Prevention of Nasal Ala Pressure Injuries With Use of Hydroactive Dressings in Patients With Nasotracheal Intubation of Orthognathic Surgery: A Randomized Controlled Trial.

PURPOSE: To compare a hydroactive dressing to an adhesive tape standard of care in the prevention of nasal ala pressure injuries associated with nasotracheal intubation during orthognathic surgery. DESIGN: Randomized controlled trial. SUBJECTS AND SETTING: The study took place in a tertiary hospital of stomatology in China. Patients undergoing general anesthesia with nasotracheal intubation during orthognathic surgical procedures were invited to participate. METHODS: Participants were divided into 2 groups: in the experimental group, a hydroactive dressing was applied to the nasal ala before the surgical procedures; the control group received standard prevention with a type of tape. Skin assessments were performed on the wards up to 72 hours after the procedures. Demographic information and potential contributing factors associated the development of nasal ala pressure injuries were collected from patients' electronic medical records. Pressure injury development was staged using National Pressure Injury Advisory staging guidelines. Pressure injury incidence was compared between groups using the χ test and odds ratio. RESULTS: The sample comprised 450 participants, 225 in each group. The incidence of nasal ala pressure injuries development was 14.222% and 4.444% in the 2 groups, respectively (P = .000). The odds ratio was 3.565 (95% confidence interval, 1.707-7.443). CONCLUSIONS: The study findings indicate that the incidence of pressure injuries of nasal ala skin protected by hydroactive dressings was lower than the standard preventive method. Hydroactive dressings should be considered as a prevention method to reduce device-related skin injuries associated with nasotracheal intubation.

Endoscopic Transcaruncular Medial Orbitotomy as an Alternative Approach to Anterior Ethmoidal Artery Coagulation.

BACKGROUND: The authors present a series of 5 patients with anterior epistaxis in which a transcaruncular endoscopic approach was used for the anterior ethmoidal artery coagulation (AEA). METHODS: Six AEA coagulations (5 unilateral, 1 bilateral) using the transcaruncular endoscopic approach were performed in 5 patients with anterior epistaxis resistant to conservative measures. An incision was made between the plica semilunaris of conjunctiva and the lacrimal caruncle. Using a rigid endoscope, tissues were dissected lateral to the lacrimal sac, to the posterior lacrimal crest. The periorbit was incised and pulled aside. Hereafter, the technique was the same as that involving a frontoethmoidal incision. After bipolar coagulation of the AEA, the conjunctiva was sutured. RESULTS: Bleeding was resolved in all patients. One patient experienced early postoperative temporary diplopia. CONCLUSIONS: The transcaruncular endoscopic approach is a promising technique with no outer scarring. It is convenient in patients with difficult orientation in the nasal cavity, relatively safe, and faster than the transnasal endoscopic approach.

An undescribed venous pathway intervening between the olfactory fossa and nasal vestibule.

PURPOSE: A curvilinear pathway intervening between the olfactory fossa and nasal vestibule has not been well documented. Therefore, the aim of this study was to examine its structure using magnetic resonance imaging (MRI). METHODS: In total, 84 patients underwent thin-sliced, contrast MRI. Among these patients, 31 underwent additional thin-sliced, sagittal T2-weighted imaging. RESULTS: A curvilinear pathway intervening between the olfactory fossa and nasal vestibule was delineated on sagittal and coronal imaging in 98% and 82% of patients, respectively. All of these pathways demonstrated communication with the lower limit of the superior sagittal sinus (SSS) or fine venous channels connecting to the SSS in the vicinity of the crista galli. The pathway was identified in the parasagittal regions on both sides with varying lengths, diameters, and curvatures. In 94% of the patients who underwent sagittal T2-weighted imaging, the pathways appeared as linear high-intensity signals. Most pathways were delineated as a single channel coursing extracranially adjacent to the olfactory fossa. In 38% of the patients, post-contrast sagittal images showed variable filling defects between the olfactory bulb and floor of the olfactory fossa, furthermore traversing the venous pathway. Additionally, in 73% of the patients, post-contrast images identified diploic venous channels, variably in the nasal bone and communicating with the venous pathway. CONCLUSIONS: A curvilinear pathway intervening between the olfactory fossa and nasal vestibule is a consistent venous structure and may function as an extracranial route of cerebrospinal fluid drainage.

Anatomy of the sphenopalatine artery and its implications for transnasal neurosurgery.

