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Yue H, Yao F, Yin X, Li S, Zhang Q, Zhang W, Mi Y, Lao L, Xu S. Electroacupuncture for Pain Relief After Endoscopic Sinus Surgery: A Randomized Controlled Trial. THE JOURNAL OF PAIN 2023; 24:2014-2023. [PMID: 37348776 DOI: 10.1016/j.jpain.2023.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 06/02/2023] [Accepted: 06/09/2023] [Indexed: 06/24/2023]
Abstract
Postoperative pain is a common problem after endoscopic sinus surgery (ESS). Electroacupuncture (EA) is proven to be effective in relieving postoperative pain. However, EA has not been studied in patients undergoing ESS. This study was designed to evaluate the efficacy and safety of EA compared to a sham control in relieving pain after ESS. A total of 62 patients were randomly allocated to receive either EA (n = 31) or sham EA (n = 31) for 5 sessions, 30 minutes per session for 4 days (2 hours before and 2 hours after surgery, and 3 sessions daily for the following 3 days). There were no significant differences between the 2 groups with regard to demographic characteristics. Compared to the sham EA group, the EA group showed a significantly greater reduction in the pain intensity of single daily scoring with a numerical rating scale at the day following surgery (postoperative day 1, POD1) (-1.35; 95% confidence interval [CI], -1.74 to -0.97; P < .001) and POD2 (-1.16; 95% CI, -1.55 to -0.77; P < .001), whereas no significant between-group difference was detected at the day of surgery (POD0), POD3 or POD6. Intraoperative heart rate and mean blood pressure in the EA group showed a more stable trend. A significant improvement was found for an actigraphy-measured average time of night wakings, recovery time from anesthesia, and quality of recovery-15 in the EA group. No severe adverse events occurred during the trial. Our results demonstrate that EA can serve as an effective adjuvant therapeutic tool for pain relief after ESS. PERSPECTIVE: This randomized sham-controlled, patient-and-assessor blinded trial provided evidence for the first time that EA can relieve postoperative pain and other symptom management in patients after ESS. TRIAL REGISTRATION NUMBER: Chinese Clinical Trial Registry, ChiCTR1900024183, http://www.chictr.org.cn/showproj.aspx?proj=40573.
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Affiliation(s)
- Hongyu Yue
- Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Fei Yao
- Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China; School of Acupuncture-Moxibustion and Tuina, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Xuan Yin
- Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Shanshan Li
- Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Qing Zhang
- Department of anesthesiology, Shanghai Jingan District Zhabei Central Hospital, Shanghai, China
| | - Wei Zhang
- Department of Biostatistics, School of Public Health, Fudan University, Shanghai, China
| | - Yiqun Mi
- Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Lixing Lao
- Virginia University of Integrative Medicine, Fairfax, Virginia
| | - Shifen Xu
- Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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Zhou LZ, Li X, Zhou LM. Global Trends in Research of Perioperative Analgesia Over Past 10 Years: A Bibliometric Analysis. J Pain Res 2023; 16:3491-3502. [PMID: 37876889 PMCID: PMC10591619 DOI: 10.2147/jpr.s429719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 09/26/2023] [Indexed: 10/26/2023] Open
Abstract
Background The postoperative acute pain caused by surgery has been a major problem plaguing anesthesiologists, and even some acute pain progresses to chronic pain syndrome, terribly reducing the quality of life of patients. To this end, increasing attention has been paid to the management of perioperative analgesia. At present, with the increase of research on perioperative analgesia, the understanding and solution of this clinical problem have been further developed. Bibliometrics can estimate research hot-spots and trends of related fields in a certain period of time. However, a systematic bibliometric analysis has not been conducted to explore current research hotspots and future development trends, which is thus the purpose of this study. Methods Articles and reviews published from 2012 to 2021 were retrieved from the Web of Science Core Collection (WoSCC) database, and the bibliometric analysis of the keywords and references of articles was performed using VOSviewer1.6.18. Besides, the number of articles related to perioperative analgesia in term of countries, affiliations, authors, and journals were analyzed. Results Finally, 3157 articles meeting the screening requirements were retrieved, and it was hereby found that the research on perioperative analgesia had received more attention and interest in the past 10 years, with the United States making more contributions, where there were eight of the top ten affiliations by the number of publications. Kaye AD was the most active researcher in this field. Most related articles were published in Anesthesia and Analgesia, accounting for 2.76% of all literature. Enhanced recovery after surgery, different types of anesthesia and multi-mode analgesic drug intervention were the main trends and hotspots. Conclusion Perioperative analgesia has attracted considerable academic interest. In the past decade, the effects of enhanced recovery after surgery, different types of anesthesia and multi-mode analgesic drug intervention on perioperative analgesia have become the research hotspots, which are also likely to be the focus of future study.
