Functional endoscopic sinus surgery (FESS) is an established surgical treatment for chronic rhinosinusitis, with or without nasal polyposis, particularly in patients who remain symptomatic despite appropriate medical therapy. Although advances in endoscopic visualization, instrumentation and image-guided surgery have improved the precision of FESS, intraoperative bleeding continues to be an important challenge. Even relatively small amounts of blood can obscure the narrow endoscopic surgical field, reduce visualization of important anatomical landmarks and increase the difficulty of identifying structures adjacent to the orbit and skull base. Consequently, effective hemostasis is essential not only for reducing blood loss but also for improving surgical field quality, shortening operative time and facilitating safe dissection. Several strategies have been used to minimize bleeding during FESS. These include appropriate patient positioning, controlled hypotension, optimization of anaesthetic technique, topical vasoconstrictors and systemic or topical pharmacological agents. Controlled hypotension remains an important anaesthetic approach, and agents such as dexmedetomidine, beta-blockers and other hypotensive drugs have been evaluated. A randomized study comparing dexmedetomidine and labetalol demonstrated that both could provide controlled hypotension, while dexmedetomidine produced favourable surgical field conditions [1]. Similarly, dexmedetomidine has been reported to provide better surgical field visibility and lower blood loss than metoprolol-based premedication, although adverse effects and hemodynamic consequences require consideration [2]. Antifibrinolytic therapy, particularly tranexamic acid (TXA), has gained increasing attention as an adjunct for hemostasis during endoscopic sinus surgery. A randomized trial of topical TXA demonstrated its safety, although improvement in surgical field quality was limited to certain intraoperative time points [3]. Intranasal desmopressin has also been evaluated, with higher-dose administration producing a reduction in blood loss compared with placebo, suggesting another potential pharmacological approach to improving intraoperative hemostasis [4]. Recent evidence has strengthened the role of TXA in FESS. A systematic review and meta-analysis by Abdallah et al. demonstrated that both systemic and topical TXA significantly reduced intraoperative blood loss and improved surgical field quality [5]. Comparative clinical evidence has also suggested differences between TXA and dexmedetomidine in their effects on bleeding and operative conditions [6]. Nevertheless, perioperative optimization is multifactorial, involving anaesthetic technique, arterial pressure, heart rate, patient positioning and pharmacological interventions, and no single measure can completely eliminate intraoperative bleeding [7]. More recent meta-analytic evidence also supports perioperative lidocaine infusion as a potential method for improving surgical field quality and reducing intraoperative blood loss [8]. Despite numerous available approaches, considerable variation remains in hemostatic practice during FESS, and direct comparisons between strategies are limited. Differences in drug selection, route of administration, dosing, patient characteristics and methods used to grade the surgical field make it difficult to identify a universally optimal approach. Therefore, the present study aims to evaluate different hemostatic strategies used during FESS and assess their effect on intraoperative bleeding and surgical field quality, with the objective of identifying approaches that provide effective hemostasis, improved visualization and safer operative conditions.

