Epinephrine Use in Endoscopic Ear Surgery: Quantitative Safety Assessment

Abstract

Introduction: The management of bleeding in exclusive endoscopic ear surgery (EES) is largely dependent on epinephrine use. However, to date its suitability and safety has not been assessed. The aim of the present study would be to assess the safety profile of topical application and/or local infiltration of diluted epinephrine during EES regarding the intra-and postoperative periods. We hypothesize that epinephrine may be safely used during EES.Methods: Retrospective analysis of 90 EES cases performed at the University Hospital of Modena, Italy. Patient's charts and video recordings of the operations were assessed.Results: Epinephrine was used in all cases for hemostatic purposes as following: (1) diluted epinephrine (1:200.000) injection: mean 1.2 mL (range: 0 -3.5) corresponding to 0.006 mg (range 0 -0.018) and (2) topical application (1:1000) directly in the surgical field: mean 7 cottonoids (range: 0 -18) corresponding to mean 0.56 mg (range: 0 -1.44). No major cardiovascular adverse effects were assessed. Only 2 intraoperative hypertensive events were recorded. One sensorineural hearing loss was observed in a case of cholesteatoma involving the stapes; no facial palsy occurred during the study period. Conclusion:The combined use of local injection and topical epinephrine is a safe and effective strategy to control bleeding in exclusive EES, when used within the dilutions and quantities reported in this study.

Minimally invasive tympanoplasty: review of outcomes and technical refinements

“…However, associated morbidity in terms of cosmetical outcome and postoperative pain as well as shorter surgical time argument in favor of the endoscopic technique. Initial concerns about bleeding control 14 and possible inner ear damage due to heat generation by the endoscope or one-handed manipulation of the ossicular chain could not be confirmed 15 . In particular, even in larger number of patients, the endoscopic approach has achieved low complication rates and is therefore a reliable minimally invasive therapeutic option for tympanoplasty 16 .…”

Efficacy of Topical Epinephrine in Tympanoplasty

“…Reports of serious and fatal events associated with correct use or inadvertent injection of TE are exceedingly rare. 21,[24][25][26][27][28][29][30] The true impact on patient safety is difficult to quantify as "no harm" or "near miss" events are not generally published. Most clinical series are far too small to capture such rare complications.…”

Learning curve for endoscopic tympanoplasty type I: comparison of endoscopic-native and microscopically-trained surgeons

“…Apart from the utility of otologic training models, it is important to remember that not all surgical steps can be properly practiced there. Especially onehanded bleeding control in endoscopic ear surgery, which is unusual for beginners, can be challenging, but is safe and allows sufficient hemostasis [16,17]. According to the literature further advantages of EES are the lack of retroauricular skin incision due to the transcanal endoscopic approach [13] as well as better postoperative health status and lower postoperative pain scores compared to microscopic tympanoplasty [18].…”

“…Apart from the utility of otologic training models, it is important to remember that not all surgical steps can be properly practiced there. Especially one-handed bleeding control in endoscopic ear surgery, which is unusual for beginners, can be challenging, but is safe and allows sufficient hemostasis [ 16 , 17 ].…”