***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background R and omized Controlled Trials ( RCTs ) represent the most valuable study design to evaluate the effectiveness of therapeutic interventions . However , flaws in design , conduct , analysis , and reporting of RCTs can cause the effect of an intervention to be under- or overestimated . These biased RCTs may be included in literature review s. To make the assessment of Risk of Bias ( RoB ) consistent and transparent , Cochrane published a RoB tool , with which RoB is assessed per item as “ low ” , “ unclear ” or “ high ” . Our objective was to provide an overview of RoB assessment s of RCTs in otorhinolaryngology over time , and to identify items where improvement is still warranted . Methods We retrieved Cochrane review s in the otorhinolaryngologic research field published in 2012 and 2013 . We used all judgments per item as assessed by the review authors of the included RCTs . We evaluated the association between “ low RoB ” vs. “ unclear and high RoB ” and the year of publication ( time strata : ‘ < 1990 ’ , ‘ 1990–1995 ’ , ‘ 1996–2000 ’ , ‘ 2001–2005 ’ , ‘ 2006–2012 ’ ) per item using binary logistic regression . Results We extracted the RoB assessment  s from 42 Cochrane review s that had included 402 RCTs ( median number of RCTs per review : 7 , range 1–40 ) . In total 2,356 items were assessed ( mean number of assessed items per RCT : 5.9 , st and ard deviation 1.8 ) . On binary logistic regression , RCTs published in 2006–2012 , compared with those published before 1990 , were more likely to have a low RoB for two items : r and om sequence generation ( odds ratio 6.09 [ 95 % confidence interval : 3.11–11.95 ] ) and allocation concealment ( 3.59 [ 1.87–6.90 ] ) . On all other items , there was no significant increase in the proportion of low RoB when comparing RCTs published in 2006–2012 with RCTs published before 1990 . Conclusion Although there were some positive developments in the RoB assessment s in otorhinolaryngology , a further decrease in RoB is still warranted on several items . Currently , biased RCTs are included in Cochrane review s and effects of therapeutic interventions can be under- or overestimated , with implication s for clinical patient care Background  Endoscopic sinus surgery  ( ESS ) is a common procedure preferably done with an anesthetic technique ensuring effective postoperative analgesia while speeding discharge home . Although anesthesia administered locally in conjunction with vasoconstricting agents is known to minimize intraoperative bleeding , its usefulness in providing postoperative analgesia has not been well characterized . The results supporting the use of regional anesthesia for sinus surgery have also been limited . Using a r and omized , double-blinded and placebo-controlled design , we evaluated recovery times , opioid consumption , and nausea and vomiting after ESS when patients were r and omized to either general anesthesia ( GA ) alone or with regional blockade . Methods Subjects were 70 adults scheduled for sinus surgery . All participants underwent propofol/remifentanil/nitrous oxide anesthesia and similar intraoperative care . Patients received either GA alone or with sphenopalatine ganglion ( SPG ) blocks in a double-masked study design . Independent observers recorded readiness for discharge , incidence of nausea/vomiting , and pain scores every 15 minutes until discharge . Overall opioid use in the recovery area was also a secondary end point . Twenty-four hours later , patients were called and asked to rate their pain and overall satisfaction with their pain control . Results Block group participants were considered ready for discharge after 45 minutes and discharged from the hospital ∼40 minutes sooner than GA group participants . The block group required less total fentanyl in the recovery room than did the A group . The incidences of nausea and vomiting did not differ significantly . Data at 24 hours postoperatively did not differ significantly between groups but trended toward increased satisfaction in the block group . No lasting adverse events were observed . Conclusion Regional anesthesia using targeted nerve blocks is effective in ESS . The combination of GA and SPG blockade appears to shorten hospital stay and reduce narcotic requirements in the recovery area . No demonstrable benefits were observed after 24 hours regarding pain management Background The aim of this study was to determine the effect of pterygopalatine fossa infiltration with lidocaine and adrenalin on bleeding in the surgical field during endoscopic sinus surgery . Methods A prospect i ve blind r and omized controlled trial was performed . Fifty-five patients were r and omized to receive