‘Moffett's’ solution: a review of the evidence and scientific basis for the topical preparation of the nose

General anaesthesia, often causes a widespread vasodilation, producing a hyperaemic nasal mucosa, hence the need for a topical application to decongest the nose and reduce the nasal blood flow to optimize the operative field. The use of a combination of cocaine, sodium bicarbonate and adrenaline given the eponymous title of ‘Moffett's Solution’ is standard practice in many rhinological procedures to provide local anaesthesia, vasoconstriction and decongestion. We discuss each component of ‘Moffett's’ reviewing the science and evidence behind its usage and the huge variation in the techniques of its application.     

Nasal sensation of airflow following blockade of the nasal trigeminal afferents

A matched-pair parallel, group trial was carried out on 2 groups of 13 subjects (26 subjects in total), using 2% aqueous lignocaine to anaesthetize both the nasal vestibule and the nasal mucous membrane. Both groups had lignocaine infiltrated into the nasal vestibule and lignocaine applied topically to the nasal mucous membrane. The groups differed in the order in which the medication was given, one group having the infiltration first and the other group the topical application first. Local anaesthesia of the nasal vestibule caused a marked decrease in the nasal sensation of airflow (P less than 0.05) with no accompanying change in nasal resistance to airflow. Topical anaesthesia of the nasal mucous membrane had no effect on either nasal sensation of airflow or nasal resistance. The study demonstrates that the nasal vestibule is the dominant area for sensing nasal airflow. The nasal cavum (the major part of the nasal cavities that is lined by respiratory mucosa) appears to be unimportant as regards the sensation of nasal airflow. The clinical significance of the study is discussed with reference to other work, in this field.     

Nasal mucosal anaesthesia and airflow resistance

The effect of topical lidocaine solution on nasal airflow resistance was examined in five adult subjects with normal noses, seated and recumbent. The increasing use of upper airway anaesthesia in the investigation of upper airway function and the lack of published information concerning its effect on nasal airflow resistance led to this investigation. Nasal airflow resistance did not significantly change during 30 minutes observation following topical application of 4% lidocaine solution.     

A randomized comparison of manipulation of the fractured nose under local and general anaesthesia

Reduction of simple nasal fractures may be performed under local or general anaesthesia: the latter is by far the most popular method in Britain, though why is hard to define. We have attempted to compare the 2 approaches by means of a randomized, prospective trial. Fifty consecutive, adult patients with radiologically proved fractures of the nasal bones were randomized to a local or general anaesthesia group and underwent manipulation with Asch's and Walsham's forceps between 7 and 15 days post-injury. Analysis of results at 4 h and 8 weeks post-operatively showed no significant benefit conferred by fracture reduction under general anaesthesia as opposed to local anaesthesia with respect to post-operative airway patency or cosmesis. It is suggested that significant benefits can be obtained in terms of patient convenience and cost effectiveness if nasal fractures are reduced under local anaesthesia as an outpatient procedure.     

A randomized comparison of manipulation of the fractured nose under local and general anaesthesia*

Reduction of simple nasal fractures may be performed under local or general anaesthesia: the latter is by far the most popular method in Britain, though why is hard to define. We have attempted to compare the 2 approaches by means of a randomized, prospective trial. Fifty consecutive, adult patients with radiologically proved fractures of the nasal bones were randomized to a local or general anaesthesia group and underwent manipulation with Asch's and Walsham's forceps between 7 and 15 days post-injury. Analysis of results at 4 h and 8 weeks post-operatively showed no significant benefit conferred by fracture reduction under general anaesthesia as opposed to local anaesthesia with respect to post-operative airway patency or cosmesis. It is suggested that significant benefits can be obtained in terms of patient convenience and cost effectiveness if nasal fractures are reduced under local anaesthesia as an outpatient procedure.     

Acute angle closure glaucoma precipitated by intranasal application of cocaine.

We describe a patient who developed acute angle-closure glaucoma following the application of topical intranasal cocaine. A 46-year-old woman underwent an elective antral washout under general anaesthesia and with local application of 25 per cent cocaine paste to the nasal mucosa. Twenty-four hours post-operatively the patient developed sudden painful blindness which was found to be due to acute glaucoma. Cocaine with its indirect sympathomimetic activity causes mydriasis, that can precipitate acute angle-closure glaucoma in predisposed individuals with a shallow anterior chamber. Although the incidence is rare, otolaryngologists need to be aware of this potential complication.     

The effect of local anaesthesia of the nasal vestibule on nasal sensation of airflow and nasal resistance

The effect of local anaesthesia of the nasal vestibule on nasal sensation of airflow and nasal resistance was assessed in 15 subjects. A single blind parallel group trial was undertaken in 30 subjects, with lignocaine as the active drug, and normal saline as the placebo. Fifteen subjects were included in each group. Both agents were infiltrated bilaterally into the floor of the nasal vestibule on each side via the sublabial route. Local anaesthesia of the nasal vestibule by infiltrating lignocaine produced a sensation of nasal obstruction in 9 out of 15 subjects (P less than 0.02). The infiltration of normal saline had no such effect. The difference between the effect of the 2 agents on nasal airflow sensation was significant (P less than 0.05). Neither injection had any significant effect on nasal resistance to airflow as assessed by active anterior rhinomanometry.     

