1Otorhinolaryngology Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
2Medical Student, Iran University of Medical Sciences, Tehran, Iran
Introduction: Bleeding is a common concern during functional endoscopic sinus surgery (FESS) that can increase the risk of damage to adjacent vital elements by reducing the surgeon’s field of view. This study aimed to explore the efficacy of topical tranexamic acid in reducing intraoperative bleeding. Materials and Methods: This double-blind, randomized clinical trial was conducted in 60 patients with chronic rhinosinusitis with polyposis (CRSwP) who underwent FESS. Patients were randomly divided into two groups; tranexamic or salinetreatment. During surgery, normal saline (400 mL) or tranexamic acid (2 g) in normal saline with a total volume of 400 mL were used in the saline and tranexamic groups, respectively, for irrigation and suctioning. The surgeons’ assessment of field of view during surgery and intraoperative blood loss were recorded. Results: Mean blood loss was 254.13 mL in the saline group and 235.6 mL in the tranexamic group (P=0.31). No statistically significant differences between the two groups were found in terms of other investigated variables, such as surgical field quality based on Boezzart’s scale (P=0.30), surgeon satisfaction based on a Likert scale (P=0.54), or duration of surgery (P=0.22). Conclusion: Use of tranexamic acid (2 g in 400 mL normal saline) through washing of the nasal mucosa during FESS did not significantly reduce blood loss or improve the surgical field of view. Further studies with larger sample sizes and higher drug concentrations, and using other methods of administration, such as spraying or applying pledgets soaked in tranexamic acid, are recommended.
1. Benninger MS, Ferguson BJ, Hadley JA, Hamilos DL, Jacobs M, Kennedy DW, et al. Adult chronic rhinosinusitis: definitions, diagnosis, epidemiology, and pathophysiology. Otolaryngol Head Neck Surg. 2003;129(3):S1–S32.
2. Meltzer EO, Hamilos DL, Hadley JA, Lanza DC, Marple BF, Nicklas RA, et al. Rhinosinusitis: establishing definitions for clinical research and patient care. J Allergy Clin Immunol. 2004;114(6):155–212.
3. Devyani Lal JAS. Primary Sinus Surgery. In: Flint P HB, Lund V, Niparko J, Richardson M, Robbins K,Thomas J, editor. Cummings Otolaryngol Head Neck Surg 1: Elsevier Health Sciences; 2010. p. 741.
4. Stammberger H. Functional Endoscopic Sinus Surgery: The Messerklinger Technique Decker. Philadelphia; 1991.
5. Ragab SM, Hassanin MZ. Optimizing the surgical field in pediatric functional endoscopic sinus surgery: a new evidence-based approach. Otolaryngol Head Neck Surg. 2010;142(1):48–54.
6. Atighechi S, Azimi MR, Mirvakili SA, Baradaranfar MH, Dadgarnia MH. Evaluation of intraoperative bleeding during an endoscopic surgery of nasal polyposis after a pre-operative single dose versus a 5-day course of corticosteroid. Eur Arch OtoRhinoLaryngol. 2013;270(9):2451–4.
7. Casati V, Sandrelli L, Speziali G, Calori G, Grasso MA, Spagnolo S. Hemostatic effects of tranexamic acid in elective thoracic aortic surgery: a prospective, randomized, double-blind, placebo-controlled study. J Thorac Cardiovasc Surg. 2002;123(6):1084–91.
8. Dunn CJ, Goa KL. Tranexamic acid. Drugs. 1999;57(6):1005–32.
10. Wellington K, Wagstaff AJ. Tranexamic acid. Drugs. 2003;63(13):1417–33.
11. De Bonis M, Cavaliere F, Alessandrini F, Lapenna E, Santarelli F, Moscato U, et al. Topical use of tranexamic acid in coronary artery bypass operations: a double-blind, prospective, randomized, placebo-controlled study. J Thorac Cardiovasc Surg. 2000;119(3):575–80.
12. Krohn C, Sørensen R, Lange J, Riise R, Bjørnsen S, Brosstad F. Tranexamic acid given into the wound reduces postoperative blood loss by half in major orthopaedic surgery. Eur J Surg Suppl: Acta Chirurg Suppl. 2003(588):57–61.
