Reduction of Bleeding From Pterygopalatal Injection: A Systematic Review and Meta-Analysis.

Importance: Endoscopic sinus surgery (ESS) is a minimally invasive surgical method that is widely used in the treatment of various sinonasal conditions, including chronic sinusitis, nasal polyps, and fungal sinusitis. However, intraoperative bleeding remains a significant challenge.

Objective: To evaluate the effects of pterygopalatal injections with lidocaine and adrenaline during sinus surgery.

Data sources: PubMed/MEDLINE, the Cochrane Library, and EMBASE were systematically searched from database inception through July 31, 2024. Two authors also manually and independently searched all relevant studies.

Study selection: Randomized clinical trials with (1) patients diagnosed with sinusitis; (2) interventions that included pterygopalatal injections with lidocaine and adrenaline; (3) comparisons that were specified as normal saline or no injection; and (4) outcomes that used subjective scores (Boezaart surgical field grading [BSFG]) and objective markers (amount of bleeding, duration of surgery, and mean arterial pressure [MAP]).

Data extraction and synthesis: Data extraction was completed independently by 2 extractors and cross-checked for research integrity. The pairwise meta-analysis was performed to compare the treatment group with control used in ESS. Hedges g standardized mean differences (SMDs) and mean differences (MDs) were used for improvement in all outcomes.

Main outcomes and measures: Efficacy outcomes included subjective scores, such as BSFG, as well as objective markers measuring amount of bleeding, duration of surgery, and MAP.

Results: A comprehensive literature search identified 322 patients from 7 studies. The studies were conducted in Australia, Canada, Egypt, India, and Iran. The mean age range was 30 to 48.8 years, and 36.7% to 66.7% of the study populations were male. In most studies, the observation time of BSFG was measured at 15-minute intervals and measured from a minimum of 15 minutes to a maximum of 150 minutes. The pooled SMD for BSFG between treatments vs the control group was -1.01 (95% CI, -1.72 to -0.30), indicating that pterygopalatal injection with lidocaine and adrenaline was associated with improvement in the surgical field condition. The pooled MD for MAP between treatments vs the control group was -0.49 mm Hg (95% CI, -0.91 to -0.07), indicating that pterygopalatal injection was associated with significantly reduced MAP. The pooled MD for amount of bleeding between treatments vs the control group was -9.47 mL (95% CI, -29.05 to 10.11), and the pooled MD for duration of surgery between treatments vs the control group was -4.28 minutes (95% CI, -12.85 to 4.29), indicating that that this technique was not significantly associated with amount of bleeding or duration of surgery.

Conclusions and relevance: The findings of this systematic review and meta-analysis indicate that pterygopalatal injection can be an effective method for reducing BSFG during ESS to improve the surgical field. This can be achieved by significantly improving the surgical field of view and lowering MAP.