Establishing a near perfect surgical field during endoscopic nasal surgery is essential and even a minor bleeding can severely compromise an already restricted view. So, if controlled hypotension can be provided without compromising the safety of patient by a relatively effortless method, surgical field can be improved greatly, Studies have shown that reducing in both systolic blood pressure and heart rate to less than 60 beats per minute reduces intraoperative bleeding. These rates can be achieved by using beta-blocker drugs. <br />In this study, using a double-dose of metoprolol significantly reduced intraoperative bleeding and improved the quality of the operative field. It also reduced patients’ agitation in the recovery room , the most common method to administration of metoprolol its received oral metoprolol 50 mg on night and 2 h before surgery as premedication, risk Hypotension, or low blood pressure, is not typically a common side effect of metoprolol, individual responses to medications can vary, and some people may experience low blood pressure as a side effect, metoprolol a preferred choice for individuals with asthma or chronic obstructive pulmonary disease (COPD). <br /> Introduction<br />Excessive bleeding in the surgical field during an intervention appears to be one of the most serious problems of head and neck surgery. Incomplete blocks may be associated with topical anesthesia of head and neck, which can lead to a requirement for multiple injections and discomfort for both patients and doctors. In these types of surgery general anesthesia is often preferred over topical anesthesia. In addition, general anesthesia allows hypotensive anesthesia to be achieved [1, 2]. The unique and complicated anatomical structures of the head and neck, along with their proximity to the cranial base, brain, eyes, blood vessels and nerves requires the surgeon to have detailed anatomical knowledge and the ability to accurately identify structures. It is also very important for the surgeon to have a good view during surgery [1, 3].<br />Controlled hypotension or deliberate or reduced hypotension is a technique where the arterial blood pressure (BP) is reduced in a deliberate but controllable manner to minimize surgical blood loss and enhance operative field visibility [4]. For half a century, controlled hypotension has been used to reduce bleeding and the need for blood transfusions and provide a satisfactory bloodless surgical field. It has been indicated in oromaxillofacial surgery, endoscopic (sinus or middle ear) microsurgery, spinal surgery and other neurosurgery (aneurysm), major orthopedic surgery (hip and knee replacement), prostatectomy, cardiovascular surgery, and liver transplant surgery [5]. This technique has been used for various ENT surgeries such as tympanoplasty, functional endoscopic sinus surgery (FESS), septoplasty, rhinoplasty, and angiofibroma excision. <br />Induced/controlled hypotension is defined as the pharmacologically induced reduction in the mean arterial BP to 50–70 mm Hg either by inducing changes in the myocardial contractility (inhalation anesthetic agents and beta-blockers) or by peripheral vasodilatation (regional anesthesia, sodium nitroprusside, nitroglycerine, and trimethaphan) [6].<br />Inappropriate bleeding is one of the complications of nasal surgeries because it can lead to poor visibility for the surgeon and visibility is further reduced the longer the time of the intervention is extended. Increased bleeding can also cause surgeries to finish before they are fully completed. Improvement of intraoperative visibility by reducing bleeding is an important task for an anesthetist during head and neck surgery. Studies show that using beta-blockers before surgery reduces long term cardiovascular complications and intraoperative bleeding [7]. The probable mechanism of beta-blockers in hemodynamic control is a reduction and attenuation of the excitatory effect caused by a sudden increase of catecholamine during surgery. It is believed that beta-blockers are responsible for improvement of the cardiovascular condition and patients’ hemodynamic stability via changes in stress related physiological response [8]. <br />Literature Review <br />2.1 Nasal Surgery <br />Surgery of the nose or sinuses may be offered if medicine such as antibiotics, nose sprays, or steroids do not make a patient better. All types of surgery have risks, including surgery of the nose and sinuses. Patients must be aware of these risks before electing to proceed and weigh the benefits of the procedure against the risks involved. A discussion regarding the risks, benefits and possible alternatives to surgery between the patient and surgeon is strongly encouraged [10]. <br />Most textbooks on rhinoplasty include a description of angles and proportions that are generally perceived as being attractive. Leonardo da Vinci and Albrecht Duerer divided the face according to aesthetic principles. This concept was extended by Powell and Humphreys in 1984 <br />nalyses of the ideal nasal length and nasal tip projection have been proposed to help plan the surgery. Most surgeons, however, keep it simple by looking at the nasolabial angle which should be larger than 90° and 100° for male and female patients respectively. In profile the columella should be 2-3 mm below the inferior border of the nostril and a double break of the columella as well as a slight depression in the supra-tip (supra-tip break) are also found to be pleasing, especially in women. This may be helpful as an orientation for the surgeon but cannot be imposed on the patient in most cases, as the patient is interested in improving appearance and not in matching ideal proportions. Emphasizing the deviation from ideal proportions may be perceived as offensive by the patient who wishes to improve his or her looks and expects personal and ethnic character to be respected [8]. Review of previous studies <br />3.1 First study: The Efficacy of Hypotensive Agents on Intraoperative Bleeding and Recovery Following General Anesthesia for Nasal Surgery: A Network Meta-Analysis. [41]<br />A systematic review of the literature was conducted to evaluate hypotensive agents in terms of their adverse effects and associations with perioperative morbidity in patients undergoing nasal surgery. Two authors independently searched databases (Medline, Scopus, and Cochrane databases) up to February 2020 for randomized controlled trials comparing the perioperative administration of a hypotensive agent with a placebo or other agent. The outcomes of interest for this analysis were intraoperative morbidity, operative time, intraoperative bleeding, hypotension, postoperative nausea/vomiting, and postoperative pain. Both a standard pairwise meta-analysis and network meta-analysis were conducted. Analysis was based on 37 trials. Treatment networks consisting of six interventions (placebo, clonidine, dexmedetomidine, beta-blockers, opioids, and nitroglycerine) were defined for the network meta-analysis. Dexmedetomidine resulted in the greatest differences in intraoperative bleeding (−0.971; 95% confidence interval [CI], −1.161 to −0.781), intraoperative fentanyl administration (−3.683; 95% CI, −4.848 to −2.518), and postoperative pain (−2.065; 95% CI, −3.170 to −0.960) compared with placebo. The greatest difference in operative time compared with placebo was achieved with clonidine (−0.699; 95% CI, −0.977 to −0.421). All other agents also had beneficial effects on the measured outcomes. Dexmedetomidine was less likely than other agents to cause adverse effects. This study demonstrated the superiority of the systemic use of dexmedetomidine as a perioperative hypotensive agent compared with the other five tested agents. However, the other agents were also superior to placebo in improving operative time, intraoperative bleeding, and postoperative pain.<br />4. Conclusions: <br />It's important to note that the use of metoprolol or any other beta-blocker for controlling bleeding during nasal surgeries is not universally standard, and the decision to use such medications depends on various factors, including the patient's overall health, medical history, and the specific surgical procedure being performed. The choice to use metoprolol or any other medication to control bleeding during nasal surgery is typically made by the surgeon and anesthesiologist, taking into account the individual patient's needs and circumstances. Additionally, the use of medications to control bleeding may be part of a broader strategy that includes surgical techniques, hemostatic agents, and other considerations.<br />