13. Alshryda S, Sarda P, Sukeik M, Nargol A, Blenkinsopp J, Mason J. Tranexamic acid in total knee replacement A systematic review and meta-analysis. J Bone Joint Surg, Brit Vol. 2011;93(12):1577–85.
14. Pieramici DJ, Goldberg MF, Melia M, Fekrat S, Bradford CA, Faulkner A, et al. A phase III, multicenter, randomized, placebo-controlled clinical trial of topical aminocaproic acid (Caprogel) in the management of traumatic hyphema. Ophthalmol. 2003;110(11):2106–12.
15. Ishida K, Tsumura N, Kitagawa A, Hamamura S, Fukuda K, Dogaki Y, et al. Intra-articular injection of tranexamic acid reduces not only blood loss but also knee joint swelling after total knee arthroplasty. Int Orthopaed. 2011;35(11):1639–45.
16. Roy SP, Tanki UF, Dutta A, Jain SK, Nagi ON. Efficacy of intra-articular tranexamic acid in blood loss reduction following primary unilateral total knee arthroplasty. Knee Surg Sport Traumatol Arthrosc. 2012;20(12):2494–501.
17.Baradaranfar MH, Aghaei MA, Behniafard N, Nabi-Meibodi M, Atighechi S, Dadgarnia MH, Vajihinejad M, Baradaranfar A. Effect of Topical Furosemide on Intraoperative Bleeding During Functional Endoscopic Sinus Surgery. Journal of Craniofacial Surgery. 2016 Jun 1;27(4):970-2.
18. Orlandi RR, Warrier S, Sato S, Han JK. Concentrated topical epinephrine is safe in endoscopic sinus surgery. Am J Rhinol Allerg. 2010;24(2): 140–2.
19. Javer AR, Gheriani H, Mechor B, Flamer D, Genoway K, Yunker WK. Effect of intraoperative injection of 0.25% bupivacaine with 1:200,000 epinephrine on intraoperative blood loss in FESS. Am J Rhinol Allerg. 2009;23(4):437–41.
20. Yaniv E, Shvero J, Hadar T. Hemostatic effect of tranexamic acid in elective nasal surgery. Am J Rhinol. 2006;20(2):227–9.
21. Jabalameli M & Zakeri K. Evaluation of Topical Tranexamic Acid on Intraoperative Bleeding in Endoscopic Sinus Surgery. Iran J Med Sci. 2006;31(4).
22. Athanasiadis T, Beule AG, Wormald PJ. Effects of topical antifibrinolytics in endoscopic sinus surgery: a pilot randomized controlled trial. Am J Rhinol. 2007; 21(6):737–42.
23. Moise A, Agachi L, Dragulin E, Mincu N, Stelea G. Tranexamic acid reduces with 50% the total nasal bleeding of patients that underwent functional endoscopic sinus surgery: 6AP6–6. Eur J Anaesthesiol. 2010;27(47):115.
24. Alimian M, Mohseni M. The effect of intravenous tranexamic acid on blood loss and surgical field quality during endoscopic sinus surgery: a placebo-controlled clinical trial. J Clin Anesthes. 2011; 23(8): 611–5.
25. Abbasi H, Behdad S, Ayatollahi V, Nazemian N, Mirshamsi P. Comparison of two doses of tranexamic acid on bleeding and surgery site quality during sinus endoscopy surgery. Adv Clin Exper Med. 2011; 21(6):773–80.
26. Langille MA, Chiarella A, Côté DW, Mulholland G, Sowerby LJ, Dziegielewski PT, et al., ed. Intravenous tranexamic acid and intraoperative visualization during functional endoscopic sinus surgery: a double‐blind randomized controlled trial. Int Forum Allerg Rhinol. 2013: Wiley Online Library.
27. Eldaba AA, Amr YM, Albirmawy OA. Effects of tranexamic acid during endoscopic sinsus surgery in children. Saudi J Anaesthes. 2013;7(3):229.