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Affiliation(s)
- Lian Zhen Zhou
- Department of Anesthesiology, the Second Affiliated Hospital of Shandong First Medical University, Tai’ an, People’s Republic of China
| | - Xuan Li
- Department of Anesthesiology and Pain Clinic, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, People’s Republic of China
| | - Li Min Zhou
- Department of Anesthesiology, the Second Affiliated Hospital of Shandong First Medical University, Tai’ an, People’s Republic of China
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Lee DJ, Grose E, Brenna CTA, Philteos J, Lightfoot D, Kirubalingam K, Chan Y, Palmer JN, Adappa ND, Lee JM. The benefits and risks of non-steroidal anti-inflammatory drugs for postoperative analgesia in sinonasal surgery: a systematic review and meta-analysis. Int Forum Allergy Rhinol 2023; 13:1738-1757. [PMID: 36762711 DOI: 10.1002/alr.23140] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/26/2023] [Accepted: 02/06/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Non-steroidal anti-inflammatory drugs (NSAIDs) have emerged as an alternative to opioids for optimal postoperative pain management. However, the adoption of NSAIDs in sinonasal surgery has been impeded by a theoretical concern for postoperative bleeding. Our objective is to systematically review the efficacy and safety of NSAIDs for patients undergoing sinonasal surgery. METHODS MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, CINAHL, and the WHO International Clinical Trials Registry Platform were searched from inception to January 27, 2022. Randomized controlled trials (RCTs) and comparative observational studies in any language were considered. Screening, data extraction, and risk of bias assessment were performed in duplicate. Our outcomes were postoperative pain scores, requirement for rescue analgesia, and postoperative adverse events (epistaxis, nausea/vomiting). RESULTS Out of 4661 records, 15 RCTs (enrolling 1210 patients) and two observational studies were included. Following endoscopic sinus surgery, there was no difference in pain scores between NSAIDs and non-NSAIDs groups (standardized mean differences [SMD] 0.44 units better, 95% CI -0.18 to 1.05). Following septorhinoplasty, NSAIDs decreased pain scores compared to non-NSAID regimens (SMD 1.14 units better, 95% CI 0.61 to 1.67 units better). Overall, NSAIDs reduced the need for rescue medication with a relative risk (RR) of 0.45 (95% CI 0.24 to 0.84). In addition, NSAIDs decreased the risk of nausea with an RR of 0.62 (95% CI 0.42 to 0.91) and did not increase the risk of epistaxis (RR 0.72, 95% CI 0.23-2.22). CONCLUSION Among patients undergoing sinonasal surgery, NSAIDs are beneficial in postoperative pain management and avoidance of postoperative nausea without increasing the risk of postoperative epistaxis.
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Affiliation(s)
- Daniel J Lee
- Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Elysia Grose
- Division of Rhinology, Department of Otolaryngology - Head & Neck Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Connor T A Brenna
- Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Justine Philteos
- Division of Rhinology, Department of Otolaryngology - Head & Neck Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - David Lightfoot
- St. Michael's Hospital Health Sciences Library, Unity Health Toronto, Toronto, Ontario, Canada
| | | | - Yvonne Chan
- Division of Rhinology, Department of Otolaryngology - Head & Neck Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - James N Palmer
- Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nithin D Adappa
- Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John M Lee
- Division of Rhinology, Department of Otolaryngology - Head & Neck Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
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Bishop JL, Marshall RV, McCormick JP, Tomblin C, Garcia N, Feinstein J, Cho DY, Grayson JW, Woodworth BA. Long-duration pain block for postoperative anesthesia after endoscopic sinus surgery. Int Forum Allergy Rhinol 2023; 13:1825-1828. [PMID: 36811323 DOI: 10.1002/alr.23143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 01/26/2023] [Accepted: 02/16/2023] [Indexed: 02/24/2023]
Abstract
KEY POINTS A long-duration pain block did not decrease postoperative pain or opioid consumption. Extended sinus procedures do not lead to additional postoperative pain or opioid consumption.
