A narrative review of anesthetics in rhinology

Introduction

Background

Anesthesia plays a vital role in otolaryngology by providing sedation, pain management, and immobility, all of which are critical for enhancing surgical outcomes and patient experiences. Otolaryngologic procedures, especially those involving the sinonasal cavity, pose unique anesthetic challenges due to frequent airway obstruction caused by the pathology necessitating these surgeries and the high vascularity of the anatomical structures (1). Effective anesthesia management is essential for these procedures, as it facilitates a controlled and safe surgical environment. Hypotensive anesthesia, a method of cardiovascular output reduction, and topical vasoconstriction are particularly important in creating a bloodless surgical field in many rhinological surgeries (2). Additionally, there is a growing trend toward performing office based procedures, contingent on the type of procedure, patient selection, facility resources, and the training of the otolaryngologist (3). Effective pain management remains a cornerstone of these procedures, ensuring minimal discomfort and promoting quicker recovery for patients.

Rationale and knowledge gap

Despite the numerous anesthetic techniques described for various sinonasal procedures, there is a lack of resources that consolidate best practices across the literature for these procedures. The evolution of anesthetic techniques over the past few decades, driven by advances in surgical procedures and new anesthetic discoveries, highlights the need to identify and document general trends and enduring practices that improve surgical outcomes and patient experiences. The absence of an integrated reference detailing these techniques and their efficacy presents a knowledge gap that this review aims to address.

Objective

This narrative review aims to examine common anesthesia techniques, their mechanisms of action, and best anesthesia practices for sinus and rhinology procedures. By consolidating current knowledge and practice trends, this review intends to provide valuable insights for otolaryngologists and anesthesiologists. These findings could inform clinical decision-making on the selection of anesthetic techniques and provide valuable insights for residency programs on which anesthetic training to emphasize for otolaryngology and anesthesiology residents. We present this article in accordance with the Narrative Review reporting checklist (available at https://joma.amegroups.com/article/view/10.21037/joma-24-20/rc).

Methods

In July 2024, the authors performed a focused literature search through PubMed, Google Scholar, ClinicalKey, the Kaiser Permanente online library, Wiley, UpToDate, and Cochrane for articles published from January 1986 to June 2024 related to anesthetic management techniques and mechanisms for rhinological procedures. The search terms included key terms as shown in Table 1. Articles selected included randomized control trials, meta-analyses, scoping reviews, cohort studies, and institutional standard practices. Inclusion criteria were studies published in English, availability of literature online, and relevance to the review’s scope. The selection process was independently undertaken by the first author (K.B.). Titles and abstracts were initially screened for relevance, followed by a thorough review of selected articles.

Section 1: analgesics in sinus and rhinology

Local anesthetics

In sinonasal and rhinologic surgeries, the choice between local anesthesia (LA) and general anesthesia (GA) can impact patient outcome and surgical efficacy. LA has become the preferred option in less complex surgeries or those where either LA or GA could be suitably employed due to their advantages over GA such as targeted action, reduced systemic effects, and shorter recovery times (4). Unlike GA, which induces a state of unconsciousness and requires more extensive postoperative monitoring, LA provides effective pain control while allowing patients to remain awake and responsive. This approach minimizes certain risks associated with GA, such as respiratory complications and cardiovascular instability, making it particularly advantageous for certain sinonasal and rhinologic procedures, like those employed in outpatient surgeries such as balloon catheter dilation, traditional functional endoscopic sinus surgery (FESS), polypectomy, and ethmoidectomy (5).

Preference for LA in these surgeries is further supported by its ability to reduce intraoperative bleeding (6). This is crucial in the highly vascularized sinonasal region, where excessive bleeding can obscure the surgical field and prolong operative times. The vasoconstrictive properties of certain LA, such as those combined with epinephrine, help to minimize blood loss and improve surgical visibility, contributing to more precise and efficient procedures (7,8).

