Total intravenous anesthesia improves intraoperative visualization during surgery for high‐grade chronic rhinosinusitis: a double‐blind randomized controlled trial

Background Total intravenous anesthesia (TIVA) has been proposed as a method to reduce blood loss during endoscopic sinus surgery (ESS). Impaired sinonasal visualization due to mucosal bleeding may be burdensome in cases of chronic rhinosinusitis (CRS) with high‐grade inflammatory disease, suggesting a role for TIVA in that disease subgroup. Methods A double‐blind, randomized controlled trial was conducted of adults undergoing ESS at a tertiary medical center. Patients considered for inclusion had high‐grade CRS defined as either sinonasal polyposis or a preoperative Lund‐Mackay score of ≥12. Subjects were randomized to receive either TIVA or inhaled anesthesia (IA) during ESS. The primary outcome measure was intraoperative visibility as rated by 3 blinded reviewers utilizing the 10‐point Wormald Surgical Field Grading Scale. Secondary outcomes included operative blood loss, complications, and change in quality of life evaluated by the 22‐item Sino‐Nasal Outcome Test (SNOT‐22). Results A total of 72 patients were randomized into TIVA (n = 37) and IA (n = 35) study arms. Aggregate median (interquartile range) Wormald scores across all reviewers demonstrated a more favorable visual field with TIVA compared to IA (3.5 [2.4‐3.9] vs IA 4.1[3.0‐5.8], p = 0.0089). There was significantly less blood loss in the TIVA group compared to the IA group (200 mL [100‐450] vs 300 mL [200‐500], p = 0.046). Baseline patient characteristics were comparable between cohorts with no significant postoperative complications. No significant changes were detected between postoperative SNOT‐22 scores at 3 months (p = 0.278) and at 6 months (p = 0.396) following ESS. Conclusion TIVA contributes to improved intraoperative visualization and decreased blood loss in patients undergoing ESS for high‐grade inflammatory sinus disease.