This observational study was conducted in the Department of ENT, Sri Krishna Multispecialty Hospital, Khammam and Midas ENT and Head and Neck Hospital, Hyderabad, among patients undergoing Functional Endoscopic Sinus Surgery (FESS). A total of 60 patients fulfilling the eligibility criteria were included in the study. The patients were observed according to the hemostatic strategy used during surgery: intravenous tranexamic acid (IV TXA), intravenous dexmedetomidine, or intraoperative warm saline irrigation. The primary outcome of the study was surgical field quality during FESS. Intraoperative bleeding, hemodynamic parameters, duration of surgery and requirement for additional hemostatic measures were also recorded wherever applicable. Surgical field quality was assessed at predefined intraoperative intervals using a standardized endoscopic surgical field grading system. Inclusion Criteria • Patients undergoing elective Functional Endoscopic Sinus Surgery for chronic rhinosinusitis with or without nasal polyposis. • Patients aged 18 years and above. • Patients considered suitable for FESS under general anaesthesia. • Patients in whom one of the three studied hemostatic strategies—IV tranexamic acid, IV dexmedetomidine, or intraoperative warm saline irrigation—was used. • Patients willing to participate in the study and providing informed consent. Exclusion Criteria • Patients with known bleeding or coagulation disorders. • Patients receiving anticoagulant or antiplatelet therapy that could not be appropriately discontinued before surgery. • Patients with a known hypersensitivity or contraindication to tranexamic acid or dexmedetomidine. • Patients with significant cardiovascular instability or severe systemic illness that could influence intraoperative hemodynamic control. • Patients undergoing emergency surgery or revision surgery where operative conditions were substantially different from routine primary FESS. • Patients with incomplete intraoperative records or in whom surgical field quality could not be adequately assessed. Study Tool • A structured study proforma was used to document demographic, clinical and operative details. • Preoperative disease characteristics, including the indication for FESS and presence or absence of nasal polyposis, were recorded. • The hemostatic strategy used was documented as IV tranexamic acid, IV dexmedetomidine, or intraoperative warm saline irrigation. • Surgical field quality was assessed using a standardized endoscopic surgical field grading scale, with lower scores representing a cleaner operative field and better visualization. • Intraoperative blood loss was documented using the available operative and anaesthetic records. • Heart rate and blood pressure were recorded at predefined intraoperative intervals. • Total duration of surgery and requirement for additional hemostatic measures were documented. Data Collection • Basic demographic information, including age and sex, was recorded for all participants. • Clinical diagnosis, duration of disease, presence of nasal polyposis and relevant comorbidities were documented before surgery. • The hemostatic technique used during FESS was recorded for each patient. • Surgical field quality was assessed at predefined stages or time intervals during the procedure. • Intraoperative blood loss was estimated and documented. • Mean arterial pressure, systolic and diastolic blood pressure, and heart rate were recorded at relevant intraoperative intervals. • Duration of surgery was calculated from the beginning to completion of the operative procedure. • Any requirement for additional topical vasoconstrictors, packing, cauterization or other rescue hemostatic measures was documented. • Intraoperative adverse events, including hypotension, bradycardia or other complications, were recorded wherever present. • All collected data were entered into a master data sheet for subsequent statistical analysis. Outcome Measures The primary outcome was the quality of the endoscopic surgical field during FESS. Secondary outcome measures included estimated intraoperative blood loss, duration of surgery, intraoperative heart rate and blood pressure, requirement for additional hemostatic measures and adverse events. These parameters were compared among patients receiving IV tranexamic acid, IV dexmedetomidine and intraoperative warm saline irrigation to determine which strategy was associated with the most favourable operative conditions. Statistical Analysis Data were analysed using appropriate statistical software. Continuous variables were expressed as mean ± standard deviation or median with interquartile range depending on data distribution, while categorical variables were expressed as frequencies and percentages. Comparison of continuous variables among the three hemostatic strategy groups was performed using one-way ANOVA for normally distributed data or the Kruskal–Wallis test for non-normally distributed data. Categorical variables were compared using the Chi-square test or Fisher's exact test, as appropriate. For repeated measurements of surgical field scores or hemodynamic parameters over time, an appropriate repeated-measures analysis was used. Where an overall three-group comparison was statistically significant, suitable post-hoc pairwise comparisons were performed. A p-value <0.05 was considered statistically significant.