Additionally, LA facilitates quicker postoperative recovery, allowing patients to resume normal activities sooner (9). This is particularly beneficial in outpatient settings, where minimizing hospital stay and associated healthcare cost is a priority. Despite these advantages, anesthetic choice must be tailored to each patient’s needs and specific surgical requirements, with key consideration being the patient’s preference for sedation and the underlying pathology (5). Thus, balancing patient comfort and procedural complexity are important in determining the use of either LA or GA.

Types and mechanisms

LA serves as a cornerstone in sinonasal and rhinologic surgery, providing a reversible blockade of nerve generation or conduction that results in a localized loss of sensation. The mechanism of action for LA involves the inhibition of ionic influxes necessary for the propagation of neural impulses. This interruption in nerve signal transmission is achieved through compounds that, despite varying durations of action, consistently result in spontaneous, predictable, and complete recovery (10).

LA can be classified into two main types: amino amides and amino esters. The discovery of lidocaine in 1948 (11) was a key advancement because amino amides are more stable and less likely to trigger allergic reactions compared to amino esters (12). This led to the development of widely used amino amides such as mepivacaine, bupivacaine, and ropivacaine. LA works by reducing the number of voltage-gated sodium channels available to open, thereby preventing nerve conduction, resulting in localized anesthesia (13). Factors like pKa and hydrophobicity influence the rate of onset and potency of LA. Agents with lower pKa values and higher hydrophobicity penetrate nerve membranes more effectively, leading to faster, stronger, and longer-lasting anesthetic effects, though at the cost of increased toxicity (14-16).

Epinephrine is a common additive to LA and acts as a local vasoconstrictor, which slows the rate of tissue absorption of the anesthetic and decreases the peak systemic concentration, thereby lowering the risk of systemic toxicity (17). Additionally, the vasoconstrictive properties of epinephrine help to prolong the duration of anesthesia and reduce intraoperative bleeding, which is particularly beneficial in the highly vascularized tissues of the sinonasal region (18,19).

Clinical applications

LA is integral to sinus and rhinologic surgeries, providing both intraoperative and postoperative analgesia. When selecting LA, it’s important to consider its pharmacologic properties such as rate of onset, maximum dosage, and duration of effect.

In these procedures, effective pain management and reducing bleeding are essential. The anterior ethmoidal and sphenopalatine branches of the trigeminal nerve provide sensory innervation to the nasal septum and lateral walls. Topical anesthesia, often combined with a vasoconstrictor, is frequently employed to manage this area (1). These nerve branches can be effectively anesthetized using a mixture of LA and vasoconstrictors to achieve optimal analgesia and minimize bleeding.

Regional nerve blocks are another technique employed in sinus and rhinologic surgeries. These blocks not only provide effective pain relief but also induce vasoconstriction, which improves the surgical field. For instance, the anterior ethmoidal nerve can be blocked by endonasal infiltration of the middle turbinate and the infraorbital nerve can be blocked intraorally or transnasally with a local anesthetic (20). An injection into the pterygopalatine fossa via the greater palatine canal with a local anesthetic and epinephrine induces vasoconstriction of the sphenopalatine artery, optimizing the surgical field and producing analgesia in the V2 distribution (21).

Cocaine, while unique among local anesthetics for its vasoconstrictive properties, is generally not recommended for certain procedures due to the availability of safer alternatives (22). Phenylephrine and oxymetazoline, for example, are effective topical vasoconstrictors that provide an optimal surgical field without many of the adverse cardiotoxic effects associated with cocaine and epinephrine (21,23). These drugs, which have predominant alpha-1 agonist action, are also safe for use in pediatric populations (24).