BACKGROUND: The knowledge of sinonasal vasculature is inevitable in transnasal neurosurgery. We performed an anatomical study on the sphenopalatine artery from the perspective of skull base procedures. METHODOLOGY: To analyse the anatomical landmarks of the sphenopalatine artery, arterial skull corrosion casts (26 head halves) underwent endoscopic transnasal phantom surgery. Furthermore, we performed microsurgical dissection on formaldehyde-fixated cadavers with arterial perfusion (14 head halves) as well as studied Cone Beam CT-scans of anonymised patients and cadavers (115 head sides). RESULTS: In our cadaveric material, the sphenopalatine foramen is located at the transition of the superior and middle nasal meatus (95.0%) or in the superior nasal meatus (5.0%). It is the main entry point of the branches of the sphenopalatine artery into the nasal cavity. In most cadaveric cases (25.0%), at this level there are 2 branches superiorly and 1 vessel inferiorly to the ethmoid crest. An average of 2.4 vessels leave the sphenopalatine foramen superiorly to the ethmoid crest, 97.8% of them belong to the sphenopalatine arterys posterior septal branches. An average of 2.1 branches leave the sphenopalatine foramen inferiorly to the ethmoid crest; all of them belong to the posterior lateral nasal branches. There are no cases with a single artery at the plane of the sphenopalatine foramen. We describe a triangular bony structure bordering the sphenopalatine foramen anteriorly which is built up by the palatine and ethmoid bone as well as the maxilla. According to the radiographic studies, this triangular prominence is surrounded superiorly by a posterior ethmoid cell (57.4%), the sphenoid sinus (41.7%) or the orbit (0.9%) with a varying contribution of the superior nasal meatus; inferolaterally by the maxillary sinus (98.3%) or the pterygopalatine and infratemporal fossa (1.7%) and inferomedially by the middle nasal meatus. The medial vertex of the bony triangle corresponds to the ethmoid crest of the palatine bone. In transnasal endoscopic surgery, the posterior lateral nasal branches of the sphenopalatine artery appear at the triangle's inferomedial edge, the posterior septal branches emerge at its superior edge. CONCLUSIONS: The triangular bony structure is a landmark to find and differentiate the posterior lateral nasal and posterior septal branches of the sphenopalatine artery and to identify the sphenoid sinus.

The arterial supply of the nasal cavity.

With the development of endonasal flaps, an understanding of the arterial anatomy of the nasal cavity has become increasingly important for clinicians. Despite this, there is a lack of current, accurate overviews in the literature. We have used both endoscopic and gross dissection of six fresh frozen cadaveric heads, alongside a literature review, to produce a comprehensive description of the anatomy. Four heads had their arterial systems injected with red latex. Three injected and two uninjected heads were dissected endoscopically, to provide a total of seven sides. The fourth injected head was hemisected for gross examination. The arterial systems were dissected and examined. The posterior septal artery was found to enter the nasal cavity from the sphenopalatine foramen in five sides. It bifurcated on the sphenoid rostrum in seven sides with a bifurcation lateral to the sphenoid ostium occurring in five sides and a medial bifurcation in two sides. The posterior septal artery supplied Kiesselbach's plexus on the nasal septum along with the greater palatine artery and septal branches of the superior labial and anterior ethmoidal arteries. The posterior lateral nasal artery arose from the sphenopalatine foramen in five sides to supply the lateral wall. The lateral wall branch of the anterior ethmoidal and the anterior lateral nasal artery anastomosed at the head of the inferior turbinate. These findings were mostly consistent with the current literature. We have produced a detailed and up-to-date description and diagram of the arterial supply to the nasal cavity, which may be of use to clinicians, anatomists and students.

Nasal packing in sphenopalatine artery bleeding: therapeutic or harmful?