The effects of nasal anaesthesia upon nasal sensation of airflow

The effect of nasal anaesthesia upon the sensation of nasal airflow and activity of menthol was investigated in 25 subjects using a visual analogue scale. Nasal anaesthesia was shown to decrease the sensation of nasal airflow, and also decrease the action of menthol in enhancing the sensation of nasal airflow. These differences were shown to be highly significant p less than 0.001. Physiological mechanisms responsible for conveying the subjective appreciation of a nasal airflow stimulus are discussed, and also the site and nature of the sensory nerve endings involved.     

Reduction of fractured nasal bones; local versus general anaesthesia

This prospective study was designed to asses whether the results of reducing simple fractures of the nasal bones were different using local or general anaesthesia. Two consecutive groups of 50 patients had their fractures manipulated under (a) general, or (b) local anaesthesia. The results of reduction as assessed by the patients and surgeons were not significantly different between the 2 groups. The reoperation rate for nasal obstruction and external deformity was similar in the 2 groups. We suggest that fractured nasal bones may be reduced under local anaesthesia without detriment to the results. This represents a significant saving of hospital resources.     

Manipulation of the fractured nose using topical local anaesthesia

Simple fracture of the nasal bone can be reduced under local or general anaesthesia. A combination of topical anaesthetic (EMLA cream) and cocainization of the nasal mucosa was used successfully in manipulation of fractured nasal bones in twelve patients without discomfort.     

A pilot study to determine the effects of nasal co-phenylcaine on drug-induced sleep endoscopy

European Archives of Oto-Rhino-Laryngology - The use of nasal decongestant and nasal anaesthesia is currently not recommended during drug-induced sleep endoscopy (DISE) according to the European...     

Submucous resection of the nasal septum as an outpatient procedure

We report our experience of submucous resection of the nasal septum under local anaesthesia as an outpatient procedure. We have audited 50 consecutive cases and compared the results with a similar group of patients in whom the operation was carried out in the usual way under general anaesthesia. We have found the procedure to be safe, effective and economically advantageous.     

Management of nasal injuries: a postal questionnaire survey of UK ENT consultants

Nasal injuries are one of the commonest conditions seen in ENT out-patients. There is no uniform policy or protocol for the management of this condition. A postal questionnaire was sent to all UK-based ENT consultants. The aim of this study was to ascertain current practice in the management of this common problem. We were also interested to know if consultants believed that the septum should be addressed and dealt with at the same time as manipulation to improve cosmetic and functional results. Manipulation of nasal bones without anaesthesia, under local anaesthesia, and general anaesthesia with digital pressure or using instruments are all practised. The digital pressure under general anaesthesia with use of septal and nasal forceps, if needed, is practised by the majority of consultants (55.8 per cent). Only a minority considered the role of the septum to be important in the initial management of the patient.     

194例儿童OSAHS手术治疗的临床分析

目的：探讨手术治疗儿童OSAHS的临床疗效。方法回顾分析2010年1月～2013年6月在我科住院194例儿童OSAHS的患儿,采用在全麻下行双侧扁桃体摘除术＋鼻内窥镜下经口径行腺样体电动吸切术,观察其临床效果。结果194例手术均取得良好效果,随访6个月～1年完全消除打鼾或仅有轻微鼾声。治愈140例,好效52例,无效2例,有效率98．9％。结论全麻下行双侧扁桃体摘除术＋鼻内镜下经口径行腺样体电动吸切术治疗儿童OSAHS具有良好的临床疗效,值得临床推广应用。     

The role of radiography in the management of nasal fractures

The role of radiographs in the management of nasal fractures is assessed. The injury is common and the total cost of radiographs significant. A retrospective study concluded that radiographs were not definitive in the management of nasal fractures. This prompted a prospective study, in which 54 patients were assessed clinically, radiologically and under anaesthesia. At each stage they were grouped into treatment and pathological categories and the contribution of each type of assessment studied. Radiographs were not found to be useful in the routine management of nasal fractures.     

Inferior nasal turbinate mucosa shrinkage prior to surgery under local anaesthesia

Introduction and ObjectivesChronic rhinitis-related complaints may result from isolated hypertrophy of the inferior nasal turbinates. If the symptoms persist despite conservative management, turbinoplasty is indicated. However, the nasal mucosa lining the inferior turbinates seems decongested immediately before the surgery performed under local anaesthesia, compared to the examination when the patients were entered for surgery. The study aimed to confirm this observation and to hypothesize as to the reasons for its occurrence.Patients and MethodsThe measurements of the longest distances between the medial rim of the inferior nasal turbinate mucosa and nasal septum and the shortest distances between the lower rim of the turbinate and floor of the nasal cavity in the inferior part of both common nasal meatus, were carried out on photos taken during endoscopic examinations: the one entering the patient for turbinoplasty, and the other immediately before the procedure. The results in this group were compared to those obtained from patients operated on under general anaesthesia.ResultsIn 130 patients aged 18-60 (mean = 40.7) years, operated on under local anaesthesia, the sum of the mean distances between the nasal septum and the medial rim of the lower turbinate in both nasal cavities, was 3.4 mm during the first examination, and 4.5 mm (p = .0008) during the second one. In the group of 42 participants aged 26-47, mean = 36.8 years operated on under general anaesthesia, the values were: 4.8 mm and 3.6 mm (p = .02), respectively. The differences were significantly smaller in the smokers (.3) compared to non-smokers (1.3; p = .04) mm.ConclusionsRecords of the entering examination must be considered before turbinoplasty under local anaesthesia.     