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Affiliation(s)
- Jessica L Bishop
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ryan V Marshall
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Justin P McCormick
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Caitlyn Tomblin
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Natalie Garcia
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Joel Feinstein
- Department of Anesthesiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Do Yeon Cho
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Division of Otolaryngology-Head and Neck Surgery, Department of Veterans Affairs, Birmingham, Alabama, USA
| | - Jessica W Grayson
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Bradford A Woodworth
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Steigerwald L, Schinz K, Sievert M, Mantsopoulos K, Gostian AO, Iro H, Mueller SK. Differences in Need for Opioids After Sinonasal Surgery at Day of Surgery and in the Postoperative Period. EAR, NOSE & THROAT JOURNAL 2023; 102:110-116. [PMID: 33433234 DOI: 10.1177/0145561320983180] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION In the last years, the use of opioid analgesics has increased, as well as their morbidity and mortality, especially in the United States. Most patients after sinonasal surgery receive opioid analgesics, although up to 90% have leftover opioid pills. Around 70% of these patients keep the opioid analgesics, which could possibly lead to improper use. The objective of the following study was the investigation of the need for, use of, timing and side effects of opioid and non-opioid analgesics after sinonasal surgery. METHODS This was a retrospective study of (n = 280) patients who underwent sinonasal surgery in the Otolaryngology Department of the University Erlangen-Nürnberg between January and December 2018. The postoperative pain (3-5 days after surgery) using the numeric rating scale and the postoperative need for on-demand opioids and non-opioid analgesics in relation to demographic and surgical parameters were evaluated. RESULTS Of total, 59.64% of all patients received opioid analgesics postoperatively on the day of surgery. On the first postoperative day (POD1), the mean pain score yielded the highest values; however, only 0.71% of the patients needed opioid analgesics, and pain was sufficiently controlled with non-opioids or no pain medication at all. There was a significant reduction of the pain score from POD2 to 5 (P = .01; P < .01, respectively). Only 1.8% of the patients needed an opioid analgesic from POD1-5. Of total, 2.1% of the patients presented with a postoperative bleeding complication, and only 1 (0.4%) patient needed endoscopic coagulation. CONCLUSION Our results indicate that the majority of patients need opioid analgesics almost exclusively on the day of surgery. There were no major complications in patients taking either opioid or non-opioids. Our results indicate that the postoperative pain regimen from POD1 should initially be started using non-opioid analgesics and be further escalated to opioid analgesics in individual cases.
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Affiliation(s)
- Lukas Steigerwald
- Department of Otorhinolaryngology, Head and Neck Surgery, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Katharina Schinz
- Department of Otorhinolaryngology, Head and Neck Surgery, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Matti Sievert
- Department of Otorhinolaryngology, Head and Neck Surgery, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Konstantinos Mantsopoulos
- Department of Otorhinolaryngology, Head and Neck Surgery, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Antoniu-Oreste Gostian
- Department of Otorhinolaryngology, Head and Neck Surgery, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Heinrich Iro
- Department of Otorhinolaryngology, Head and Neck Surgery, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Sarina K Mueller
- Department of Otorhinolaryngology, Head and Neck Surgery, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
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Abiri A, Patel TR, Nguyen E, Birkenbeuel JL, Tajudeen BA, Choby G, Wang EW, Schlosser RJ, Palmer JN, Adappa ND, Kuan EC. Postoperative protocols following endoscopic skull base surgery: An evidence-based review with recommendations. Int Forum Allergy Rhinol 2023; 13:42-71. [PMID: 35678720 DOI: 10.1002/alr.23041] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 05/30/2022] [Accepted: 05/31/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Postoperative management strategies for endoscopic skull base surgery (ESBS) vary widely because of limited evidence-based guidance. METHODS The PubMed, EMBASE, and Cochrane databases were systematically reviewed from January 1990 through February 2022 to examine 18 postoperative considerations for ESBS. Nonhuman studies, articles written in a language other than English, and case reports were excluded. Studies were assessed for levels of evidence, and each topic's aggregate grade of evidence was evaluated. RESULTS A total of 74 studies reporting on 18 postoperative practices were reviewed. Postoperative pain management, prophylactic antibiotics, and lumbar drain use had the highest grades of evidence (B). The literature currently lacks high quality evidence for a majority of the reviewed ESBS precautions. There were no relevant studies to address postoperative urinary catheter use and medical intracranial pressure reduction. CONCLUSION The evidence for postoperative ESBS precautions is heterogeneous, scarce, and generally of low quality. Although this review identified the best evidence available in the literature, it suggests the urgent need for more robust evidence. Therefore, additional high-quality studies are needed in order to devise optimal postoperative ESBS protocols.
