RHINOLOGY

Evaluation of intraoperative bleeding during an endoscopicsurgery of nasal polyposis after a pre-operative single doseversus a 5-day course of corticosteroid

Saeid Atighechi • Mohammad Reza Azimi • Seyyed Abbas Mirvakili •

Mohammad Hossein Baradaranfar • Mohammad Hossein Dadgarnia

Received: 22 June 2012 / Accepted: 18 December 2012

� Springer-Verlag Berlin Heidelberg 2013

Abstract Nasal polyps are associated with the inflammation

of the nasal cavity and the sinus mucosa. When medical

treatment cannot solve a patient’s problem, a functional

endoscopic sinus surgery may be indicated. Bleeding impairs

the surgery field during operation and increases the operation

risk and time. Pre-operative corticosteroids can reduce

bleeding during surgery. In this study, we have evaluated the

effect of pre-operative single-dose prednisolone (1 mg/Kg/

dose 24 h before surgery) versus 5-day prednisolone (1 mg/

Kg/day before operation) on the bleeding volume and the

surgery field quality during FESS. In this mono blind ran-

domized clinical trial, 80 patients with bilateral nasal polyps

were randomly assigned in two groups. The first group

(A) received a single dose of 1 mg/Kg/dose prednisolone on

the day before the surgery. The second group (B) received

1 mg/Kg/day prednisolone for 5 days before the operation.

The patients were operated on under general anesthesia

through the same protocol. The mean arterial blood pressure

was 70–80 mm Hg in both groups. The surgeons were not

aware of the patients’ group. The bleeding volume and the

surgeons’ opinion about the surgery field quality were recor-

ded at the end of the procedure and analyzed by Chi-square

and t test. The two groups were not significantly different in

their overall demographic and clinical characteristics. The

mean bleeding volume during the operation was

266.5 ± 96.31 ml in group A and 206 ± 52.81 ml in group

B; there was a significant difference between the groups

(P value = 0.038). There was no significant difference

between the groups in the surgeons’ opinion about the surgery

field quality (P value = 0.09). In conclusion, unlike a single

dose (1 mg/kg/dose), treatment with 5-day prednisolone

(1 mg/kg/day) can reduce blood loss during FESS more

efficiently and may improve the surgery field quality slightly.

But this difference is not clinically significant.

Keywords Nasal polyps � Prednisolone � Endoscopic

sinus surgery � Bleeding � Complication � Corticosteroids

Introduction

Rhinosinusitis is an inflammatory process in nose and

paranasal sinuses characterized by at least two of these:

clinical presentation, endoscopic finding, and CT scan

changes [1]. Many patients may be asymptomatic, but large

polyps may lead to a nasal passage block and become

symptomatic. The most common symptoms are hyposmia,

rhinorrhea, posterior nasal discharge, etc [2]. There is a

correlation between nasal polyps and allergy. 68.5 % of

patients with nasal polyps had a positive allergy skin test

although allergy may not be responsible for the rhinosi-

nusitis [3]. Medical therapy for nasal polyps is the main

stage of treatment. It consists of a course of antibiotics with

an effective bacterial coverage and topical steroids [4].

Long-term topical steroids with a reduction in the polyp

size can remove patients’ symptom. Short-term systemic

steroids may be used in more severe cases [5]. When

medical treatment cannot solve the patients’ problem,

surgery may be indicated. The best approach for chronic

rhino sinusitis with nasal polyps is a functional endoscopic

sinus surgery [6]. One of the most common complications

S. Atighechi � M. R. Azimi � S. A. Mirvakili �M. H. Baradaranfar � M. H. Dadgarnia

Department of Otolaryngology, Shahid Sadooghi

University of Medical Sciences, Yazd, Iran

S. Atighechi (&)

Department of Otolaryngology, Shahid Sadooghi Hospital,

Sina Street, Janbaz Square, Yazd, Iran

e-mail: saeidatighechi@yahoo.com

123

Eur Arch Otorhinolaryngol

DOI 10.1007/s00405-012-2340-9

during FESS is bleeding [7]. Bleeding impairs the surgery

field during the operation and increase the risk of compli-

cations like those in the skull base or orbital damages.

Bleeding increases operation time due to multiple stops

during surgery for suctioning and packing [7]. One of the

strategies to reduce bleeding during an operation is the use

of pre-operative corticosteroid, which makes a reduction in

the polyp size and mucosal inflammation [4].