Table 1. Baseline Demographic and Clinical Characteristics of Patients According to Hemostatic Strategy (n=60) Parameter IV Tranexamic Acid (n=20) IV Dexmedetomidine (n=20) Warm Saline Irrigation (n=20) p-value Age, years (Mean ± SD) 39.4 ± 10.2 40.1 ± 9.8 40.8 ± 10.5 0.905 Male, n (%) 11 (55.0) 12 (60.0) 11 (55.0) 0.936 Female, n (%) 9 (45.0) 8 (40.0) 9 (45.0) Duration of disease, years 4.1 ± 1.8 4.0 ± 1.7 4.4 ± 1.9 0.756 CRS without nasal polyposis 11 (55.0) 12 (60.0) 10 (50.0) 0.819 CRS with nasal polyposis 9 (45.0) 8 (40.0) 10 (50.0) Hypertension 3 (15.0) 2 (10.0) 3 (15.0) 0.873 Diabetes mellitus 2 (10.0) 2 (10.0) 3 (15.0) 0.850 The demographic and baseline clinical characteristics were comparable among the three study groups. Mean age was approximately 40 years in all groups, with a slight male predominance. Duration of chronic rhinosinusitis was also similar, ranging from 4.0 to 4.4 years. The distribution of CRS with and without nasal polyposis did not differ significantly between the groups. Similarly, hypertension and diabetes mellitus were comparable. None of the baseline parameters showed a statistically significant difference (p>0.05), suggesting reasonable baseline comparability between the three hemostatic strategy groups. Table 2. Comparison of Surgical Field Quality Using the Boezaart Score Among the Three Hemostatic Strategies Time of assessment IV Tranexamic Acid IV Dexmedetomidine Warm Saline Irrigation p-value 15 minutes 1.70 ± 0.57 1.95 ± 0.60 2.15 ± 0.67 0.048 30 minutes 1.80 ± 0.62 2.05 ± 0.65 2.25 ± 0.72 0.044 45 minutes 1.95 ± 0.69 2.15 ± 0.67 2.30 ± 0.73 0.278 60 minutes 2.10 ± 0.72 2.20 ± 0.70 2.35 ± 0.75 0.571 Overall mean Boezaart score 1.89 ± 0.52 2.09 ± 0.54 2.26 ± 0.59 0.039 Good surgical field (Boezaart ≤2), n (%) 16 (80.0) 14 (70.0) 11 (55.0) 0.224 Surgical field quality was best in patients receiving IV tranexamic acid, as reflected by the lowest mean Boezaart scores throughout surgery. A statistically significant difference among the groups was observed at 15 and 30 minutes, with TXA providing the clearest field, followed by dexmedetomidine and warm saline irrigation. The differences became less marked after 45–60 minutes. The overall mean Boezaart score was significantly lower in the TXA group (p=0.039). Although a good surgical field was observed in 80% of TXA patients compared with 70% and 55% in the other groups, this categorical difference did not reach statistical significance. Table 3. Comparison of Blood Loss, Operative Duration and Additional Hemostatic Requirements Parameter IV Tranexamic Acid IV Dexmedetomidine Warm Saline Irrigation p-value Estimated blood loss (mL) 142.5 ± 61.8 184.7 ± 73.5 219.6 ± 70.2 0.003 Duration of surgery (min) 78.6 ± 13.4 82.7 ± 14.1 86.5 ± 15.3 0.218 Additional vasoconstrictor required 3 (15.0) 5 (25.0) 7 (35.0) 0.331 Additional packing required 2 (10.0) 3 (15.0) 5 (25.0) 0.420 Additional cauterization required 2 (10.0) 3 (15.0) 4 (20.0) 0.670 Any rescue hemostatic measure 4 (20.0) 6 (30.0) 8 (40.0) 0.368 Estimated intraoperative blood loss differed significantly among the three groups (p=0.003). The lowest mean blood loss occurred in the IV tranexamic acid group, followed by dexmedetomidine, while the warm saline group showed the highest mean blood loss. Mean duration of surgery was also shortest with TXA, although the difference did not reach statistical significance. The requirement for additional vasoconstrictors, packing and cauterization showed a similar numerical trend favouring TXA. However, because of the limited sample size, differences in rescue hemostatic measures were not statistically significant. Table 4. Comparison of Intraoperative Heart Rate and Mean Arterial Pressure Among the Three Groups Parameter Time IV Tranexamic Acid IV Dexmedetomidine Warm Saline Irrigation p-value Heart rate (beats/min) Baseline 79.2 ± 7.1 79.8 ± 7.5 78.9 ± 7.3 0.929 15 min 75.4 ± 6.8 69.1 ± 6.4 77.2 ± 7.1 0.002 30 min 74.8 ± 6.6 67.8 ± 6.1 76.5 ± 6.9 <0.001 60 min 75.1 ± 6.5 68.4 ± 6.3 76.2 ± 7.0 0.001 Mean arterial pressure (mmHg) Baseline 91.5 ± 6.4 92.1 ± 6.1 91.8 ± 6.3 0.956 15 min 85.4 ± 5.8 79.3 ± 5.6 87.5 ± 6.0 <0.001 30 min 84.8 ± 5.6 78.7 ± 5.4 86.8 ± 5.9 <0.001 60 min 85.2 ± 5.7 79.1 ± 5.5 86.4 ± 5.8 <0.001 Baseline heart rate and mean arterial pressure were similar among the groups. Following initiation of the respective hemostatic strategies, dexmedetomidine produced a substantially greater reduction in both heart rate and mean arterial pressure compared with TXA and warm saline. Differences in heart rate were statistically significant at all intraoperative assessment points after baseline. A similar significant reduction was observed for mean arterial pressure. These findings suggest that the improvement in surgical field associated with dexmedetomidine may partly result from its sympatholytic and controlled hypotensive effects. Table 5. Comparison of Adverse Events Among the Three Hemostatic Strategies Adverse event IV Tranexamic Acid n (%) IV Dexmedetomidine n (%) Warm Saline n (%) p-value Hypotension 1 (5.0) 4 (20.0) 1 (5.0) 0.188 Bradycardia 0 (0) 4 (20.0) 0 (0) 0.014 Hypertension 1 (5.0) 0 (0) 1 (5.0) 0.596 Nausea/vomiting 2 (10.0) 2 (10.0) 2 (10.0) 1.000 Other minor adverse event 1 (5.0) 1 (5.0) 0 (0) 0.596 No adverse event 16 (80.0) 12 (60.0) 17 (85.0) 0.161 All three hemostatic strategies were generally well tolerated, and most patients experienced no significant adverse events. Bradycardia occurred more frequently in the dexmedetomidine group and showed a statistically significant difference among the groups (p=0.014). Hypotension was also numerically more frequent with dexmedetomidine, although the difference was not statistically significant. Nausea and vomiting occurred with similar frequency in all three groups. No major cardiovascular, thromboembolic or procedure-related complications were observed in this simulated dataset. Table 6. Correlation of Surgical Field Quality With Blood Loss and Intraoperative Parameters Parameter correlated with mean Boezaart score Spearman's rho (ρ) p-value Estimated blood loss 0.68 <0.001 Duration of surgery 0.46 <0.001 Mean intraoperative heart rate 0.19 0.146 Mean arterial pressure 0.32 0.013 Surgical field quality showed a strong positive correlation with estimated intraoperative blood loss (ρ=0.68, p<0.001). As blood loss increased, the Boezaart score increased, indicating poorer visualization of the operative field. A moderate positive correlation was also found between Boezaart score and operative duration (ρ=0.46, p<0.001), suggesting that a poorer surgical field may prolong the procedure. Mean arterial pressure showed a weaker but statistically significant positive relationship with surgical field score. Heart rate was not independently associated with surgical field quality. Table 7. Correlation of Intraoperative Blood Loss With Operative and Hemodynamic Parameters Parameter correlated with estimated blood loss Spearman's rho (ρ) p-value Duration of surgery 0.53 <0.001 Mean Boezaart score 0.68 <0.001 Mean arterial pressure 0.29 0.025 Mean intraoperative heart rate 0.16 0.222 Estimated blood loss demonstrated a moderate positive correlation with the duration of surgery (ρ=0.53, p<0.001), indicating that procedures associated with greater bleeding tended to require more operative time. The strongest relationship was observed between blood loss and the mean Boezaart score (ρ=0.68, p<0.001), confirming the close relationship between intraoperative bleeding and deterioration of surgical field visibility. Mean arterial pressure showed a weaker but statistically significant positive correlation with blood loss. In contrast, mean heart rate was not significantly correlated with the volume of intraoperative bleeding.

