Original Article Optimum Degree of Head Elevation/ Reverse Trendelenburg Position for Sinus Surgery: Systematic Review Haissan Iftikhar, FCPS 1 , Shahzada Khuram Ahmed, PhD, FRCS 2 , Syed Akbar Abbas, FCPS 1 , Mubasher Ikram, FRCS 1 , Khawaja Mustafa, PhD 3 , and Jai K. Das, MD 4 Abstract Background: This review aims to evaluate the effect of Reverse Trendelenburg Position (RTP) on bleeding and Boezaart score and to determine the optimum degree of head elevation through a systematic review and meta-analysis. Methodology: We conducted a systematic review according to PRISMA guidelines and a literature search was performed on PubMed, Web of Science, Cochrane, Dental and Oral Science, Google scholar and Clinicaltrials.gov and included ran- domized controlled trials (RCTs) in English language only. We extracted all relevant data and conducted quality assessment using Cochrane risk of Bias tool (Version 2). We also performed quality assessment of the outcomes using GRADE. Meta- analysis for all the outcomes using conducted on RevMan version 5.3. Results: The search identified 629 articles and three RCTs that met our inclusion criteria. Two were included in the meta- analysis. A total of 124 patients were assessed for bleeding during sinus surgery and there was a significant reduction in total blood loss in RTP (10–15  ) when compared to horizontal position by 134 ml (Mean Difference (MD): 134.23; 95% confidence interval (CI): 184.13 to 67.27). RTP also had a significant reduction in bleeding per minute by 1.07 ml/min (MD: 1.07; 95%CI: (1.69 to 0.44), while the Boezaart score was significantly lower in the RTP group (MD: 0.69; 95% CI: 0.94 to 0.43) when compared to horizontal position. Conclusion: Though with limited evidence RTP for ESS reduces total blood loss, blood loss per minute and improves visualization. Further studies are needed to assess the actual impact and optimal degree of head elevation. Keywords bleeding, chronic rhinosinusitis, head elevation, reverse Trendelenburg position, sinus surgery, sinusitis Introduction It is estimated that 13% of Americans are affected by chronic rhinosinusitis (CRS) with health related cost of over $5 $10 billion 1–3 including the direct costs (physi- cian visit, medical and surgical management) and indirect cost attributed to decreased quality of life. 3 Endoscopic sinus surgery (ESS) is considered a “Gold standard” for treatment of sinus disease refractory to medical treat- ment. 4,5 This may be either for reduction in polyp load in CRS with polyposis or widening of ostia and creating a drainage pathway in CRS without polyposis. Endoscopic skull base resection of lesions has gained wide spread popularity due to decreased morbidity 1 Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan 2 Department of Otolaryngology, Queen Elizabeth Hospital, Birmingham, UK 3 Faculty of Health Sciences Library, Aga Khan University Medical College, Karachi, Pakistan 4 Division of Women and Child Health, Aga Khan University, Karachi, Pakistan Corresponding Author: Haissan Iftikhar, Department of Surgery, Aga Khan University Hospital, Karachi, Sindh 74800, Pakistan. Email: haissaniftikhar@gmail.com American Journal of Rhinology & Allergy 0(0) 1–6 ! The Author(s) 2020 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/1945892420954794 journals.sagepub.com/home/ajr