Outcomes and Complications with Topical Epinephrine in Endoscopic Sinus Surgery: A Systematic Review and Meta-analysis

Otolaryngol Head Neck Surg. 2020 Sep;163(3):410-417. doi: 10.1177/0194599820915478. Epub 2020 Apr 14.


Objective: To assess the safety and efficacy of topical epinephrine in adults undergoing endoscopic sinus surgery (ESS).

Data sources: PubMed, Embase, and Ovid MEDLINE online databases.

Review methods: Non-case report English articles studying the effects of topical epinephrine as the topical vasoconstrictor used in adult ESS were found from the online databases through January 2019. The PRISMA literature selection process was used (Preferred Reporting Items for Systematic Reviews and Meta-analyses).

Results: An overall 2216 articles were identified, with 9 meeting inclusion criteria involving a total of 5043 patients. All 9 studies assessed the safety of topical epinephrine, while 5 examined efficacy. Intraoperative average blood loss (ABL) ranged from 60 to 426 mL. Topical epinephrine concentrations varied from 1:1000 to 1:100,000, and 3 major complications were found for a rate of 0.06%. There were no reports of ophthalmic, orbital, or skull base injury, nor were there reports of cerebrospinal fluid leaks. A meta-analysis was performed on the 4 studies examining ABL. Estimated mean (95% CI) ABL was 119.4 mL (39.1-199.6) in the higher-concentration cohort (>1:10,000) and 372.2 mL (296.8-447.5) in the lower-concentration cohort (≤1:10,000) (P = .001).

Conclusion: Topical epinephrine is generally safe and provides acceptable hemostasis during ESS, with higher concentrations (>1:10,000) providing improved hemostasis. Caution is advised for its use in patients with preexisting cardiovascular disease or in combination with other topical or injected vasoconstrictive agents. More prospective comparative studies are necessary to determine the ideal hemostatic concentration of epinephrine in ESS.

Keywords: ESS; adrenaline; endoscopic sinus surgery; epinephrine; hemostasis; safety.

Publication types

  • Meta-Analysis
  • Systematic Review

MeSH terms

  • Administration, Topical
  • Endoscopy / adverse effects*
  • Epinephrine / administration & dosage*
  • Epinephrine / adverse effects*
  • Humans
  • Paranasal Sinuses / surgery*
  • Postoperative Complications / epidemiology*
  • Vasoconstrictor Agents / administration & dosage
  • Vasoconstrictor Agents / adverse effects*


  • Vasoconstrictor Agents
  • Epinephrine