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Affiliation(s)
- Arash Abiri
- Department of Otolaryngology, Head and Neck Surgery, University of California Irvine, Orange, California, USA
| | - Tirth R Patel
- Department of Otolaryngology, Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Emily Nguyen
- Department of Otolaryngology, Head and Neck Surgery, University of California Irvine, Orange, California, USA
| | - Jack L Birkenbeuel
- Department of Otolaryngology, Head and Neck Surgery, University of California Irvine, Orange, California, USA
| | - Bobby A Tajudeen
- Department of Otolaryngology, Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Garret Choby
- Department of Otolaryngology, Head and Neck Surgery and Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Eric W Wang
- Department of Otolaryngology, Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Rodney J Schlosser
- Department of Otolaryngology, Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - James N Palmer
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Nithin D Adappa
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Edward C Kuan
- Department of Otolaryngology, Head and Neck Surgery, University of California Irvine, Orange, California, USA
- Department of Neurological Surgery, University of California Irvine, Orange, California, USA
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Hoke AT, Malfitano M, Zanation AM, Ebert CS, Senior BA, Kimple AJ, Thorp BD. Postoperative Pain Management and Perceived Patient Outcomes following Endoscopic Pituitary Surgery. J Neurol Surg B Skull Base 2022; 83:397-404. [PMID: 35903651 PMCID: PMC9324296 DOI: 10.1055/a-1692-9879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 11/06/2021] [Indexed: 10/19/2022] Open
Abstract
Objectives Pain management remains a point of emphasis given the ongoing opioid crisis. There are no studies in the literature interrogating opioid prescribing and use following endoscopic pituitary surgery. This study investigates provider prescribing tendency, patient utilization of analgesics, and patient outcomes regarding pain management after endoscopic pituitary surgery. Methods We identified 100 patients undergoing endoscopic pituitary surgery at one institution from 2016 to 2018 in the electronic medical record (EMR) and state narcotic database to determine postoperative analgesic regimens. A telephone survey was used to characterize postoperative analgesic use and satisfaction with prescribed regimen. Results Fifty-two different pain control regimens were prescribed to the study patients. Also, 93% of study patients were prescribed an opioid postoperatively. The average quantity of opioids prescribed per patient in morphine milligram equivalents (MMEs) was 625 (equivalent 83 oxycodone 5-mg tablets) with an average MME/day of 59 (equivalent 8 oxycodone 5-mg tablets). A total of 71% survey respondents who used opioids reported using <25% of their prescription. The majority of prescription narcotic users consumed >50% of their postoperative opioid intake in the first 24 to 48 hours after discharge. There were no significant differences in pain outcome between opioid users and nonopioid users. Conclusion Vast heterogeneity exists in narcotic prescribing by providers at our institution following endoscopic pituitary surgery. Narcotic prescribing patterns exceeded most patients' analgesic needs. Opioid analgesics were not superior to nonopioids regimens in patient-reported pain outcomes in this study population.