In this study, we tried to answer the question: ‘‘can a pre-

operative regimen of prednisolone be reduced to a single

day before the procedure?’’ A single dose may be better

complied with than a five-course one, and perhaps better

tolerated. So, we evaluated the effect of pre-operative sin-

gle-dose prednisolone (1 mg/Kg/dose 24 h before surgery)

versus a 5-day prednisolone protocol (1 mg/Kg/day before

surgery) on the bleeding volume and the surgery field

quality during FESS.

Method and materials

A total of 80 patients with bilateral nasal polyps were the

candidates for our mono blind randomized clinical trial. All

the patients were in a good health condition (ASA class I) and

aged between 18 and 50 (the inclusion criterion was age

between 18 and 50). They were randomly assigned in two

groups according to the table of random numbers. The first

group (group A) received a single dose of 1 mg/Kg/dose

prednisolone on the day before the surgery. The second

group (group B) received 1 mg/Kg/day prednisolone for

5 days before the operation. The exclusion criteria were

history of previous nasal surgery, antrochoanal polyps,

hemorrhagic disease, hypertension (SBP [ 140 mm Hg or

DBP [ 90 mm Hg), corticosteroid use in 2 months before

screening, and allergy or other contraindications for corti-

costeroid use. Written consents were taken from the patients.

The baseline assessment included the collecting of the

patients’ medical and surgical history and nasal examination.

The size of the nasal polyps was recorded in a diagnostic

endoscopic examination, and the sinus involvement was

determined by CT-scan images according to Lund–Mackay

score. Treatment complications such as high blood glucose

levels, euphoria, stomach irritation, and sleeplessness were

recorded too. The study was approved by the ethics com-

mittee of Shahid Sadoughi Hospital, Yazd, Iran.

The patients were operated on under general anesthesia

by the same protocol (Table 1). The mean arterial blood

pressure was 70–80 mm Hg in both groups during the

surgery. All the surgeons used topical vasoconstriction

(1/10,000 epinephrine solution) and used a 2-ml local

injection of 1/100,000 epinephrine solution in the middle

and inferior turbinate and to the attachment of the middle

turbinate to the lateral nasal wall. The surgeons were not

aware of the patients’ group. The bleeding volume was

precisely assessed according to the volume in the suction

jar (total volume minus irrigation volume) and the excess

weight of the pharyngeal pack. The surgeons’ opinion

about the surgery field quality was recorded according to

0–10 score (Table 2) at the end of the procedure.

A sample t test and Chi-square test were used to com-

pare the baseline and the outcome values. Differences

would prove to be statistically significant if P value was

less than 0.05. All the statistical analyses were performed

with an SPSS software version 11.5 for windows.

Results

80 patients who had the inclusion criteria were randomly

assigned in two equal groups. The overall demographic as

well as the clinical characteristics was not statistically

different in the two groups at the baseline (Table 3). The

prevalence of concomitant asthma in two groups was also

mentioned in Table 3, but the difference was not

significant.

The mean bleeding volume during the operation was

266.5 ± 96.31 ml in group A and 206 ± 52.81 ml in

group B. In this regard, there was a significant difference

between the groups (P value = 0.038).

Table 1 Anesthesia protocol

Premedication Midazolam 1 mg IV ? fentanyl 2.5

micro g/kg IV ? clonidine 1 tablet

Induction Propofol 1.5–2 mg/kg ? atracurium

0.5 mg/kg

Maintenance Propofol 5–10 mg/kg/h ? atracurium

0.5 mg/kg itch 30 min ? N2O 50 %

If

MAP [ 80 mm Hg

TNG drip 0.25-0.5 micro g/kg/min till

MAP \ 80 mm Hg

Table 2 Quality of surgical field during functional endoscopic sinus

surgery

Score Quality of intraoperative surgical field during functional

endoscopic sinus surgery

0–1 No bleeding; excellent to outstanding surgical conditions

2–3 Slight bleeding. Surgery fairly easy. No stop for hemostasis

and/or suctioning is required

4–5 Slight bleeding. Surgery mildly difficult. One stop for

hemostasis and/or suctioning is required

6–7 Moderate bleeding. Surgery Moderately difficult. Occasional

stops for hemostasis and/or suctioning are required

8–9 Moderate to severe bleeding. Surgery very difficult. Multiple

stops for hemostasis and/or suctioning are required.

10 Surgery terminated due to severe bleeding in surgical field

Eur Arch Otorhinolaryngol

123

The surgeons’ evaluation about the surgery field quality

is recorded in Fig. 1. As it can be seen, the two groups were

not significantly different (P value = 0.09).

