Epidemiology of postoperative bleeding after endoscopic nasal and sinus surgery and factors associated with bleeding

Endoscopic nasal and sinus surgery is a surgical procedure frequently performed by otolaryngologists. Although safer and more effective techniques and innovations have been reported daily, it is difficult to reduce the number of adverse events caused by surgery to zero, and postoperative bleeding is detrimental to both healthcare providers and patients.

There are few reports on postoperative bleeding after endoscopic nasal and sinus surgery [1, 2], and the factors contributing to postoperative bleeding are still debatable. In addition, it is crucial to understand when postoperative bleeding is most likely to occur and the types of procedures that are most likely to cause postoperative bleeding to provide more appropriate medical care.

This study investigated the epidemiology of postoperative bleeding during endoscopic nasal and sinus surgery and explored possible bleeding triggers.

The frequency and typical timing of postoperative bleeding during various surgical procedures were determined. Although it is a rare and essentially nonfatal adverse event, efforts should be made to reduce postoperative bleeding to zero whenever possible. A previous study reported a postoperative bleeding frequency of 8.4%, which is generally similar to the results of the present study, but with no marked difference in bleeding frequency according to surgical technique [1]. This is because instruments and workmanship differ among facilities, even for the same surgical procedure with the same name.

PNN suppresses secretagogue motor and neurogenic inflammation by severing the parasympathetic and sensory nerve fibers [8]. Conventional practice is to sever the SPA and nerve fibers [9], but methods to preserve the SPA to control intraoperative bleeding have been reported [10]. Although some reports indicate that PNN is a complication-free technique [11, 12], postoperative bleeding occurs at a higher rate than in other endoscopic procedures, as shown in this study. Postoperative bleeding from the surgical site should be considered, especially when the SPA is spared, as blood flow to its branches is preserved. PNN is a common procedure in Japan and a good option for patients who do not show improvement with conservative treatment. However, it is important to keep in mind that there is a risk of postoperative bleeding, especially for patients who cannot tolerate this risk. In cases of EMMM, Nakayama et al. reported postoperative bleeding as a complication [5]. EMMM is a very effective technique for managing maxillary sinus lesions; however, postoperative bleeding can occur. In inferior turbinectomy, preservation of the mucosal epithelium prevents postoperative bleeding and crust adhesion [3]. Our department also performed surgery according to this method; however, sutures at the mucosal incision were omitted in cases that resulted in postoperative bleeding. Surgeons must acquire the skill to suture the nasal cavity properly and not skimp on the time and effort required to place sutures. Postoperative bleeding is reported to occur in 6% of patients who undergo FESS, and anticoagulant medications, hypertension, and high Lund–Mackay scores are significant risk factors [2]. Although these previous results differ somewhat from those of the present study, those studies did not examine the effect of postoperative antimicrobial use on postoperative hemorrhaging. Increased blood flow associated with postoperative infection may be a factor contributing to postoperative bleeding.

In animal experiments using rabbits, it was observed that the damaged nasal mucosa showed inflammatory cell infiltration after roughly 1 week, and epithelialization was completed in 1 month [13]. Most postoperative bleeding occurred within 1 week after surgery, suggesting that problems in the wound healing process were a factor in bleeding. Wound infections may cause bleeding, as bleeding was observed at a significant frequency in patients who did not receive postoperative oral antimicrobial administration. In addition to local treatment, such as cleaning and rinsing after surgery, antimicrobial administration may reduce postoperative bleeding. Prospective studies on septoplasty have reported that antimicrobial administration is unnecessary [14]. However, as the present study revealed that septoplasty is not prone to postoperative bleeding, it is necessary to examine various procedures to determine whether or not antimicrobials should be administered after endoscopic nasal and sinus surgery.

Several limitations associated with the present study warrant mention. First, the patient population in this study included those who visited a hospital in a specific region of Japan. Therefore, the results of this study may differ across different areas and periods. Second, only univariate statistical analysis was performed because of the sample size. However, postoperative bleeding is a rare complication, this problem cannot be easily resolved. This study is valuable for informing surgeons about the types of procedures prone to postoperative bleeding and when they are most likely to occur.

Postoperative bleeding requiring intervention occurs in 4.8% of cases, and PNN is associated with a high risk of postoperative bleeding. Wound infection is a potential cause of postoperative bleeding, and antimicrobial administration should be considered in addition to local treatment.