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Affiliation(s)
- Austin T.K. Hoke
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel, North Carolina, United States
| | - Madison Malfitano
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel, North Carolina, United States
| | - Adam M. Zanation
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel, North Carolina, United States
| | - Charles S. Ebert
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel, North Carolina, United States
| | - Brent A. Senior
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel, North Carolina, United States
| | - Adam J. Kimple
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel, North Carolina, United States
| | - Brian D. Thorp
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel, North Carolina, United States
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Yang HH, Wu TJ, Suh JD, Wang MB, Holliday MA, Beswick DM, Zhang H, Wells C, McCormick J, Maxim T, Regev A, Chandy ZK, Lee JT. Postoperative Gabapentin's Effect on Opioid Consumption and Pain Control Following Sinonasal Surgery. Laryngoscope 2022; 133:1065-1072. [PMID: 35833722 DOI: 10.1002/lary.30282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 06/20/2022] [Accepted: 06/21/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVE This study investigates the impact of postoperative gabapentin on opioid consumption and pain control following endoscopic sinus surgery (ESS) and/or septoplasty. METHODS Patients who underwent ESS and/or septoplasty at a single institution from 2021 to 2022 were enrolled. All patients received postoperative hydrocodone-acetaminophen for pain control. Half of the patients were also prescribed gabapentin for the first postoperative day in addition to hydrocodone-acetaminophen. Subjects completed the Revised American Pain Society Patient Outcome Questionnaire 24 h and 7 days after surgery. We conducted a multivariable regression analysis to assess opioid consumption and improvement in pain scores in the first week between gabapentin and non-gabapentin groups. RESULTS A total of 102 subjects, 51 in each arm, were enrolled. The mean age was 52 years and 53% of participants were female. Controlling for important baseline demographic, clinical, and surgically related variables, the addition of postoperative gabapentin was associated with a 44% (9.5 mg from 21.6 mg) reduction in opioids consumed in the first postoperative week (B = -9.54, 95% C.I. = [-17.84, -1.24], p = 0.025). In addition, patients in both arms exhibited similar improvement in pain severity and sleep interference in the first 7 days (B = -1.59, 95% C.I. = [-5.03, 1.84], p = 0.36). CONCLUSION To the best of our knowledge, this is the first study to investigate the impact of postoperative gabapentin on opioid consumption and pain control following ESS and/or septoplasty. Our analysis demonstrated that postoperative gabapentin effectively reduced opioid use during the first postoperative week without compromising pain control. LEVEL OF EVIDENCE 3 Laryngoscope, 2022.
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Affiliation(s)
- Hong-Ho Yang
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Tara J Wu
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Jeffrey D Suh
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Marilene B Wang
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Michael A Holliday
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Daniel M Beswick
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Huan Zhang
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Christine Wells
- Office of Academic Research and Computing, University of California, Los Angeles, California, USA
| | - Justin McCormick
- Department of Otolaryngology-Head and Neck Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Tom Maxim
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Aviva Regev
- Department of Anesthesiology, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Zachariah K Chandy
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Jivianne T Lee
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, California, USA
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Go BC, Go CC, Chorath K, Moreira A, Rajasekaran K. Nonopioid perioperative analgesia in head and neck cancer surgery: A systematic review. World J Otorhinolaryngol Head Neck Surg 2022; 8:107-117. [PMID: 35782401 PMCID: PMC9242426 DOI: 10.1002/wjo2.62] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 01/30/2022] [Indexed: 12/12/2022] Open
Abstract
Objective Management of postoperative pain after head and neck cancer surgery is a complex issue, requiring a careful balance of analgesic properties and side effects. The objective of this review is to discuss the efficacy and safety of multimodal analgesia (MMA) for these patients. Methods Pubmed, Cochrane, Embase, Scopus, and clinicaltrials.gov were systematically searched for all comparative studies of patients receiving MMA (nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, anticonvulsants, local anesthetics, and corticosteroids) for head and neck cancer surgeries. The primary outcome was additional postoperative opioid usage, and secondary outcomes included subjective pain scores, complications, adverse effects, and 30-day outcomes. Results A total of five studies representing 592 patients (MMA, n = 275; non-MMA, n = 317) met inclusion criteria. The most commonly used agents were gabapentin, NSAIDs, and acetaminophen (n = 221), NSAIDs (n = 221), followed by corticosteroids (n = 35), dextromethorphan (n = 40), and local nerve block (n = 19). Four studies described a significant decrease in overall postoperative narcotic usage with two studies reporting a significant decrease in hospital time. Subjective pain scores widely varied with two studies reporting reduced pain at postoperative day 3. There were no differences in surgical outcomes, medical complications, adverse effects, or 30-day mortality and readmission rates. Conclusion MMA is an increasingly popular strategy that may reduce dependence on opioids for the treatment of postoperative pain. A variety of regimens and protocols are available for providers to utilize in the appropriate head and neck cancer patient.
