TRIO Best Practice articles are brief, structured reviews designed to provide the busy clinician with a handy outline and reference for day-to-day clinical decision making. The ENTtoday summaries below include the Background and Best Practice sections of the original article. To view the complete Laryngoscope articles free of charge, visit Laryngoscope.
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July 2017Background
Adequate surgical visualization is paramount to safe and successful endoscopic sinus surgery (ESS). Minimizing bleeding facilitates identification of anatomical landmarks, ensuring a safer surgery. Topical vasoconstriction is a fundamental method for controlling intraoperative hemorrhage, and there are several different agents available for this purpose. Topical cocaine has traditionally been used by otolaryngologists and is particularly attractive given its unique dual local anesthetic and vasoconstrictive properties. A maximal safe dose of 200 mg, or 1.5 mg/kg to 3 mg/kg, of intranasal cocaine is widely published; however, this value is largely based on historical anecdote and untested clinical practice rather than rigorous scientific evidence. In recent years, the safety and role of cocaine in endoscopic sinus surgery has been questioned largely due to occasional case reports of adverse events (predominantly cardiac) and administrative control measures surrounding access and storages. Yet, other topical medication options lack the aforementioned dual properties of cocaine that made it ideal for sinus surgery in the first place. The question thus arises as to whether topical cocaine is still an appropriate and safe topical vasoconstrictor for continued routine use in modern ESS practice.
Best Practice
Although the potential toxicities and adverse reactions associated with cocaine topical application are well recognized, their incidences are extremely infrequent and apparently idiosyncratic in nature, whereas the benefits of cocaine are unique in terms of its singular ability to both vasoconstrict and anesthetize the nasal mucosa. Further higher level studies investigating the systemic absorption of topical cocaine, the actual incidence of directly attributable adverse effects, and its safety and utility in comparison to other topical vasoconstrictor agents should be conducted. Based on the available evidence, no specific recommendation for or against the use of cocaine during ESS can be made at this time, and surgeons can use their own judgment when weighing benefits versus risks of topical cocaine while also recognizing that there is no direct replacement for its useful unique characteristics. Consideration should be given to use of alternative topical vasoconstrictive agents such as oxymetazoline in patients with a strong history of comorbid cardiovascular risk factors (Laryngoscope. 2016;126:1721–1723).