Despite the widespread use of LA in sinus and rhinological surgeries, there is considerable heterogeneity amongst studies regarding specific preparations, concentrations, modes of application, and endoscopic stimuli. This variability makes it challenging to draw definitive conclusions about the efficacy of different anesthetic regimens (22). Therefore, further research is needed to standardize these factors and optimize the use of LA in these procedures. GA is used far more frequently in certain sinus and rhinology surgeries such as FESS, especially in more complex cases where LA is not appropriate for patient safety and best outcome. However, if a patient is motivated, and overall disease burden limited, LA provides a good alternative to GA for lower risk cases with no difference in postoperative pain nausea, vomiting, and overall tolerance of FESS (25).

Efficacy and safety

The efficacy and safety of LA in sinonasal and rhinological surgeries is well-documented (26). LA are chosen based on several pharmacologic properties, such as rate of onset, maximum dosage, and duration of effect, with lidocaine (an amide) and tetracaine (an ester) being commonly used. These anesthetics provide effective anesthesia while minimizing systemic side effects, which are generally rare when used appropriately. Potential adverse reactions include local irritation, allergic responses, and systemic toxicity, particularly with higher doses or prolonged use.

A retrospective study that followed nearly 200 patients one year after sinonasal surgery, including FESS or septoplasty, found that LA with sedation may lead to shorter total operative times, quicker recovery, and less frequent occurrences of nausea, emesis, and epistaxis compared to GA (4). All hospital admissions were in the GA group, with complications such as epistaxis, nausea, and vomiting occurring at a statistically higher rate in the GA group. However, surgical times were statistically similar between local anesthetic with sedation and GA groups.

In FESS, the combination of LA with monitored anesthesia care compared to GA proved to optimize surgical and postoperative outcomes, raise satisfaction for surgeons and patients, and lower overall costs associated with the surgery (27). Additionally, the inclusion of LA in nasal packs following septal surgery has been shown to reduce postoperative pain within the first 12 hours compared to nasal packing with a placebo, though the benefits 24 hours and beyond remain unclear (28).

Overall, the use of LA in sinonasal and rhinologic surgeries offers several advantages, including shorter operative and recovery times, fewer complications, and lower costs compared to GA. These findings underscore the efficacy and safety of LA, making them a valuable option for anesthesia in these procedures.

General anesthetics

In rhinologic surgeries, GA is often preferred over LA due to its comprehensive benefits in managing patient comfort and surgical conditions. GA, a drug-induced and reversible condition, induces unconsciousness, antinociception, and immobility, ensuring that patients remain unaware and free from pain throughout surgery (29). This is particularly crucial in complex or long surgeries where complete patient stillness and optimal operating conditions are required.

Compared to LA, GA provides several unique advantages. It ensures amnesia, eliminating any memory of the surgical experience, which in many surgeries is optimal for patient comfort and psychological well-being. Additionally, GA protects the patient’s airway, maintains adequate gas exchange, and abolishes patient movement, all of which are critical for the safety and success of intricate sinonasal and rhinological procedures (30). These factors collectively create a controlled and safe surgical environment, reducing the risk of complications associated with patient movement or airway management issues.

Balanced GA, which involves the use of multiple anesthetic techniques, is a common strategy employed to avoid sole reliance on any single anesthetic agent. This approach helps mitigate the side effects associated with large doses of individual drugs and enhances the overall safety and efficacy of anesthesia (31,32). Most anesthetic drug classes exhibit synergistic effects, with inhaled anesthetics (IAs) typically enhancing the effects of intravenous anesthetics, except for specific combinations like nitrous oxide and isoflurane, where the effects are additive (33). This synergistic action allows for lower doses of each drug, minimizing potential side effects and optimizing patient outcomes.

Types and mechanisms

Balanced GA typically involves a combination of a hypnotic agent like propofol for induction, followed by maintenance with an IA or continuous hypnotic infusion (34). Propofol, a global central nervous system depressant, is a widely used total intravenous anesthetic (TIVA) due to its rapid onset and reversible effects, making it ideal for inducing anesthesia quickly (35). Acting as a gamma-aminobutyric_A (GABA_A) acid receptor agonist and N-methyl-D-aspartate (NMDA) receptor antagonist, propofol enhances inhibitory neurotransmission and inhibits excitatory signals, leading to anesthesia (36-40). This is especially crucial in delicate procedures like sinonasal surgeries, where precise control over the patient’s consciousness is necessary.