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Affiliation(s)
- Beatrice C. Go
- Department of OtorhinolaryngologyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Cammille C. Go
- Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Kevin Chorath
- Department of OtorhinolaryngologyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Alvaro Moreira
- Department of Pediatrics, Division of NeonatologyUniversity of Texas Health‐San AntonioSan AntonioTexasUSA
| | - Karthik Rajasekaran
- Department of OtorhinolaryngologyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
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Schinz K, Steigerwald L, Mantsopoulos K, Gostian AO, Traxdorf M, Sievert M, Rupp R, Iro H, Mueller SK. Depression and female gender associated with higher postoperative pain scores after sinonasal surgery. Acta Otolaryngol 2022; 142:73-77. [PMID: 34939889 DOI: 10.1080/00016489.2021.2012254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Although it is extremely necessary to reduce the number of opioids taken postoperatively after sinonasal surgery, this is the subject of controversial discussion. OBJECTIVES The objective of this study was to identify factors that predict higher postoperative pain scores (PPS) and the need for opioid analgesics after sinonasal surgery. MATERIAL AND METHODS This was a retrospective study of n = 492 patients who underwent functional endoscopic sinus surgery (FESS), septoplasty or a combination of both in the Otolaryngology Department in Erlangen between January and December 2018. Postoperative pain using the numeric rating scale and the postoperative need for non-opioid and opioid analgesics in relation to demographic and surgical parameters were evaluated. RESULTS Significant predictors for a higher pain score were depression (p = .009) and female gender (p < .001). A significant predictor of the need for postoperative opioids was the female gender (p < .001), whereas FESS alone showed a significantly lower need for opioids (p = .035) and a significantly lower PPS compared to septoplasty (p < .001). CONCLUSIONS AND SIGNIFICANCE The study identified risk factors for a higher PPS and the need for opioids. The results indicated that reducing postoperative opioids might be possible in patients without these risk factors and might help guide individualized postoperative therapy.
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Affiliation(s)
- Katharina Schinz
- Department of Otorhinolaryngology, Head and Neck Surgery, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Lukas Steigerwald
- Department of Otorhinolaryngology, Head and Neck Surgery, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Konstantinos Mantsopoulos
- Department of Otorhinolaryngology, Head and Neck Surgery, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Antoniu-Oreste Gostian
- Department of Otorhinolaryngology, Head and Neck Surgery, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Maximilian Traxdorf
- Department of Otorhinolaryngology, Head and Neck Surgery, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
- Department of Otorhinolaryngology, Head and Neck Surgery, Paracelsus University, Nürnberg, Germany
| | - Matti Sievert
- Department of Otorhinolaryngology, Head and Neck Surgery, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Robin Rupp
- Department of Otorhinolaryngology, Head and Neck Surgery, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Heinrich Iro
- Department of Otorhinolaryngology, Head and Neck Surgery, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Sarina Katrin Mueller
- Department of Otorhinolaryngology, Head and Neck Surgery, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
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Saini AT, Jiang ZY, Starr NC, Talmadge J, Schmale I, Radabaugh P, Yao WC, Luong AU, Citardi MJ. Are NSAIDs effective enough for postoperative pain control after functional endoscopic sinus surgery and septoplasty: A randomized controlled study. Int Forum Allergy Rhinol 2021; 12:910-916. [PMID: 34936232 DOI: 10.1002/alr.22941] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 10/21/2021] [Accepted: 12/07/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Endoscopic sinus surgery (ESS) and septoplasty are commonly performed procedures without standardized post-operative pain regimens. There is reluctance to prescribe opioids for postoperative pain given their potential for abuse. NSAIDS have been previously demonstrated to reduce or even obviate the