a unilateral transoral infiltration of the pterygopalatine fossa with 2 mL of 2 % lidocaine and 1:80,000 adrenalin . The operating surgeon was blinded as to which side had been infiltrated at the start of surgery . The surgical field was grade d on a previously vali date d surgical field grading scale every 15 minutes with the side being operated on alternated every 30 minutes . The pulse , mean arterial blood pressure , and end-tidal CO2 concentration were monitored with each surgical field observation . Results At each individual time point from 30 minutes to 3.5 hours there was a significant difference in surgical grade between injected and noninjected sides in favor of the injected side ( p = 0.01 ) . The difference between surgical grade s averaged across all time points was slight but significant . The injected side had an overall mean of 2.59 ( SE , 0.22 ) compared with 2.99 ( SE , 0.23 ) for the noninjected side . Heart rate also was found to correlate independently to surgical grade . Conclusion Injection of the pterygopalatine fossa result ed in an improved surgical field during endoscopic sinus surgery Background . A strong ongoing intraoperative stress response can cause serious adverse reactions and affect the postoperative outcome . This study evaluated the effect of intranasally administered dexmedetomidine ( DEX ) in combination with local anesthesia ( LA ) on the relief of stress and the inflammatory response during functional endoscopic sinus surgery ( FESS ) . Methods . Sixty patients undergoing FESS were r and omly allocated to receive either intranasal DEX ( DEX group ) or intranasal saline ( Placebo group ) 1 h before surgery . Stress hormones , inflammatory markers , postoperative pain relief , hemodynamic variables , blood loss , surgical field quality , body movements , and satisfaction were assessed . Results . Plasma epinephrine , norepinephrine , and blood glucose levels were significantly lower in DEX group as were the plasma IL-6 and TNF-α levels ( P < 0.05 ) . The weighted areas under the curve ( AUCw ) of the VAS scores were also significantly lower in DEX group at 2–12 h after surgery ( P < 0.001 ) . Furthermore , hemodynamic variables , blood loss , body movements , discomfort with hemostatic stuffing , surgical field quality , and satisfaction scores of patients and surgeons were significantly better ( P < 0.05 ) in DEX group . Conclusions . Patients receiving intranasal DEX with LA for FESS exhibited less perioperative stress and inflammatory response as well as better postoperative comfort with hemostatic stuffing and analgesia Objectives Achieving adequate anesthesia with inferior alveolar nerve blocks ( IANB ) is of great importance during dental procedures . The aim of the present study was to assess the success rate of two anesthetic agents ( bupivacaine and lidocaine ) for IANB when treating teeth with irreversible pulpitis . Material s and Methods Sixty volunteer male and female patients who required root canal treatment of a m and ibular molar due to caries participated in the present study . The inclusion criteria included prolonged pain to thermal stimulus but no spontaneous pain . The patients were r and omly allocated to receive either 2 % lidocaine with 1:80,000 epinephrine or 0.5 % bupivacaine with 1:200,000 epinephrine as an IANB injection . The sensitivity of the teeth to a cold test as well as the amount of pain during access cavity preparation and root canal instrumentation were recorded . Results were statistically analyzed with the Chi-Square and Fischer 's exact tests . Results At the final step , fifty-nine patients were included in the study . The success rate for bupivacaine and lidocaine groups were 20.0 % and 24.1 % , respectively . There was no significant difference between the two groups at any stage of the treatment procedure . Conclusions There was no difference in success rates of anesthesia when bupivacaine and lidocaine were used for IANB injections to treat m and ibular molar teeth with irreversible pulpitis . Neither agent was able to completely anesthetize the teeth effectively . Therefore , practitioners should be prepared to administer supplemental anesthesia to overcome pain during root canal treatment Nasal polyps are associated with the inflammation of the nasal cavity and the sinus mucosa . When medical treatment can not solve a patient ’s problem , a functional endoscopic sinus surgery may be indicated . Bleeding impairs the surgery field during operation and increases the operation risk and time . Pre-operative corticosteroids can reduce bleeding during surgery . In this study , we have evaluated the effect of pre-operative single-dose prednisolone ( 1 mg/Kg/dose 24 h before surgery ) versus 5-day