Quality of surgical field during endoscopic sinus surgery: A systematic literature review of the effect of total intravenous compared to inhalational anesthesia

Background: Adequate surgical field visualization is imperative for successful outcomes in endoscopic sinus surgery (ESS). The type of anesthetic administered can alter a patient's hemodynamics and impact endoscopic visualization during surgery. We review the current evidence regarding the effect of total intravenous anesthesia (TIVA) compared to inhalational anesthesia (INA) on visualization of the surgical field during ESS. Methods: A systematic review of the literature was performed. Ovid MEDLINE, Scopus, and Cochrane databases were searched from 1946 to January 2012. Citations from the primary search were reviewed and filtered to identify all relevant abstracts in English. Articles meriting full review included prospective controlled trials enrolling adult patients undergoing ESS that were randomized to a group receiving INA or TIVA with outcome measures focused on surgical field visualization. Results: Seven eligible trials fulfilled inclusion criteria. Four of the 7 demonstrated a statistically significant improvement in surgical field grade during ESS when receiving TIVA compared with INA. However, detailed INA concentrations were often not provided. High levels of INA may have been administered; therefore, side effects of INA rather than effects of an ideal INA administration were possibly represented. Analgesic administration also varied widely among the anesthetic groups, further complicating interpretation of study results. The lack of power and the heterogeneity of the studies precluded a formal meta-analysis. Conclusion: Although several studies reported that TIVA improves surgical conditions in ESS, there are significant limitations. These findings prevent any definite recommendation at this point, emphasizing the need for further high-quality studies.