Management of Bleeding in Exclusive Endoscopic Ear Surgery: Pilot Clinical Experience

Abstract

Objective Transcanal exclusive endoscopic ear surgery requires the management of the endoscope and the surgical instruments in the external auditory canal. Bleeding in this narrow space is one of the most challenging issues, especially for novice endoscopic ear surgeons. We aim to assess the severity and occurrence of bleeding and describe strategies to control the bleeding during endoscopic ear surgery. We hypothesize that bleeding is reasonably controllable in endoscopic ear surgery. Study Design Case series with chart review. Setting Tertiary referral center. Subjects and Methods We retrospectively assessed 104 consecutive cases of exclusive endoscopic ear surgery at the University Hospital of Modena, Italy. The surgical videos and the patient charts were carefully investigated and analyzed. Results Hemostatic agents included injection of diluted epinephrine (1:200,000, 2% mepivacaine), cottonoids soaked with epinephrine (1:1000), mono- or bipolar cautery, washing with hydrogen peroxide, and self-suctioning instruments. The localization of bleeding in the external auditory canal was most frequently the posterior superior part, and inside of the middle ear, it was the pathology itself. Statistical analysis revealed significant differences comparing the mean arterial pressure and the type of intervention among bleeding scores. Conclusion The management of bleeding in endoscopic ear surgery is feasible through widely available hemostatic agents in reasonable frequency. This study gives an instructive overview on how to manage the bleeding in the exclusive endoscopic technique. Even the highest bleeding scores could be managed in an exclusively endoscopic technique.

Management of Jugular Bulb Injuries during Endoscopic Ear Surgery: Our Experience

“…Anschuetz et al published a description of their experience in the management of regular bleeding during TEES, but description of massive bleeding due to vascular injuries to JB has never been described. 10 Our experience shows that even massive bleeding coming from JB injuries can be managed by means of an exclusive endoscopic approach. As previously described in the results subheading, specific surgical maneuvers should be performed to progressively reduce the bleeding and, if possible, complete the surgical intervention (►Table 1).…”

Self-Expandable Retainer for Endoscopic Visualization in the External Auditory Canal: Proof of Concept in Human Cadavers

“…Bleeding in EES is a major concern for the operating surgeon because the non-dominant hand also must hold the endoscope. Techniques utilized to achieve hemostasis include diathermy probes (monopolar and bipolar) [11], diluted epinephrine injection, epinephrine-soaked cotton balls that can also be used as adjuncts for soft tissue dissection [18], and preoperative injection of tranexamic acid [12] which is an anti-fibrinolytic used in a variety of surgical procedures [19][20][21].…”

“…Because our study used cadavers, we could not assess the advantage of the SER with regard to bleeding. The most common site of bleeding is in the posterior and superior portion of the EAC [11], where the main vascular supply comes from the anterior tympanic and deep auricular branches of the internal maxillary artery, the superficial temporal artery, and the posterior auricular artery [22]. We hypothesize that the SER might reduce bleeding by protecting the EAC skin from trauma from sharp surgical instruments and also by pressing against the vascular structures and reducing blood flow by the outward expanding force of the SER putting pressure on the soft tissues of the EAC.…”

“…Because the space in the EAC and middle ear is limited, a clean surgical field is required to assure patient safety and benefit from the wide-angle vision offered by the endoscope [11]. The lens of the endoscope is easily smeared by the hair and earwax in the EAC and blood, however minimal, can obscure the view.…”

Era of Bloodless Surgery: Spotlights on Hemostasic Materials and Techniques

“…With evidence that epinephrine induces platelet aggregation, epinephrine also has a role as vasoconstrictive-hemostatic agent applied by injection at endoscopic surgery, tissue biopsies and surgeries in many fields [31,32]. But postoperative rebound hyperemia increasing the risk of blood loss and reduced vasoconstrictive effect with lidocaine administration is known as significant precautions [30].…”