Fractured-nose reduction under local anaesthesia. Is it acceptable to the patient?

This article examines patients' acceptance of fractured-nose reduction under local anaesthesia, both objectively and subjectively. At each stage of the reduction the level of the discomfort, the patients' experiences were recorded. The success rate of complete reduction of the nasal fracture was found to be 71% and this was similar to that obtained in other studies that have used general anaesthesia. An overall level of discomfort for the procedure in terms a layman can understand was obtained by comparing the manipulation with that of having a tooth filled at the dentist. Sixty-three percent of the patients said that the nasal fracture reduction was no worse or the same as a dental filling. Our study showed that 96% of patients would be willing to undergo the same local anaesthetic procedure if they fractured their nose a second time. We conclude that it is possible to reduce the majority of fractured noses adequately with little inconvenience to the patient under local anaesthesia, and so we recommend that this procedure should be considered in the first-line treatment of the displaced fractured nose.     

Neurofibrosarcoma in the nasal cavity

A nine month old male child presented with a swelling protruding from the right nasal cavity for two months. Other symptoms were mild breathlessness during suckling and blood stained nasal discharge. CT Scan sshowed a mass arising from the lasteral wall of the right nasal cavity with mild erosion of the adjacent bones. The tumor was excised with wide margin through a lateral rhinotomy approach under general anaesthesia. In histopathological examination it was found to be a low grade neurofibrosarcoma. The child recovered well and is free from any recurrence till the time of reporting.     

Effect of intranasal treatment with capsaicin on the recurrence of polyps after polypectomy and ethmoidectomy

The aim of this study was to evaluate the influence of five intranasal applications of capsaicin, performed after endoscopic polypectomy associated with partial middle turbinectomy and anterior ethmoidectomy, on the recurrence of nasal polyps and the intensity of nasal obstruction and rhinorrhea. Fifty-one patients (19 females, 32 males, mean age 43 years) suffering from nasal polyposis for more than 1 year were included in this double blind, randomized, placebo-controlled study. During post-surgical controls, local anaesthesia and vasoconstriction of the middle meatus area were performed in all patients with a cotton pellet soaked with lidocain and adrenaline. In 29 patients, the same type of cotton pellet soaked with capsaicin (3 x 10(-6) mol. dissolved in 70% ethanol) was left into the middle meatus of both nostrils for 20 min. As a control group, 22 patients, matched for age and sex, were treated with the capsaicin vehicle alone (70% ethanol). All patients studied received the intranasal treatment once a week for 5 weeks. Subjective evaluations of nasal airway resistance (NAR) and rhinorrhea were recorded by means of a visual analogue scale. Clinical staging of the nasal polyposis (graded from stage 0 = absence of polyp to stage 3 = polyps occupying the entire nasal cavity) was evaluated by the same ENT specialist (ZW) using a 0 degrees endoscope. All parameters were recorded for each patient 1 week before surgery, then once a month for 9 months. Patients treated by endoscopic surgery followed by intranasal capsaicin application, reported a marked reduction in their NAR compared with the pretreatment evaluation (p<0.001). In contrast, patients treated with the vehicle alone did not have any significant improvement of their subjective NAR. Subjective rhinorrhea was not modified by either treatment. Patients treated with capsaicin showed a significant smaller staging of their nasal polyposis compared with the control group (p<0.001). These observations suggest that endoscopic surgery followed by intranasal capsaicin application reduces polyps and nasal obstruction recurrence and could be an alternative treatment to expensive corticosteroids in developing countries.     

Manipulation of the fractured nose under local anaesthesia.

Simple fractures of the nasal pyramid without significant septal deformity may be reduced as effectively under local as under general anaesthesia. Currently, the former may involve regional nerve blockade by intranasal infiltration and is often unpleasant. We have attempted to find a more acceptable method. Fifty consecutive, adult patients with clinically displaced nasal fractures were randomized to receive either blocks of the infraorbital, infratrochlear and external nasal nerves by intranasal infiltration or generalized infiltration of the nasal dorsum by an external route. All patients received intranasal cocaine. Following manipulation, each patient recorded their overall discomfort level and subjective nasal airway patency. The surgeon recorded the cosmetic result. Analysis revealed the internal route to be significantly more painful (P less than 0.001) and with no advantage to the patient with respect to post-operative airway patency or cosmesis. We recommend the technically easier external method for this procedure.