IAs such as nitrous oxide, isoflurane, and sevoflurane maintain anesthesia by modulating ion channels, including GABA receptors and potassium channels, thereby depressing neurotransmission and sustaining sedation throughout the procedure (41). These agents, used in combination with TIVA hypnotics, ensure the patient remains unconscious for the duration of the surgery.

Muscle relaxants like succinylcholine are commonly used to achieve immobility during surgery. Succinylcholine, a depolarizing neuromuscular blocker, induces rapid depolarization of motor endplates, resulting in muscle paralysis (42,43). Additionally, antinociception, or the prevention of pain-induced arousal, is managed primarily with opioids such as fentanyl and remifentanil, which modulate nociceptive transmission through opioid receptor pathways. Other agents like ketamine and non-steroidal anti-inflammatory medications may also contribute to pain control by targeting various nociceptive mechanisms (34,44).

Clinical applications

GA is often preferred in rhinologic surgeries due to its ability to provide a controlled and safe environment, especially for more complex and invasive procedures. Surgeries such as septoplasty and FESS frequently require GA. This preference is driven by the need for patient immobility, amnesia, and airway protection during these more intricate and lengthy procedures.

Although some studies have shown a trend toward better outcomes with GA in surgeries where either LA or GA is a viable option, LA offers greater safety, lower cost, reduced hospital resource utilization, and shorter hospital stays (45). But, despite these advantages, GA remains the most common and physician preferred choice for most sinus and rhinologic surgeries, especially more difficult cases due to its ability to provide a controlled and comfortable surgical experience.

Efficacy and safety

The efficacy and safety of GA in sinonasal surgeries are supported by several important considerations and findings. In terms of comparative efficacy, GA is often chosen for its comprehensive management capabilities in various surgical scenarios. It is particularly beneficial for managing patient anxiety, and lengthy surgical procedures (25).

Within GA, preoperative administration of acetaminophen and the intraoperative use of remifentanil in FESS were shown to significantly improve anesthesia recovery outcomes, measured as reduced recovery times and lower incidences of severe pain, respiratory depression, oversedation, and the need for rescue opioids (46).

The safety profiles of GA highlights its ability to provide controlled and comfortable surgical experiences. As documented in the balanced approach of GA, the use of multiple antinociceptive agents, in conjunction with opioids, allows for a more complete antinociceptive effect. This multimodal approach reduces the reliance on opioids and minimizes the required doses, thereby decreasing the risk of opioid-related side effects and promoting a safer anesthetic regimen (34).

Overall, the selection of GA for sinonasal surgeries is often driven by the need for thorough patient management and the ability to tailor anesthetic plans to specific clinical needs, ensuring both efficacy and safety in surgical outcomes.

Intravenous vs. inhaled general anesthetics

In sinus and rhinological surgeries, the choice between TIVA and IA can significantly impact surgical outcomes, particularly regarding blood loss and surgical field visibility. The sinonasal mucosa is highly vascularized, making surgeries in this region prone to significant blood loss, which can obstruct the surgical field. Therefore, strategies to minimize bleeding are crucial for these procedures. Unlike IAs, which relax precapillary sphincters in the mucosa and increase blood flow to surgical fields, TIVA depresses central sympathetic tone without directly affecting peripheral vasculature (47). This allows local and topical adrenergic medications to maintain precapillary sphincter tone and decrease blood flow to the surgical field.

