect of topical sucralfate and clindamycin on local pain reduction after tonsillectomy in children aged 6 to 12 years. DESIGN, SETTING, AND PARTICIPANTS: Triple-blind randomized clinical trial of children aged 6 to 12 years with sleep apnea or snoring due to adenotonsillar hypertrophy and chronic airway obstruction or with chronic infections who were candidates for tonsillectomy at Besat Hospital, Hamadan University of Medical Sciences, from May to October 2013. INTERVENTIONS: Patients were randomly assigned to receive sucralfate mouthwash, clindamycin mouthwash, or placebo (cellulose). The oral cavity was washed before and immediately after surgery with 10 mL of the prepared solution for 1 minute and then suctioned. Then, 8 hours after surgery, the patients were asked to keep 10 mL of the prepared mouthwash solution in their mouths for 1 minute 3 times a day for 3 days. MAIN OUTCOMES AND MEASURES: Postoperative sore throat evaluated daily for 5 days using the Faces Pain Scale-Revised. RESULTS: Of 110 patients enrolled, 101 patients remained for analysis. Patients in the placebo group had significantly higher mean (SD) throat pain scores than did patients in both drug groups on postsurgery days 1 through 4. Day 1 scores were 8.00 (1.84) for placebo and 6.00 (1.84) for sucralfate and 6.79 (1.87) for clindamycin (P = .001). Pain scores were not significantly different on day 5. Acetaminophen use was more common in the placebo group on days 3 and 4 (2.97 and 2.44) vs the sucralfate group (2.24 and 2.15) and the clindamycin group (2.36 and 2.12) (P = .001 and .02, respectively). Bleeding on day 1 was more common in the placebo group (3 of 34) vs none in the drug groups. Food intolerance on day 1 was less common in patients receiving sucralfate (2 of 34) than placebo (9 of 34) or clindamycin (11 of 33) (P = .02). There was no significant difference among the 3 groups in numbers of episodes of nocturnal waking, halitosis, earache, nausea, and vomiting. CONCLUSIONS AND RELEVANCE: This trial indicated that topical sucralfate and clindamycin are safe drugs with no important adverse effects that can significantly reduce posttonsillectomy pain in children and help them return to normal life sooner. TRIAL REGISTRATION: Iranian Registry of Clinical Trials registration number: IRCT201303209014N16.

The effect of excisional biopsy on the accuracy of sentinel lymph node mapping in early stage breast cancer: comparison with core needle biopsy.

Despite the successful application of sentinel node mapping in breast cancer patients, its use in patients with a history of previous excisional biopsy of the breast tumors is a matter of controversy. In the present study we evaluated the accuracy of sentinel node biopsy in this group of patients and compared the results with those in whom the diagnosis of breast cancer was established by core needle biopsy. Eighty patients with early stage breast carcinoma were included into our study. Forty patients had a history of previous excisional biopsy and the remainder 40 had undergone core needle biopsy. Intradermal injections of 99mTc-antimony sulfide colloid as well as patent blue were both used for sentinel node mapping. Sentinel nodes were harvested during surgery with the aid of surgical gamma probe. All patients underwent standard axillary lymph node dissection subsequently. Detection rate was 97.5 per cent for both groups of the study. Number of detected sentinel node during surgery was not significantly different between groups. False negative rate was 0 per cent for both groups of the study. In conclusion sentinel node biopsy is reliable in patients with previous history of excisional biopsy of the breast tumors and has a low false negative rate.

Comparison of early and delayed lymphoscintigraphy images of early breast cancer patients undergoing sentinel node mapping.

OBJECTIVE: We compared early and delayed lymphoscintigraphy images using intradermal injection of (99m)Tc-antimony sulfide colloid, which has small particles. METHODS: Eighty patients with early-stage breast cancer were included into the study. Intradermal injection of (99m)Tc-antimony sulfide colloid was used for sentinel node mapping. After radiotracer injection, 30 min and 20 h later, lymphoscitigraphy images were obtained in lateral and anterior views. After the completion of each image sets, the location of the visible nodes in the axilla was marked on the skin. Two nuclear medicine specialists reviewed the images independently and the number and location of detected nodes were recorded. RESULTS: At least one hotspot was detected in the axillary region in 78 (97.5%) and 79 (98.75%) patients on the early and delayed images, respectively. No extra-axillary drainage was noted in the patients. The number and location of detected hot spots were the same in 77 patients on both image sets. In one patient the early image did not show any axillary hot spot despite its visualization on the delayed image set and in one patient no hot spot was noted on either images. In one patient an additional axillary hot spot was noted on the delayed image, which was not apparent on the early image. CONCLUSION: Our study showed that a delay of up to 20 h in sentinel lymph node biopsy using intradermal injection of (99m)Tc-antimony sulfide colloid does not result in washout of the tracer from the true sentinel node or migration of the radiotracer into second-echelon nodes.

Changes in growth pattern after adenotonsillectomy in children under 12 years old.

The aim of the present study was to determine the effects of adenotonsillectomy on height, weight and body mass index (BMI) in children under 12 years old, with or without airway obstruction and evaluation of the risk of overweight in them. In this case-control study, 120 children with the age of 2-12 years old were studied; 60 children as case group who underwent adenotonsillectomy and 60 healthy children as control group. After collecting the data related to appetite status and sleep breathing disorder of the case group, height, weight and BMI have been measured for all children in two stages; preoperatively and 6 months later. Also in the case group, BMI percentiles, pre and postoperatively have been calculated. Patients with Low appetite in the initiation and at the end of the study in the case group were 80% and 8.3% respectively (P=0.01). Mean of height, weight and BMI variation after 6 months were significantly different between case and control groups (P<0.05). BMI percentiles in the case group preoperatively were: 20% underweight, 67% healthy weight, 10% at risk of over weight, 3% over weight. Postoperatively, after 6 months BMI percentiles in order of above frequency were: 10%, 57%, 22% and 11% (P=0.02). Analysis of the results showed that adenotonsillectomy can lead to increase of height, weight, BMI and appetite not only in the children with low weight due to airway obstruction but also in the normal weight and over weight children. Therefore risk of overweight should be mentioned as a probable undesirable outcome of adenotonsillectomy.