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The initial response to intraoperative hemorrhage should be to apply firm pressure to the bleeding area. Direct mechanical pressure is a very effective way to limit blood loss during and after surgery. If bleeding vessels can be visualized, they should be clamped and ligated. Collagen sponges, microfibrillar collagen, gelatin sponges, oxidized regenerated cellulose, and bone wax are all topical mechanical hemostatic agents that apply pressure to the area of bleeding [26]. Topical thrombin and fibrin‐based sealants promote formation of fibrin clots, and are applied onto the bleeding areas [27]. Surgical sealants such as polyethylene glycol polymers are used as an adjunct for vascular reconstruction, but are quite expensive [28].

A tourniquet can be used on the distal limb in order to improve visualization of transected vessels. In the case of diffuse bleeding, such as after debridement of exuberant granulation tissue, pressure bandages can be used on the distal limb. If substantial bleeding is encountered during paranasal sinus surgery, the sinus should be packed firmly with gauze packing and the sinusotomy bone flap can be temporarily stapled closed [29]. Chilled saline and topical vasoconstrictive agents such as epinephrine or phenylephrine can also be used as topical adjuncts (alone or on gauze packing) in sinus surgery to promote local vasoconstriction and reduce bleeding [30]. When blood loss from the paranasal sinuses cannot be controlled with direct pressure, temporary bilateral carotid artery occlusion can be used to limit blood loss ([31].

One of the most important factors in limiting blood loss is making a quick decision to limit blood loss and postpone the remainder of the surgery until bleeding is controlled. In the case of paranasal sinus surgery, the packing can be removed during a standing procedure 24 to 48 hours later, with reevaluation of the sinus and completion of the procedure under better visualization.