Introduction: Surgical field clarity is crucial in middle ear microsurgery where even minimal oozing deteriorates visibility and increases operative time. Total intravenous anaesthesia (TIVA) with propofol–remifentanil is hypothesised to reduce mucosal blood flow and improve visibility versus volatile maintenance (sevoflurane or desflurane). Materials and Methods: Prospective, parallel-group randomised study in adult ASA I–II patients undergoing elective tympanoplasty/mastoidectomy. Patients received either TIVA (propofol–remifentanil target-controlled infusion) or inhalational anaesthesia (sevoflurane/desflurane with remifentanil). Primary outcome was surgical field quality measured on a 6-point Boezaart bleeding scale at fixed timepoints. Secondary outcomes included blood loss, hemodynamics, operative time, emergence and recovery milestones, postoperative nausea–vomiting (PONV), and complications. Results: 120 patients were analysed (TIVA n=60; Inhalational n=60). Mean Boezaart score was lower with TIVA (2.2±0.6 vs 2.7±0.7; p<0.001). Blood loss (ml) and operative time (min) were reduced with TIVA (120±46 vs 148±52 ml, p=0.001; 84±18 vs 92±20 min, p=0.008). Emergence was faster with inhalational agents (extubation 7.6±2.1 vs 9.1±2.4 min; p<0.001) but readiness for discharge (Aldrete ≥9) was similar. PONV at 24 h was lower with TIVA (18.3% vs 38.3%; RR 0.48; p=0.014). No serious adverse events occurred. Conclusion: For middle ear surgery, propofol–remifentanil TIVA improved surgical field visibility and modestly reduced blood loss and operative time, while inhalational agents yielded slightly faster emergence. TIVA significantly decreased PONV without delaying discharge readiness.
Middle ear microsurgery (e.g., tympanoplasty, tympanomastoidectomy) demands a bloodless, stable field because limited working corridors magnify the impact of capillary oozing on visibility and surgical precision. Small differences in bleeding can translate into more suctioning, increased operative time, and potential iatrogenic injury. Anaesthetic technique is a key modulator of mucosal perfusion and venous pressure, and therefore a potential lever for improving operating conditions. Evidence from otologic and rhinologic surgery suggests that TIVA using propofol with short-acting opioids (commonly remifentanil) may improve the operative field compared with volatile maintenance, principally via sympathetic attenuation, reduced cardiac output, and favourable effects on mean arterial pressure and heart rate when carefully titrated. ¹–⁶
In middle ear surgery specifically, randomised and controlled studies have compared propofol-based TIVA with desflurane- or sevoflurane-based techniques, reporting better or at least non-inferior field visibility under TIVA without compromising safety.¹,²,⁷ Adjuncts such as dexmedetomidine (single dose or infusion) may further improve field quality in ear surgeries by attenuating sympathetic tone and salivation, although bradycardia and delayed early recovery can occur.²,⁸ Broader meta-analyses from endoscopic ear and sinus surgery corroborate a trend towards improved bleeding scores with TIVA, but also highlight heterogeneity, the influence of disease severity, and the importance of balanced hypotension and local vasoconstrictors.³–⁶
Recovery characteristics also matter in otologic day-care pathways. Volatile agents often enable quicker eye-opening and extubation, whereas propofol-based TIVA consistently reduces PONV—an outcome of particular relevance in middle ear patients where emesis can threaten grafts and increase vestibular symptoms.⁹–¹³ Contemporary PONV guidance explicitly endorses propofol-based maintenance as a prophylactic measure in at-risk populations.¹⁰
Given these considerations—and the presence of recent comparative data in middle ear microsurgery¹,⁷—this randomised study compared TIVA versus inhalational maintenance (with remifentanil in both arms) in adult patients undergoing elective middle ear surgery, focusing on surgical field visibility (Boezaart score) and clinically meaningful recovery endpoints (emergence, readiness for discharge, PONV). We hypothesised that TIVA would improve field visibility and reduce PONV, with similar discharge readiness, compared with inhalational techniques.¹–⁷,⁹–¹³
Prospective, single-centre, parallel-group, randomised controlled trial conducted in a tertiary otology unit. Institutional ethics approval was obtained; all patients provided written informed consent.
Participants
Inclusion criteria: Adults 18–65 years; ASA I–II; elective tympanoplasty (with/without cortical mastoidectomy) or canal wall-up mastoidectomy; expected duration 60–150 min.
Exclusion criteria: Uncontrolled hypertension or ischaemic heart disease; significant pulmonary disease; OSA requiring CPAP; difficult airway predictors (Mallampati IV, limited mouth opening <3 cm, cervical immobility); hepatic or renal failure; BMI ≥35 kg/m²; pregnancy; bradyarrhythmias; beta-blocker therapy within 24 h; chronic opioid use; known allergy/intolerance to study drugs; prior ear surgery within 6 months; inability to consent.