prednisolone ( 1 mg/Kg/day before operation ) on the bleeding volume and the surgery field quality during FESS . In this mono blind r and omized clinical trial , 80 patients with bilateral nasal polyps were r and omly assigned in two groups . The first group ( A ) received a single dose of 1 mg/Kg/dose prednisolone on the day before the surgery . The second group ( B ) received 1 mg/Kg/day prednisolone for 5 days before the operation . The patients were operated on under general anesthesia through the same protocol . The mean arterial blood pressure was 70–80 mm Hg in both groups . The surgeons were not aware of the patients ’ group . The bleeding volume and the surgeons ’ opinion about the surgery field quality were recorded at the end of the procedure and analyzed by Chi-square and t test . The two groups were not significantly different in their overall demographic and clinical characteristics . The mean bleeding volume during the operation was 266.5 ± 96.31 ml in group A and 206 ± 52.81 ml in group B ; there was a significant difference between the groups ( P value = 0.038 ) . There was no significant difference between the groups in the surgeons ’ opinion about the surgery field quality ( P value = 0.09 ) . In conclusion , unlike a single dose ( 1 mg/kg/dose ) , treatment with 5-day prednisolone ( 1 mg/kg/day ) can reduce blood loss during FESS more efficiently and may improve the surgery field quality slightly . But this difference is not clinical ly significant OBJECTIVE /HYPOTHESIS To find out the factors related to the volume of intraoperative blood loss during  endoscopic sinus surgery  and to vali date the role of reverse Trendelenburg position ( RTP ) in controlling blood loss . STUDY DESIGN Prospect i ve , controlled , single-blind study . METHODS  Endoscopic sinus surgeries for chronic rhinosinusitis with or without polyposis were performed in 60 patients , which were r and omly categorized into two groups . The study group ( RTP group ) consisted of 30 patients laid on operation table with the RTP of 10 degrees during the whole surgery , and the control group with 30 patients completely laid supine . All operations were performed by the same operator ( the first author ) without using hemostatic agents during the operation . Intraoperative blood loss was estimated by total volume of blood loss , blood loss per minute , and surgical field scale . Multiple factors related to blood loss , such as computed tomography scores , operation time , mean arterial pressure , polyposis , fungal sinusitis , and anesthetic agents were compared . RESULTS There existed significant differences in total blood loss , blood loss per minute , and surgical field between the RTP group and supine group . In multiple analyses within the two groups , presence of polyp , non-fungal sinusitis and use of microdebrider exhibited a significant higher blood loss rate in the RTP group . CONCLUSION RTP may reduce intraoperative blood loss . Besides , fungal sinusitis and rhinosinusitis without polyposis may contribute to a lesser intraoperative blood loss OBJECTIVE : To find out whether the constant preoperative use of a topical corticoid ( mometasone furoate [ MF ] ) could really improve the operative field quality and decrease bleeding during endoscopic sinus surgery ( ESS ) . STUDY DESIGN : Double-blind , r and omized controlled trial . SETTING : Tertiary referral center . SUBJECTS AND METHODS : Seventy patients with chronic rhinosinusitis ( CRS ) with and without polyps underwent ESS under st and ardized general anesthesia with equal r and omization into two groups . During four weeks within the preoperative period , 35 cases were treated with MF , while the other half received placebo matching sprays .  Total blood loss , operation time , and surgical field quality were recorded . RESULTS : Intraoperative blood loss in the MF-treated group was 142.8 mL , less than in the control group ( 170.6 mL ) . The difference between the groups is 27.7 mL ( 95 % confidence interval [ 
    Output:
    
Results Intraoperative bleeding ( P < .0001 ) , postoperative pain ( P = .0001 ) , nausea and vomiting ( P = .0117 ) , and recovery from sedation ( P < .0001 ) in the treatment group were significantly reduced compared with the control group .
No significant adverse effects were reported in the enrolled studies .
In subgroup analyses according to the SPGB approach ( transoral or transnasal ) , the transnasal approach showed higher positive effects on intraoperative bleeding and postoperative pain compared to the transoral approach .
Conclusion In our study , SPGB combined with a local anesthetic for ESS effectively reduced intra- and postoperative morbidities .
This procedure showed no significant adverse effects .