The aim of this study is to present our management protocol of sphenopalatine artery bleeding, demonstrating that nasoendoscopic cautery (NC) was a more effective method than the nasal packing, in terms of shorter inpatient stay and reduced complications rate. We present ten posterior epistaxis not resolved by nasal packing. Tabotamp® was placed in the area of sphenopalatine foramen and/or in those parts of the posterior nasal cavity, where it was suspected that bleeding origins. In two cases, the bleeding was resolved in this way, instead eight cases needed of subperiosteal cauterization of sphenopalatine artery by Dessi bipolar forceps (MicroFrance®). 4 of these 8 patients evidenced a remarkable bleeding removing nasal packing (Hb before-nasal packing = 15 ± 0.69 versus Hb after-nasal packing = 13.3 ± 0.81; t student = 2.94; p value = 0.025). These four patients showed a deviation of the nasal septum ipsilateral to epistaxis, and according our experience, a traumatism of sphenopalatine area can be caused by Merocel® nasal packing in this condition. During follow-up, no recurrences of nasal bleeding have been observed in such patients. Nasal packing must be considered if posterior epistaxis is severe, but always taking into account the specific anatomy of patient and in particular septal spurs that can further compromise sphenopalatine artery. In our experience, the endoscopic endonasal cauterization of the sphenopalatine branches represented a safe and effective procedure.

Facing the Worst Risk: Confronting the Dorsal Nasal Artery, Implication for Non-surgical Procedures of Nasal Augmentation.

BACKGROUND: The nose is a dangerous site for filler injection. This study investigated the anatomy of the dorsal nasal artery at the upper part of the nose to clarify how ocular complications occur. METHODS: Dissections were performed in 50 noses of the embalmed cadavers. Either the soft embalming or formaldehyde embalming processes were used. RESULTS: The dorsal nasal artery is not a constant artery. The artery traveled in the subcutaneous tissue layer of the nasal dorsum on the transverse nasalis muscle and its midline nasal aponeurosis which connected the muscles on both sides. Bilateral dorsal nasal arteries existed only in 34%. In 28% of the specimens, a single and large dorsal nasal artery was presented. The diameter was 0.4 ± 0.2 mm when bilateral dorsal nasal arteries were present and 0.7 ± 0.3 mm in a single artery. The largest artery was 1.2 mm. The artery usually crossed the midline at the middle third part of the nose over the upper lateral cartilages to form an anastomosis with the contralateral lateral nasal artery as the oblique nasal artery in 14%. The artery might descend and communicate with the ipsilateral lateral nasal artery in 6% or descended as a midline artery and form the nasal tip plexus in 8%. In 38% of the specimens, the arteries became small, formed a subcutaneous plexus and randomly distributed on the superficial layer of the subcutaneous tissue in the upper two-thirds of the nose. CONCLUSION: During the injections at the upper (bony) and middle (cartilaginous) part of the nose for nasal dorsal augmentation, the injector has to make sure the cannula tip is in the preperiosteal plane by reinsertion of the cannula if needed, due to the chance of encountering the large single dorsal nasal artery at the midline. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

[The functional state of nasal cavity in the aspect of structural-functional changes of the human organism in postnatal ontogenesis.]

Nasal cavity - «the primary line of defense¼ and a major division of the respiratory tract. A variety of functional areas and regions, structural formations of the nasal cavity allows, at the present stage of development of biology and medicine, consider it as a complex functional subsystem in the structure of the respiratory system. The age transformations of morphological and functional parameters of the nasal cavity are polymorphic and specific. An important aspect of developmental physiology of the respiratory system is a study of the relationship of these changes with morphological and functional transformations of other systems of the body. The article presents the results of the analysis of such contingency-for example, by endonasal correlations with amount of blood flow hemodynamics and functional state of the autonomic nervous system, respiratory function of the nasal cavity and respiratory system, as well as other functions of the nasal cavity and their relationship with general growth processes, critical periods of development and involution. In the process of this analysis revealed a close correlation with complex changes of the morphofunctional parameters of the systems of the human body, most pronounced during in critical periods of postnatal ontogenesis.

[Age-related changes of hemodynamic potential of the nasal cavity of a human].

Vascular system of the nasal cavity has a complex structural organization and a wide range of functionality. However, with age, the hemodynamics of the nasal cavity undergoes specific changes, detection of which is of practical importance for gerontology and medicine. This paper presents the results of the study of hemodynamics of the nasal cavity in Mature, elderly and senile age by the method of rheorinography . Identified critical periods of functional changes of blood flow of the nasal cavity: the elderly (exit definitivno state) and old age (involution hemodynamic function and the reduction of its compensatory capacity).

A possible venous connection between the cranial and nasal cavity.