A treatment complication (euphoria) was seen in one of

the patient in the 5-day treatment, but none of the patients

in the other group had a side effect. There was no statis-

tically significant difference between the two groups in this

respect (P value = 0.31).

Discussion

In the present study, there was no statistically significant

difference between the groups in terms of age, polyp size,

and CT scan scores prior to the surgery. The only differ-

ence was the duration of pre-operative prednisolone use.

The results showed that the use of 1 mg/Kg/day prednis-

olone for 5 days pre-operatively could reduce the intraop-

erative bleeding volume during FESS in comparison with

1 mg/Kg prednisolone used only 1 day before the surgery.

A control group (without any steroid treatment) was

planned, but not approved by the Ethics Committee, as

steroids have shown to be effective.

Although the surgeons’ evaluation about the surgery

field quality in the 5-day prednisolone protocol was better

than that in a single-dose administration, the difference was

not statistically significant. In other words, although the

volume of blood loss in the 5-day regimen was less than

that in the single-dose regimen, the effect was not signifi-

cantly different clinically.

In Albu’s study where the effect of local corticosteroid

was evaluated on bleeding volume reduction during FESS,

half of the patients were treated with a nasal spray and the

others were treated with a placebo. The result showed that

the bleeding volume reduction in the patients who used a

nasal spray was statistically less than that in the other

group. Also, the surgeon had a better opinion about the

surgery field in the nasal spray group [8].

In another study by Giordano, the effect of local corti-

costeroid on bleeding volume and the surgeon’s evaluation

were investigated. 21 patients were treated by oral pred-

nisolone (1 mg/Kg for 7 days before surgery) and 19 with a

placebo. The results did not show any significant difference

between the two groups according to the bleeding volume;

however, the rate of sinus involvement was higher in the

group that received oral prednisolone than in the placebo

group [9].

In Kirtsreesakul’s study, the patients were divided into

two groups. In the first group, the patients were treated with

oral prednisolone (30 mg/day) and in the second group,

they were treated with a placebo. The results showed

although the bleeding volume was a little less in the test

group, the surgery field had a significant improvement [10].

Fig. 1 Surgeons’ opinion about

surgical field quality

Table 3 Pre-operative

variables

a According to Lund–Mackay

(table 4)b Fisher’s exact test

Group A Group B p value

Age (mean ± SD) 37.3 ± 10.47 34.85 ± 9.48 0.44

Sex (m/f) 1.85/1 3/1 0.49

Concomitant asthma 7.5 % 12.5 % 1.00b

CT-score (Lund-Mackay) (mean ± SD) 19.45 ± 2.51 19 ± 2.81 0.59

Polyp gradea Grade I: 4 Grade I: 2 0.60

Grade II: 18 Grade II: 14

Grade III: 18 Grade III: 24

Table 4 polyp size and CT scan score (Lund-Mackay) in groups

Polyp size (mean) Ct scan score

Single dose 2.35 19

Multiple dose 2.55 19.45

P value 0.328 0.599

Eur Arch Otorhinolaryngol

123

An aim of the present study was to evaluate the side

effects of short-term use of corticosteroid. The results

showed that the side effects were less in the single-dose

group, but the difference was not statistically significant

(P value = 0.31).

In a study, Bolanos showed that short-term corticoste-

roid use was safe and side effects such as sleep disorders,

weight gain, euphoria, and gastrointestinal disorders were

seen rarely according to a meta-analysis done in 2005.

Severe side effects were seen in 6 % of the patients while

mild–moderate side effects were seen in 28 % of the

patients. The most common side effects in short-term

corticosteroid use were hypomania and euphoria. It was

due to hypocamp neurons disequilibrium [11].

In the Sieskiewicz study, bleeding and surgeon evalua-

tion was compared in 18 patients on 30 mg of oral pred-

nisone daily for 5 consecutive days before the operation

with control group. Although total blood loss was reduced

slightly in steroid group, but surgical field improved sig-

nificantly as a result of the anti-edematous and anti-

inflammatory activity of steroid, which provided a better

vision for the surgeon [12].

Conclusion

Treatment with 5-day prednisolone (1 mg/kg/day) as

compared to single-dose prednisolone (1 mg/kg/dose) can

reduce blood loss during FESS more efficiently, but may

not improve surgery field quality significantly. So, in case

of time restriction, a single dose of prednisolone before

operation may be useful for the reduction of bleeding

volume and the improvement of surgeon’s opinion. Also, it

has no side effect or complication.

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