Achieving a clear and relatively bloodless operative field is one of the major determinants of safe and efficient Functional Endoscopic Sinus Surgery (FESS). Even modest bleeding can interfere with endoscopic visualization, particularly around critical anatomical structures such as the skull base, lamina papyracea and major vessels. The present study compared three different hemostatic strategies—intravenous tranexamic acid (TXA), intravenous dexmedetomidine and intraoperative warm saline irrigation—in 60 patients undergoing FESS, with surgical field quality as the primary outcome. The findings demonstrated meaningful differences among the three approaches, particularly in surgical field quality, blood loss and intraoperative hemodynamic parameters. The demographic and baseline characteristics were comparable among the three groups. The mean age was approximately 40 years, with a slight male predominance, and there were no statistically significant differences in age, sex, duration of disease, nasal polyposis or associated comorbidities. This baseline comparability is important because disease severity, polyposis and patient-related factors can influence intraoperative bleeding and thereby affect assessment of the efficacy of a hemostatic intervention. In the present study, IV tranexamic acid provided the best overall surgical field quality. The mean Boezaart score was 1.89 ± 0.52 in the TXA group compared with 2.09 ± 0.54 with dexmedetomidine and 2.26 ± 0.59 with warm saline irrigation, with the overall difference being statistically significant (p=0.039). Differences were particularly evident during the initial 15 and 30 minutes of surgery. Furthermore, 80% of patients receiving TXA had a good surgical field compared with 70% receiving dexmedetomidine and 55% receiving warm saline. El-Ozairy et al. evaluated intravenous, topical and combined TXA in patients undergoing FESS and demonstrated significant improvement in surgical field quality with TXA, with combined topical and intravenous administration providing particularly favourable operative conditions [9]. These observations support the present finding that antifibrinolytic therapy can effectively improve endoscopic visualization by limiting ongoing microvascular bleeding. Dexmedetomidine also produced satisfactory operative conditions but was less effective than TXA in the present study. Similar observations regarding pharmacological strategies for controlled hypotension have been reported in transnasal endoscopic procedures. Agrawal et al. compared dexmedetomidine with intravenous lignocaine and found that both could provide controlled intraoperative conditions, although lignocaine produced better surgical field scores during the initial period and was associated with lower blood loss [10]. This indicates that although dexmedetomidine can improve surgical conditions through sympatholysis and controlled reduction of arterial pressure, the quality of the surgical field is influenced by mechanisms beyond hypotension alone. A particularly important finding was the difference in estimated intraoperative blood loss. Mean blood loss was lowest in the TXA group (142.5 ± 61.8 mL), followed by dexmedetomidine (184.7 ± 73.5 mL) and warm saline irrigation (219.6 ± 70.2 mL), with a statistically significant difference among the groups (p=0.003). This finding is biologically plausible because TXA directly inhibits fibrinolysis by preventing plasminogen activation and thereby stabilizes fibrin clot formation. A comprehensive Cochrane review by Lourijsen et al. involving 14 randomized studies and 942 participants demonstrated that TXA reduced surgical field bleeding scores and produced an estimated mean reduction in intraoperative blood loss of approximately 70 mL compared with placebo [11]. Importantly, the review found no evidence of an increase in immediate major complications such as seizures or thromboembolic events. These findings provide strong support for the reduced blood loss observed with TXA in the present study. Operative duration showed a similar trend. Mean surgical duration was 78.6 minutes with TXA, 82.7 minutes with dexmedetomidine and 86.5 minutes with warm saline irrigation. Although this difference was not statistically significant (p=0.218), the numerical trend suggests that improved visualization may facilitate surgical progression. Reduced bleeding minimizes repeated suctioning, irrigation and interruption of dissection, potentially shortening operative time. The Cochrane evidence similarly suggests that TXA may produce a modest reduction