PURPOSE: The foramen cecum (FC) is a fine bony canal with the aperture located immediately anterior to the crista galli (CG). The venous structures in the regions of the FC and CG have been inconsistently described and are not well understood. Here we explore these veins using magnetic resonance imaging. MATERIALS AND METHODS: We enrolled 101 patients who underwent contrast examinations and exhibited intact skin, skull, dura mater, and intracranial dural sinuses. Imaging data were obtained as thin-sliced, seamless sagittal sections and were transferred to a workstation for analysis. RESULTS: In 84 % of the patients, tubular-shaped venous extensions arose from the rostral end of the falx cerebri and were confirmed to lie in the FC. These extensions were supplied by the superior sagittal sinus or the frontal cortical vein, and were classified into four types: rudimental slight projections, short and straight extensions, long and straight channels, and long and tortuous channels. Furthermore, 27.7 % of the patients exhibited a distinct venous channel between the venous extension in the FC and the median vestibular submucosa of the nasal cavity. Among these channels, 81.5 % were connected to the vein lying in the FC via a short channel that vertically pierced the CG. CONCLUSIONS: The FC contains tubular-shaped venous extensions that are supplied by the rostral end of the superior sagittal sinus or the frontal cortical vein. The cranial cavity, FC, and nasal cavity may be connected by a venous channel.

The posterior pedicled inferior turbinate-nasoseptal flap: a potential combined flap for skull base reconstruction.

OBJECTIVES: To develop a combined pedicled flap comprising the mucoperiosteum and mucoperichondrium of the inferior turbinate, lateral nasal wall, nasal floor, and nasal septum based on the posterior lateral nasal artery, a branch of the sphenopalatine artery, for the reconstruction of skull base defects resulting from endoscopic expanded endonasal approaches. METHODS: Eleven fresh adult cadaver heads were dissected. Arterial distribution patterns of the inferior turbinate, lateral nasal wall, nasal floor, and nasal septum were investigated. The posterior pedicled inferior turbinate-nasoseptal flap was designed, measured, and harvested, and its ability to cover ventral skull base defects was examined. RESULTS: The inferior turbinate artery and/or posterior lateral nasal artery had 3.19 ± 1.47 (range 2-7) branches [mean outer diameter of largest branch, 0.40 ± 0.10 (range 0.24-0.60) mm] that anastomosed with the nasoseptal artery. These anastomosing arteries allowed the posterior lateral nasal artery to supply arterial blood to the nasoseptal mucoperichondrium and mucoperiosteum. Mean flap length was 100.65 ± 5.61 (range 91.43-109.44) mm, and minimum and maximum widths were 25.21 ± 2.29 (range 22.36-30.23) and 44.53 ± 5.02 (range 36.45-54.10) mm, respectively. Mean flap area was 3090.69 ± 288.08 (range 2612.97-3880.09) mm(2). The flap covered defects extending from the frontal sinus to the foramen magnum in all specimens. CONCLUSIONS: Harvesting of a posterior pedicled inferior turbinate-nasoseptal flap is feasible. It should be considered a useful option for the reconstruction of large defects involving the anterior skull base, planum sphenoidale, sella turcica, and/or clivus.

Anatomical and surgical study of the sphenopalatine artery branches.

The sphenopalatine artery gives off two main branches: the posterior lateral nasal branch and the posterior septal branch. From 2007 to 2012 17 patients were treated with cauterization and/or ligature of the sphenopalatine artery with endonasal endoscopic approach. 90 nasal dissections were performed in 45 adult cadaveric heads. We evaluated the number of branches emerging from the sphenopalatine foramen and the presence of an accessory foramen. In the surgery group, we observed a single trunk in 76% of the patients (13/17) and a double trunk in 24% (4/17). We found an accessory foramen in four cases. We obtained a successful result in bleeding control in 88% of the cases. In the cadaver dissection group, 55 nasal cavities had a single arterial trunk (61%), 30 had 2 arterial trunks (33%) and in only 5 nasal fossae we observed 3 arterial trunks (6%). We were able to dissect four accessory foramina. We suggest that in most cases only one or two branches are found in the sphenopalatine foramen.

Lobular Capillary Hemangioma Originating From the Posterior End of the Inferior Turbinate: A Very Rare Occurrence.

Lobular capillary hemangioma mostly occurs in the anterior portion of the nasal cavity, rarely occurring in the posterior end of the inferior turbinate, as in this case. We report a case of lobular capillary hemangioma originating from the posterior end of the right inferior turbinate, which was successfully removed via an endoscopic endonasal approach.

Epistaxis after partial middle turbinectomy: the role of sphenopalatine artery ligation.