FESS has become the standard approach for addressing various paranasal sinus and anterior skull base conditions. During FESS, maintaining a clear surgical field is paramount. TIVA has been shown to better achieve hypotensive anesthesia compared to traditional IAs, which is critical for reducing blood loss and improving surgical visibility in sinus and rhinological surgeries due to the highly vascularized nature of the anatomy and high risk for bleeding (48,49). A meta-analysis revealed that while there was no difference between IA and TIVA in terms of anesthesia time or heart rate for FESS, TIVA significantly improved surgical visibility, reduced estimated blood loss, and shortened operative time (50). While the meta-analysis showed the mean arterial pressure was slightly higher in TIVA compared to IA, the difference was clinically negligible (1.9 mmHg).

A prospective study found that TIVA using propofol was associated with better recovery quality and less blood loss compared to IA using desflurane, though the TIVA group experienced higher rates of intraoperative remifentanil consumption (51). A meta-analysis of randomized controlled trials (RCTs) demonstrated that TIVA significantly improved visibility scores and reduced blood loss compared to IA, with no significant differences in intraoperative heart rate or mean arterial pressure. The duration of surgery and anesthesia was comparable between the two (52). TIVA may make FESS safer and more effective; however, it is difficult to determine because of the lack of standardization across studies and little reporting of preoperative confounding variables and validating outcomes (53).

On the other hand, IAs offer advantages over TIVA in several aspects. IAs are easier to monitor and regulate, provide cardioprotective benefits that are particularly advantageous in surgeries where reducing cardiac output is beneficial, and are associated with earlier extubation times, facilitating a faster postoperative recovery (54,55). Additionally, IAs are easier to administer, provide a reliable blockade of sensory input, and act as a bronchodilator (56). The deeper level of anesthesia associated with TIVA can delay postoperative emergence and potentially hinder its suitability for outpatient surgeries. Additional disadvantages of TIVA are that it is painful upon administration and can lead to reductions in blood pressure and cardiac output, which may be undesirable in certain surgical procedures (57).

While the rates of TIVA and IA use has not been documented over time, A 2019 survey of anesthetic techniques for ESS surgery across three tertiary academic centers in the United States found that many anesthesia providers were unaware of the benefits of TIVA compared to IA and often did not factor surgical field optimization in determining anesthetic technique and used TIVA approximately 60% of the time in ESS surgeries (58). Moreover, the COVID-19 pandemic prompted GA technique evaluation which found that TIVA reduced upper airway activity and decreased infectious respiratory spread (59). With increasing education of TIVA benefits in rhinological surgeries and reducing respiratory infectious disease spread, TIVA would be expected to increase in rhinological surgery usage. Overall, while both TIVA and IA have their advantages, TIVA is often favored in many sinonasal surgeries, like FESS, due to its significant improvements in intraoperative surgical field visibility and reduction in blood loss, contributing to safer and more effective surgeries.

Section 2: common anesthetic protocols in specific sinus and rhinology surgeries

FESS

FESS is recognized as the gold standard for the surgical treatment of chronic rhinosinusitis and has expanded to address various other pathologies, including sinus tumors, skull base defects, and pituitary tumors (60). Initially, FESS procedures were commonly performed under LA. However, as the complexity of FESS has increased, GA has become the preferred approach for most surgeries due to its improved overall safety and reduced rates of operative and major complications (61,62).

Studies demonstrated that hemostasis during FESS is optimized using TIVA with propofol, often in combination with adjunct anesthetics such as remifentanil and lidocaine, as well as preoperative steroids and topical LA (63-68). Propofol-based TIVA in FESS offers several benefits, including faster emergence from anesthesia and a reduced risk of prolonged extubation when compared with desflurane IA (69). Additionally, it has been shown that dexmedetomidine infusion or desmopressin nasal spray administered prior to induction significantly reduces bleeding when used in a propofol and remifentanil-based anesthesia regimen for FESS (70-72).