Randomisation and masking
Computer-generated 1:1 randomisation (variable block sizes). Allocation was concealed in sequentially numbered opaque envelopes. Surgeons and the independent Boezaart raters were blinded to group. Anaesthesia providers were not blinded due to the nature of interventions.
Interventions
TIVA group: Target-controlled infusions (TCI) of propofol (Marsh model, effect-site 2.5–4.0 µg/mL) and remifentanil (Minto, effect-site 2–6 ng/mL), titrated to BIS 40–60 and MAP 65–75 mmHg (or within 20% of baseline).
Inhalational group: Sevoflurane or desflurane (end-tidal 0.8–1.2 MAC) plus remifentanil TCI 2–6 ng/mL, with identical BIS and MAP targets.
Common measures: Standard monitoring, head-up 15°, normothermia, controlled ventilation (EtCO₂ 35–40 mmHg), dexamethasone 8 mg IV after induction, ondansetron 4 mg at closure, local infiltration with lidocaine–epinephrine per surgeon routine. Hypotensive adjuncts (esmolol boluses) permitted if MAP >75 mmHg and HR >80 despite protocolised titration.
Outcomes
Primary outcome: Mean Boezaart bleeding score (0–5, lower is better) averaged across three predefined timepoints (incision, drilling, and graft placement), rated from intraoperative videos by two blinded otologists; disagreements resolved by consensus.
Secondary outcomes: Estimated blood loss (EBL), operative time, intraoperative hemodynamics (MAP, HR), emergence times (eye-opening, extubation), time to Aldrete ≥9, PONV incidence (0–24 h), rescue antiemetic use, unplanned admission, and adverse events.
Sample size and statistics
Assuming a between-group difference of 0.4 in Boezaart score (SD 0.7), α=0.05, power 0.9, two-sided t-test required 52 per arm; targeting 60 per group to allow attrition. Continuous variables analysed with t-test or Mann–Whitney U as appropriate; categorical with χ²/Fisher’s exact; repeated hemodynamics with mixed-effects models. Two-tailed p<0.05 significant. Analyses were by intention-to-treat.
Participants: 132 screened; 120 randomised and analysed (CONSORT not shown): TIVA 60; Inhalational 60.
Table 1. Baseline characteristics
|
Variable |
TIVA (n=60) |
Inhalational (n=60) |
p-value |
|
Age, years |
38.9 ± 11.2 |
39.6 ± 10.8 |
0.71 |
|
Male, n (%) |
34 (56.7) |
35 (58.3) |
0.86 |
|
BMI, kg/m² |
24.7 ± 3.6 |
24.9 ± 3.8 |
0.78 |
|
ASA I / II, % |
63 / 37 |
60 / 40 |
0.71 |
|
Procedure (tymp/masto), % |
68 / 32 |
70 / 30 |
0.82 |
Interpretation: Groups were comparable at baseline.
Table 2. Primary outcome—Boezaart bleeding score
|
Timepoint |
TIVA |
Inhalational |
Mean diff (95% CI) |
p-value |
|
Incision |
1.9 ± 0.6 |
2.3 ± 0.7 |
−0.4 (−0.6 to −0.2) |
<0.001 |
|
Drilling |
2.4 ± 0.7 |
3.0 ± 0.8 |
−0.6 (−0.9 to −0.3) |
<0.001 |
|
Graft placement |
2.2 ± 0.6 |
2.7 ± 0.7 |
−0.5 (−0.7 to −0.3) |
<0.001 |
|
Mean of 3 timepoints |
2.2 ± 0.6 |
2.7 ± 0.7 |
−0.5 (−0.7 to −0.3) |
<0.001 |
Interpretation: TIVA improved field visibility by ~0.5 Boezaart points—consistent with prior ENT data.¹,³–⁷
Table 3. Intraoperative metrics
|
Variable |
TIVA |
Inhalational |
p-value |
|
Estimated blood loss, mL |
120 ± 46 |
148 ± 52 |
0.001 |
|
Operative time, min |
84 ± 18 |
92 ± 20 |
0.008 |
|
Mean MAP, mmHg |
68.9 ± 4.8 |
70.7 ± 5.2 |
0.03 |
|
Mean HR, bpm |
67.2 ± 7.6 |
72.1 ± 8.1 |
<0.001 |
Interpretation: Lower HR and slightly lower MAP with TIVA likely mediated the visibility gains; small but significant reductions in EBL and duration.
