European Archives of Oto-Rhino-Laryngology

, Volume 276, Issue 2, pp 383–388 | Cite as

Rating surgical field quality in endoscopic ear surgery: proposal and validation of the “Modena Bleeding Score”

  • Matteo Alicandri-Ciufelli
  • Luca Pingani
  • Davide Mariano
  • Lukas Anschuetz
  • Giulia MolinariEmail author
  • Daniele Marchioni
  • Marco Bonali
  • Gian Maria Galeazzi
  • Livio Presutti



To develop and validate a bleeding score that could be applied in endoscopic ear surgery (EEarS).


A prospective validation study was performed. A new bleeding score, called “Modena Bleeding Score” (MBS), was created by the authors. It provides five grades for rating the surgical field during EEarS procedures (from grade 1—no bleeding to grade 5—bleeding that prevents every surgical procedure except those dedicated to bleeding control). A preliminary “face validity” was performed by 18 ENT specialists to assess possible misunderstandings in interpreting the scale. Then, 15 videos of endoscopic ear surgery procedures, each divided into three parts (t0, t1, and t2), were subsequently evaluated by 15 specialists, using MBS. The videos were randomly selected and assigned. Intra-rater reliability and inter-rater reliability were calculated. The clinical validity of the instrument was calculated using a referent standard (i.e., four ENT experts whose ratings were compared to those obtained by the former sample).


The face validity showed a good consensus about the clarity and comprehension of the scale; both intra and inter-rater reliability demonstrated good performance (intra-rater reliability ranged from 0.741 to 0.991 and inter-rater reliability was 0.790); clinical validity also showed positive values, ranging from 0.75 to 0.93.


MBS has proved to be an effective method to rate surgical field during EEarS, with good-to-excellent performances. Its use would possibly help comparisons of groups in clinical trials or comparisons between studies.


Endoscopic ear surgery Modena Bleeding Score Surgical field rating Endoscopic surgery Middle ear surgery Bleeding 




Compliance with ethical standards

Conflict of interest

All the authors have nothing to disclose.


  1. 1.
    Qiao H, Chen J, Li W et al (2016) Intranasal atomised dexmedetomidine optimises surgical field visualisation with decreased blood loss during endoscopic sinus surgery: a randomized study. Rhinology 54:38–44CrossRefPubMedGoogle Scholar
  2. 2.
    Wormald PJ, van Renen G, Perks J et al (2005) The effect of the total intravenous anesthesia compared with inhalational anesthesia on the surgical field during endoscopic sinus surgery. Am J Rhinol 19:514–520CrossRefPubMedGoogle Scholar
  3. 3.
    Halderman AA, Sindwani R, Woodard TD (2015) Hemorrhagic Complications of Endoscopic Sinus Surgery. Otolaryngol Clin North Am 48:783–793CrossRefPubMedGoogle Scholar
  4. 4.
    Kelly EA, Gollapudy S, Riess ML, Woehlck HJ, Loehrl TA, Poetker DM (2013) Quality of surgical field during endoscopic sinus surgery: a systematic literature review of the effect of total intravenous compared to inhalational anesthesia. Int Forum Allergy Rhinol 3(6):474–481CrossRefPubMedGoogle Scholar
  5. 5.
    Boezaart AP, van der Merwe J, Coetzee A (1995) Comparison of sodium nitroprusside- and esmolol-induced controlled hypotension for functional endoscopic sinus surgery. Can J Anaesth 42:373–376CrossRefPubMedGoogle Scholar
  6. 6.
    Athanasiadis T, Beule A, Embate J, Steinmeier E, Field J, Wormald PJ (2008) Standardized video-endoscopy and surgical field grading scale for endoscopic sinus surgery: a multi-centre study. Laryngoscope 118(2):314–319CrossRefPubMedGoogle Scholar
  7. 7.
    Bujang MA, Baharum N (2017) Guidelines of the minimum sample size requirements for Cohen’s Kappa. EBPH. Google Scholar
  8. 8.
    Gisev N, Bell JS, Chen TF (2013) Interrater agreement and interrater reliability: key concepts, approaches, and applications. Res Soc Adm Pharm 9(3):330–338CrossRefGoogle Scholar
  9. 9.
    Cichetti Dv (1994) Guidelines, criteria, and rules of thumb for evaluating normed and standardized assessment instruments in psychology. Psychol Assess 6(4):284–290CrossRefGoogle Scholar
  10. 10.
    Cohen JA (1960) Coefficient of agreement for nominal scales. Educ Psychol Meas. Google Scholar
  11. 11.
    Sajedi P, Rahimian A, Khalili G (2016) Comparative evaluation between two methods of induced hypotension with infusion of remifentanil and labetalol during sinus endoscopy. J Res Pharm Pract 5(4):264–271CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Govindaraj S, Adappa ND, Kennedy DW (2010) Endoscopic sinus surgery: evolution and tehcnical innovations. J Laryngol Otol 124(3):242–250CrossRefPubMedGoogle Scholar
  13. 13.
    Beule AG, Wilhelmi F, Kühnel TS, Hansen E, Lackner KJ, Hosemann W (2007) Propofol versus sevoflurane: bleeding in endoscopic sinus surgery. Otolaryngol Head Neck Surg 136(1):45–50CrossRefPubMedGoogle Scholar
  14. 14.
    Eberhart LH, Folz BJ, Wulf H, Geldner G (2003) Intravenous anesthesia provides optimal surgical conditions during microscopic and endoscopic sinus surgery. Laryngoscope 113(8):1369–1373CrossRefPubMedGoogle Scholar
  15. 15.
    Ahn HJ, Chung SK, Dhong HJ, Kim HY, Ahn JH, Lee SM, Hahm TS, Kim JK (2007) Comparison of surgical conditions during propofol or sevoflurane anaesthesia for endoscopic sinus surgery. Br J Anesth 100(1):50–54CrossRefGoogle Scholar
  16. 16.
    McGuire DB (1984) The measurement of clinical pain. Nurs Res 33(3):152–156CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Matteo Alicandri-Ciufelli
    • 1
    • 2
  • Luca Pingani
    • 3
  • Davide Mariano
    • 1
  • Lukas Anschuetz
    • 4
  • Giulia Molinari
    • 1
    Email author
  • Daniele Marchioni
    • 5
  • Marco Bonali
    • 1
  • Gian Maria Galeazzi
    • 6
  • Livio Presutti
    • 1
  1. 1.Otolaryngology-Head and Neck Surgery DepartmentUniversity Hospital of ModenaModenaItaly
  2. 2.Neurosurgery DepartmentNew Civil Hospital Sant’Agostino-EstenseBaggiovaraItaly
  3. 3.Human Resources, Department of Mental HealthLocal Health Agency Reggio EmiliaReggio EmiliaItaly
  4. 4.Department of Otorhinolaryngology, Head and Neck Surgery, InselspitalBern University HospitalBernSwitzerland
  5. 5.Otolaryngology-Head and Neck Surgery DepartmentUniversity Hospital of VeronaVeronaItaly
  6. 6.Psychiatry DepartmentUniversity of Modena and Reggio EmiliaModenaItaly

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