To that end, multiple means for hemostasis in ESS have been proposed and popularized, including the use of total intravenous anesthesia, head of bed elevation or reverse Trendelenberg positioning, mucosal infiltration with dilute epinephrine, and topical application of vasoconstrictors. The most commonly used topical vasoconstrictors include cocaine, oxymetazoline, and epinephrine, with oxymetazoline having the most well-studied safety profile. The use of concentrated topical epinephrine (1:1,000) has been shown to be highly effective in controlling mucosal bleeding across large surface areas within the operative field, and is thought to provide even more hemostasis than oxymetazoline. However, questions arise regarding the safety profile of such potent vasoconstriction and possible systemic effects, especially in light of patients with preexisting cardiovascular comorbidities. Here, we examine the literature regarding the safety profile of topical epinephrine in ESS.
Topical epinephrine is generally safe for use in ESS, with caution in adult patients with cardiovascular comorbidities (see Table 1). There are limited data regarding its safety in pediatric patients, and thus, no recommendation could be made based on the literature review. Of the above studies that provided retrospective data and review of complications, there were only two transient and reversible cardiovascular events out of 4,398 unique cases (0.05% complication rate). However, it is critically important for all members of the operating room to correctly identify both concentrated and dilute forms of epinephrine, as injection of concentrated epinephrine may likely lead to devastating consequences. It is also recommended to thoroughly wring out pledgets before use, as inadvertent application to upper airway mucosa may lead to increased systemic effects. Open communication with the anesthesia staff when administering topical epinephrine is important (Laryngoscope. 2019;129:1–3).