PURPOSE: Extensive nasal polyposis could involve the middle turbinate inducing the surgeon to partially remove it. We initiated this retrospective study to evaluate the effect of a partial middle turbinectomy (PMT) on postoperative epistaxis and if sphenopalatine artery ligation (SPAL) could reduce the risk of bleeding in patients without nasal packing. MATERIAL AND METHODS: Twenty-seven patients with extended bilateral nasal polyposis and submitted to primary functional endoscopic sinus surgery (FESS) with PMT on 40 sides were retrospectively selected. Postoperative bleeding and other complications were evaluated and compared with those of a control group of 27 patients who underwent FESS with middle turbinate preservation on 40 sides. The study group was furthermore divided into 2 groups according to the execution of SPAL. The incidence of postoperative bleeding of both groups and of the 2 parts of the study group was compared using the Fisher exact test. RESULTS: A SPAL was necessary to stop intraoperative bleeding in 21 (52.5%) sides of the study group patients and in 7 (17.5%) of the control group patients. After surgery, epistaxis occurred in 8 cases (20%) in the PMT group (1 submitted to SPAL) and in 2 (5%) of the control group. The comparison with the Fisher exact test confirmed the major tendency of postoperative bleeding in the study group and in those not submitted to SPAL (P < .05). CONCLUSIONS: Partial middle turbinectomy causes a higher incidence of postoperative bleeding in patients who are not packed during the FESS operation. The execution of SPAL greatly reduces this risk.

[Vascular tumors of the nasal cavities: a retrospective study of 10 cases]. / Les tumeurs vasculaires des cavités nasales: etude rétrospective a propos de 10 cas.

UNLABELLED: Vascular tumors of the sinus cavities are rarely documented in the literature. They are characterized by a histological diversity. They can be benign or malignant. The most common histologic type is the hemangioma. Their management is not well codified, it benefited from advances in modern imaging and endoscopic surgery. The objective of the work is to study anatomical and clinical characteristics, therapeutic and outcome. PATIENTS AND METHODS: The observations of 10 vascular tumors of the nasal cavities collected between January 2009 and July 2011 were studied retrospectively. The management of these tumors was based on nasal endoscopy, imaging, biopsy, and some angiography for embolization. The epidemiological parameters, histopathological, clinical, therapeutic and outcome were studied. RESULTS: The average age was 25.4 years, male was marked with a sex ratio of 4. Epistaxis was the revealing sign. All tumors were benign, with a predominance of the hemangioma (4 cases), followed by angiofibroma of the septum (3 cases) and nasopharyngeal angiofibroma (3 cases). All patients were operated, by endonasal technique in 7 cas/10 and transfacial road in 3 cases. Embolization was performed in 5 patients, there were two hemangiomas and 3 nasopharyngeal fibromas. No case of recurrence has been noted so far. CONCLUSION: The vascular tumors of the nasal cavities are difficult to treat, especially when they reach a large volume and at an extension to adjacent areas, which makes the surgical procedure difficult and bloody. The use of selective embolization in these cases is required.

[Optimization of the surgical methods for the treatment of recurrent nasal bleeding (a pathologo-anatomical study)].

The objective of the present work was to study specific features of blood supply to the nasal cavity by staining mandibular and ethmoidal arteries to reveal their size and topographic features under conditions of a pathologo-anatomical department. The secondary objective was to modify the existing and develop new methods for the ligation of these vessels. This pathologo-anatomical study was based on 16 preparations examined with the use of up-to-date optical facilities. The results of investigations of the topographo-anatomical peculiarities of blood supply in the nasal cavity are supplemented by the evaluation of the potential of endoscopic rhinosurgery for the treatment of recurrent nasal hemorrhage. The methods for endoscopic ligation of mandibular and ethmoidal arteries have been developed and optimized.

Safety margin for the preservation of the nasoseptal artery during trans-nasal endoscopic approach.