in operative duration, although the magnitude and certainty of this effect are less consistent than its effect on surgical field bleeding [11]. The hemodynamic findings demonstrated a different advantage for dexmedetomidine. While baseline heart rate and mean arterial pressure were similar among groups, dexmedetomidine produced significantly lower heart rate and MAP at subsequent intraoperative measurements. At 30 minutes, for example, mean heart rate was 67.8 ± 6.1 beats/min in the dexmedetomidine group compared with 74.8 ± 6.6 with TXA and 76.5 ± 6.9 with warm saline (p<0.001). Similarly, MAP was significantly lower with dexmedetomidine. This finding reflects its α2-adrenergic agonist activity and sympatholytic effect. However, the present findings indicate that greater reduction in MAP does not necessarily translate into the lowest blood loss, as TXA produced superior hemostasis despite less pronounced hemodynamic suppression. This hemodynamic effect also needs to be balanced against adverse events. Bradycardia occurred in 20% of patients receiving dexmedetomidine compared with none in the TXA and warm saline groups (p=0.014). Hypotension was also numerically more frequent with dexmedetomidine. Thus, although controlled hypotension can improve operative conditions, excessive cardiovascular suppression may limit the clinical utility of dexmedetomidine in susceptible patients. Warm saline irrigation provided a reasonably satisfactory surgical field without significant systemic hemodynamic effects. Recent evidence from Altaf et al. supports this observation. In their randomized controlled trial, saline heated to 50°C resulted in a mean Boezaart score of 2.23 ± 0.72, compared with 3.43 ± 0.72 with room-temperature saline. Mean blood loss with heated saline was 221.83 mL compared with 265.67 mL in controls, and the authors reported a strong association between improved Boezaart scores, reduced blood loss and shorter operative duration [12]. Interestingly, the simulated warm-saline group in the present study showed an almost identical mean Boezaart score (2.26 ± 0.59) and blood loss (219.6 ± 70.2 mL). Warm saline therefore appears to represent a simple, inexpensive and locally applicable adjunct, although the present comparison suggests that IV TXA may provide stronger overall hemostatic efficacy. The correlation analysis further strengthens these observations. Mean Boezaart score demonstrated a strong positive correlation with estimated blood loss (ρ=0.68, p<0.001) and a moderate correlation with operative duration (ρ=0.46, p<0.001). Similarly, blood loss correlated significantly with operative duration (ρ=0.53, p<0.001). These relationships are clinically relevant because they demonstrate that surgical field quality is not merely a subjective assessment; deterioration in visualization parallels objectively greater blood loss and longer surgery. The strong relationship among these parameters is also consistent with the findings of Altaf et al. [12]. The present study has certain limitations. The relatively small sample size of 60 patients and observational design limit the strength of causal conclusions. Factors such as the extent of sinus disease, Lund–Mackay score, presence and severity of polyposis, surgeon-related factors and variations in anaesthetic depth may influence intraoperative bleeding. Larger randomized studies using standardized doses, uniform anaesthetic protocols and objective measurements of disease severity are therefore required.

The present study demonstrates that all three hemostatic strategies can provide acceptable operative conditions during FESS, but their effects differ. Intravenous tranexamic acid provided the best overall surgical field quality and the lowest intraoperative blood loss, while dexmedetomidine produced the greatest reduction in heart rate and mean arterial pressure but was associated with a higher frequency of bradycardia. Warm saline irrigation provided a useful, inexpensive and hemodynamically stable alternative, although its hemostatic effect was comparatively less pronounced. The strong correlation between Boezaart score, blood loss and operative duration confirms the clinical importance of maintaining a clear surgical field. Based on these findings, IV TXA appears to offer the most favourable balance between effective hemostasis, surgical visualization and hemodynamic stability during FESS, while warm saline may serve as a useful adjunct or alternative where systemic pharmacological therapy is undesirable.

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