While propofol-based TIVA is often the optimal anesthetic technique in FESS surgeries, some studies show that IA with agents like nitrous oxide and isoflurane provide similar intraoperative and postoperative conditions to TIVA in FESS (73,74). In cases where propofol is unavailable or contraindicated, alternatives such as nitrous oxide, isoflurane, and other IA like desflurane and dexmedetomidine are effective and do not compromise hemostasis, extubation time, or recovery time (75,76).

Overall, the evolution of anesthesia techniques for FESS has led to significant improvements in surgical outcomes, with TIVA and propofol-based regimens being particularly effective in managing the complex requirements of these procedures. The choice of anesthetic technique can greatly influence the surgical field visibility, bleeding control, and recovery parameters, ultimately enhancing patient safety and procedural efficacy.

Septoplasty and rhinoplasty

Septoplasty is one of the most commonly performed otolaryngologic surgeries, typically indicated for septal deviation that impairs nasal airway flow (77). Rhinoplasty, on the other hand, is performed for cosmetic or reconstructive purposes to change the appearance of the nose. Both procedures can be carried out under GA or LA, though GA and deep sedation are often preferred (78,79). However, LA for select patients shows promising results due to its advantages over GA, such as fast recovery, smooth postoperative course, shorter medical procedure, and avoidance of potential side effects of GA (80-84). Despite these benefits, there is a trend of patients preferring GA to LA (85).

For septoplasties and rhinoplasties where LA with sedation is deemed the best method, the procedure typically involves applying a vasoconstrictor like phenylephrine or oxymetazoline, followed by packing the nose with gauze soaked in LA (84). This is supplemented with a submucosal injection of LA, usually 1% lidocaine with epinephrine, followed by propofol infusion for the remainder of the procedure. In the context of GA, continuous intravenous propofol with alfentanil or remifentanil is used, which allows for reduced use of volatile anesthesia and improved hemodynamic stability. Additionally, while preoperative analgesics are thought to decrease postoperative pain in septoplasty under GA, research shows that local administration of lidocaine compared to a placebo saline injection does not significantly reduce pain and therefore may not be necessary (86).

When using LA for septoplasty, lidocaine is commonly employed, though some evidence suggests that articaine results in fewer postoperative complications and less postoperative pain compared to lidocaine (87). Additionally, in comparative studies involving other surgical procedures, articaine has been shown to be a more effective LA than lidocaine (88,89). Additionally, intravenous steroid administration, such as dexamethasone, at the induction of anesthesia for septoplasty has been shown to decrease pain, postoperative nausea, and vomiting (90).

For postoperative pain relief and maintenance of hemodynamics during septoplasty, dexmedetomidine and lidocaine outperform fentanyl and also exhibit lower postoperative nausea and vomiting (91,92). In rhinoplasty, pre-induction administration of dexmedetomidine is associated with more stable hemodynamics, while remifentanil prior to induction leads to greater pain relief and patient satisfaction (93).

In patients who underwent septoplasty or rhinoplasty secondary to nasal bone fractures, better outcomes were observed under GA than LA, including higher patient satisfaction, improved nasal appearance and function, and a reduced number of subsequent corrective surgeries (45,94). These findings highlight the importance of tailored anesthetic approaches in septoplasty and rhinoplasty and understanding the evolution of anesthetic techniques to optimize outcomes and patient satisfaction.

Balloon sinuplasty

Balloon sinuplasty is a minimally invasive procedure designed to treat chronic rhinosinusitis by inserting a balloon into the sinus and dilating it to improve drainage. In comparisons of surgeries where both FESS and balloon sinuplasty can be performed, balloon sinuplasty offers several advantages including faster recovery time, greater potential for in-office procedures with LA, and lower adhesion formation (95,96). Despite these benefits, both procedures demonstrate comparable operation times, anesthesia methods, and low complication rates.

LA is a safe and effective alternative to GA for balloon sinuplasty (97). The preference for local and topical anesthesia over GA in balloon sinuplasty is driven by several factors including reduced total operation time, faster anesthesia recovery, higher patient satisfaction, and lower overall costs (98). These benefits make LA an appealing choice for both patients and healthcare providers.