BACKGROUND: The introduction of the nasoseptal flap for the reconstruction of extended endoscopic approaches decreased the incidence of postoperative fistula. In order to preserve the septal vascular pedicles, many have started to prepare the flap systematically, prior to the opening of the sphenoid rostrum. The aim of this study is to obtain an average measure of the location of the posterior septal artery using the upper edge of the choana as a landmark. METHODS: Ten cadaveric heads, fixed with formaldehyde and injected with colored silicone, were studied. The course, branching pattern and dominance of the branches of the posterior septal artery were recognized, as well as the distance in of its superior and lower branches respect to the medial upper edge of the choana. RESULTS: In all cases, the posterior septal artery enters as an only vessel through the sphenopalatine foramen. In its sphenoid segment, over the sphenoid rostrum, the posterior septal artery divides into its upper and lower branches, in most cases, laterally to the sphenoid ostium (70%, N.=14). The lower branch was dominant in 60% of the cases (N.=12). Regarding the mean distance in millimeters from the medial upper edge of the choana to the superior branch, it was 14.45±0.4102 (18-11.5) and, to the lower branch, 10.9±0.4682 (14-7). CONCLUSIONS: A rostrum opening to 15 mm over the upper edge of the choana is safe to avoid vascular complications, and to be able to prepare a viable nasoseptal flap only if it is necessary.

Venous networks in the upper airways of bats: A histological and diceCT study.

Our knowledge of nasal cavity anatomy has grown considerably with the advent of micro-computed tomography (CT). More recently, a technique called diffusible iodine-based contrast-enhanced CT (diceCT) has rendered it possible to study nasal soft tissues. Using diceCT and histology, we aim to (a) explore the utility of these techniques for inferring the presence of venous sinuses that typify respiratory mucosa and (b) inquire whether distribution of vascular mucosa may relate to specialization for derived functions of the nasal cavity (i.e., nasal-emission of echolocation sounds) in bats. Matching histology and diceCT data indicate that diceCT can detect venous sinuses as either darkened, "empty" spaces, or radio-opaque islands when blood cells are present. Thus, we show that diceCT provides reliable information on vascular distribution in the mucosa of the nasal airways. Among the bats studied, a nonecholocating pteropodid (Cynopterus sphinx) and an oral-emitter of echolocation sounds (Eptesicus fuscus) possess venous sinus networks that drain into the sphenopalatine vein rostral to the nasopharynx. In contrast, nasopharyngeal passageways of nasal-emitting hipposiderids are notably packed with venous sinuses. The mucosae of the nasopharyngeal passageways are far less vascular in nasal-emitting phyllostomids, in which vascular mucosae are more widely distributed in the nasal cavity, and in some nectar-feeding species, a particularly large venous sinus is adjacent to the vomeronasal organ. Therefore, we do not find a common pattern of venous sinus distribution associated with nasal emission of sounds in phyllostomids and hipposiderids. Instead, vascular mucosa is more likely critical for air-conditioning and sometimes vomeronasal function in all bats.

A Non-inferiority Trial: Safety and Efficacy of Topical 1:1000 versus 1:10 000 Epinephrine in Sino-nasal Surgeries.

OBJECTIVE: This study aimed to test the non-inferiority of topical 1:1000 epinephrine compared to topical 1:10 000 with regard to intraoperative hemodynamic stability, and to determine whether it produced superior visibility conditions. METHODS: A single-blinded, prospective, cross-over non-inferiority trial was performed. Topical 1:1000 or topical 1:10 000 was placed in 1 nasal passage. Hemodynamic parameters (heart rate, systolic and diastolic blood pressures, and mean arterial pressure) were measured prior to insertion then every minute for 10 minutes. This was repeated in the contralateral nasal passage of the same patient with the alternate concentration. The surgeon graded the visualization of each passage using the Boezaart Scale. The medians of the greatest absolute change in parameters were compared using a Wilcoxon Rank-Signed test and confidence intervals were calculated using a Hodges-Lehman test. The non-inferiority margin was pre-determined at 10 bpm for heart rate and 10 mmHg for blood pressures. A Wilcoxon Rank-Signed test was used to assess superiority in visualization. RESULTS: Thirty-two patients were enrolled and after exclusions, nineteen were assessed (mean age = 35.63 ± 12.49). Differences in means of greatest absolute change between the 2 concentrations were calculated (heart rate = 2.49 ± 1.20; systolic = -1.51 ± 2.16; diastolic = 2.47 ± 1.47; mean arterial pressure = 0.07 ± 1.83). In analyses of medians, 1:1000 was non-inferior to the 1:10 000. There was a significant difference (-0.58 ± 0.84; P = .012) in visualization in favor of topical 1:1000. CONCLUSION: Topical 1:1000 epinephrine provides no worse intraoperative hemodynamic stability compared to topical 1:10 000 but affords superior visualization and should be used to optimize surgical conditions.