Table 4. Emergence and early recovery
|
Endpoint |
TIVA |
Inhalational |
p-value |
|
Eye opening, min |
6.1 ± 1.9 |
5.0 ± 1.7 |
<0.001 |
|
Extubation, min |
9.1 ± 2.4 |
7.6 ± 2.1 |
<0.001 |
|
Aldrete ≥9, min |
24.5 ± 7.8 |
23.6 ± 7.1 |
0.49 |
|
PACU length of stay, min |
78 ± 22 |
80 ± 24 |
0.58 |
Interpretation: Volatiles enabled slightly faster emergence, but overall discharge readiness and PACU time were similar.⁴,¹¹–¹³
Table 5. PONV and rescue antiemetics (0–24 h)
|
Outcome |
TIVA |
Inhalational |
Risk ratio |
p-value |
|
Any PONV |
11 (18.3%) |
23 (38.3%) |
0.48 |
0.014 |
|
Vomiting |
4 (6.7%) |
12 (20.0%) |
0.33 |
0.03 |
|
Rescue antiemetic |
9 (15.0%) |
19 (31.7%) |
0.47 |
0.03 |
Interpretation: Clinically meaningful reduction in PONV with TIVA, aligning with guideline-endorsed antiemetic benefits.⁹–¹³
Table 6. Adverse events and unplanned admissions
|
Event |
TIVA |
Inhalational |
p-value |
|
Bradycardia requiring atropine |
2 (3.3%) |
0 (0%) |
0.49 |
|
Hypotension requiring vasopressor |
3 (5.0%) |
4 (6.7%) |
1.00 |
|
Airway events |
0 |
1 (1.7%) |
1.00 |
|
Unplanned admission |
1 (1.7%) |
2 (3.3%) |
1.00 |
Interpretation: Low and comparable adverse event profile; rare bradycardia in TIVA arm was expected and easily managed.²
This randomised trial demonstrates that propofol–remifentanil TIVA improves surgical field quality in middle ear microsurgery compared with volatile maintenance plus remifentanil, with modest reductions in EBL and operative time. The magnitude of improvement (~0.5 on the Boezaart scale) mirrors prior middle ear and endoscopic ear/sinus literature.¹–⁷ TIVA’s favourable chronotropic and inotropic effects, coupled with tight remifentanil titration, likely underpin these gains.⁴–⁶
Our recovery findings show a trade-off: inhalational agents yielded slightly faster emergence (eye-opening and extubation), but readiness for discharge and PACU duration were similar between groups. This aligns with broader perioperative data where volatiles hasten early emergence, while TIVA confers superior emetogenic profile without delaying discharge.⁹–¹³ Of particular relevance to otology, we observed a ~50% relative reduction in 24-h PONV with TIVA, consonant with consensus recommendations that favour propofol-based maintenance as a PONV-sparing strategy in at-risk cohorts.¹⁰
Our results cohere with middle ear–specific trials. Yuan et al. compared propofol–remifentanil with desflurane–remifentanil and reported superior intraoperative field conditions under TIVA without compromising safety.¹ Liu et al. showed that a single pre-incision dexmedetomidine dose improved field visibility and decreased hemodynamic perturbations during middle ear surgery, albeit with a bradycardia signal—an observation consistent with our low-frequency bradycardia events.² Contemporary endoscopic ear surgery data similarly suggest less bleeding and improved visibility where TIVA or sympatholytic adjuncts are used judiciously.³,⁸
In contrast, some skull-base/endoscopic sinus studies show equipoise when remifentanil is standardised and MAP targets are matched, emphasising that surgical pathology, local vasoconstrictors, and surgeon factors can overshadow anaesthetic choice.⁴,⁵,¹⁴ Nonetheless, aggregated evidence—including meta-analyses—leans toward TIVA for optimal field conditions in sinonasal/otologic microsurgery when controlled hypotension is appropriate and carefully monitored.³–⁶,¹²
Strengths include concealed randomisation, blinded field scoring from video, standardised antiemetic prophylaxis, and pragmatic inclusion of both tympanoplasty and mastoidectomy. Limitations: single-centre design; anesthetist unblinded by necessity; use of both sevoflurane and desflurane (though stratified analysis showed no interaction); and exclusion of high-risk ASA III+ patients, limiting generalisability. We did not evaluate cost or surgeon satisfaction beyond Boezaart scores; future work could incorporate validated surgeon-rated global visibility and economic analyses.
Clinical implications: For routine middle ear procedures in ASA I–II patients, TIVA with propofol–remifentanil provides measurably better visibility and less PONV, without delaying discharge readiness. When ultra-fast emergence is the priority, volatile maintenance remains reasonable, particularly if robust multimodal antiemesis is implemented.¹⁰ Adjunctive dexmedetomidine may be considered selectively, with attention to bradycardia risk.²
Conclusion
Propofol–remifentanil TIVA enhanced surgical field visibility and reduced blood loss and PONV compared with sevoflurane/desflurane-based maintenance in middle ear microsurgery, while discharge readiness was similar. Tailoring anaesthetic technique to surgical goals and recovery priorities can optimise both intraoperative conditions and patient experience.
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