The process of administering LA in balloon sinuplasty typically involves the application of a topical nasal vasoconstrictor, commonly oxymetazoline. Following this, a local anesthetic, such as lidocaine with or without epinephrine, is injected to ensure adequate pain control and minimize bleeding (99). This approach not only provides effective anesthesia but also maintains a clear surgical field, which is crucial for the success of the procedure.

In summary, the use of LA in balloon sinuplasty offers numerous advantages, including reduced recovery times and costs, while maintaining patient satisfaction and procedural efficacy. This makes it a preferable option for many patients undergoing treatment for chronic rhinosinusitis.

Endoscopic skull base surgery (ESBS)

ESBS is a minimally invasive technique employed to address various conditions at the base of the skull, such as pituitary surgery and cerebrospinal fluid leak repair (100). Initially, LA was utilized for these procedures; however, GA has become the preferred method due to the complexity and longer duration of most ESBS surgeries (101,102). GA provides a more controlled and stable environment, crucial for the intricate and prolonged nature of these operations.

In contemporary practice, GA for ESBS typically involves a mixed approach of TIVA with propofol and IA (101,102). This combination is often paired with analgesics like fentanyl or remifentanil and muscle relaxants such as succinylcholine or nondepolarizing agents. This multimodal approach helps achieve adequate anesthesia depth, optimal pain control, and muscle relaxation, ensuring a stable surgical field and patient immobility. The preparation for ESBS includes several steps to minimize intraoperative bleeding and enhance surgical visibility (103).

The shift from LA to GA in ESBS reflects the need for more comprehensive anesthesia management due to the intricate and extended nature of these procedures. The use of IAs with IV propofol, coupled with potent analgesics and muscle relaxants, provides a balanced and effective anesthetic plan that enhances patient safety and surgical outcomes.

Limitations

This review draws on multiple research databases and incorporates a range of study types, including RCTs, meta-analyses, scoping reviews, cohort studies, and institutional standard practices, to identify evidence-based anesthesia techniques for rhinological surgeries. However, it does not encompass all existing literature on the subject. The articles included in this review were independently selected by the first author and only those available in English were included which may introduce potential bias to this review. Moreover, further research is necessary to explore the efficacy of specific anesthetics within the LA and GA categories for other sinonasal surgeries as well as for the indications described in this review. This includes procedures like turbinate reduction surgery, where the existing literature is insufficient for recommendations in this review. Expanding this research could standardize anesthetic practices and improve patient outcomes across a wider range of sinus and rhinology procedures.

Conclusions

The choice of anesthesia in rhinologic surgeries varies significantly depending on the complexity and duration of the procedure. For instance, balloon sinuplasty, often performed under LA, offers advantages such as reduced operation time, faster recovery, and lower costs. In contrast, more complex surgeries like ESBS require GA due to their longer duration and greater need for patient and surgical control. LA is particularly beneficial for simpler and shorter procedures and for patients who are comfortable with such techniques, while GA, especially in the form of TIVA, is preferred for its ability to provide comprehensive sedation, controlled hypotension, and improved surgical conditions. The decision between LA and GA should be a collaborative one between the otorhinolaryngologist, anesthesiologist and patient, focusing on patient safety and optimal outcomes.

In cases where both LA and GA are viable options, LA may be favored due to its benefits, including quicker recovery and fewer systemic effects. Training programs should emphasize the importance of LA in appropriate scenarios, ensuring otorhinolaryngologists are well-prepared to utilize it effectively. While opioids remain a powerful option for anesthesia, alternative anesthetics that reduce addiction risks, such as dexmedetomidine, should be considered.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://joma.amegroups.com/article/view/10.21037/joma-24-20/rc

Peer Review File: Available at https://joma.amegroups.com/article/view/10.21037/joma-24-20/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://joma.amegroups.com/article/view/10.21037/joma-24-20/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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