need for opioid pain medications after otolaryngologic surgeries, but prospective validation is lacking. METHODS A randomized controlled study comparing the efficacy of diclofenac sodium to hydrocodone/acetaminophen (APAP) following ESS with or without septoplasty was performed. Participants were given a 100 mm visual analog pain scale (VAS) at postoperative day (POD) 1, 2, 3, and 5 following ESS. Two-sample t-tests were used to compare pain scores between groups. RESULTS One hundred patients enrolled, and 74 patients provided pain scores to the survey. Pain was greatest for both groups on postoperative day one. Treatment with diclofenac sodium versus hydrocodone/APAP did not statistically impact pain scores at POD 1, 2, 3, or 5. No cases of epistaxis requiring an emergency room visit or return to the operating room were noted during the study period. CONCLUSIONS Diclofenac sodium may be non-inferior to hydrocodone/APAP in treating pain after ESS with or without septoplasty in opioid naïve patients without preexisting pain conditions. Further studies with larger samples are warranted to investigate the potential superiority of diclofenac to hydrocodone/APAP in certain patients after ESS and septoplasty. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Alok T Saini
- Department of Otolaryngology - Head and Neck Surgery, College of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Zi Y Jiang
- Department of Otorhinolaryngology - Head and Neck Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Nicole C Starr
- Department of Otolaryngology - Head and Neck Surgery, College of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Jason Talmadge
- Department of Otolaryngology and Communicative Sciences, Medical College of Wisconsin, Kenosha, Wisconsin, USA
| | - Isaac Schmale
- Department of Otolaryngology - Head and Neck Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Paul Radabaugh
- Department of Otorhinolaryngology - Head and Neck Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - William C Yao
- Department of Otorhinolaryngology - Head and Neck Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Amber U Luong
- Department of Otorhinolaryngology - Head and Neck Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Martin J Citardi
- Department of Otorhinolaryngology - Head and Neck Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA
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12
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Pandrangi VC, Scott BL, Pailet J, Mace JC, Farrell NF, Geltzeiler M, Smith TL, Detwiller KY. Pain and Opioid Consumption Following Endoscopic Sinus Surgery: A Prospective Cohort Study. Laryngoscope 2021; 132:2096-2102. [PMID: 34843110 DOI: 10.1002/lary.29967] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 10/28/2021] [Accepted: 11/17/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS Surgeons have a critical role in the current opioid epidemic, and there is a need to prospectively understand patterns of pain and opioid use among patients undergoing endoscopic sinus surgery (ESS). STUDY DESIGN Prospective observational cohort. METHODS This was a prospective, observational cohort study that included patients undergoing ESS from November 2019 to March 2020. Demographic data were collected at baseline, as was respondent information regarding preoperative anxiety, pain, and postoperative pain expectations. Opioid use was converted to milligram morphine equivalents (MME). All patients received 10 tablets of 5 mg oxycodone (75 MME). Patients quantified postoperative pain and opioid consumption via telephone follow-up every 48 hours. The primary outcome was total MME utilized. RESULTS There were 91 patients included in the final cohort. Mean opioid use was 35.2 ± 47.3 MME. There were 29 (32%) patients who did not use any opioids after surgery, and six (7%) patients who required opioid refills. Postoperative opioid use was associated with increased preoperative anxiety (r = 0.41, P < .001), preoperative pain (r = 0.28, P = .007), and expectations for postoperative pain (r = 0.36, P < .001). Increased postoperative pain was only associated with increased opioid use on postoperative days 0-2 (r = 0.33, P = .001) and 3-4 (r = 0.59, P < .001). On multivariate regression, former smoking (β = 23.4 MME, SE = 10.1, 95% confidence interval [CI]: 3.3-43.5, P = .023) and anxiety (β = 35.9, SE = 10.2, 95% CI: 15.6-56.3, P < .001) were associated with increased MME. CONCLUSIONS The majority of patients have minimal opioid use after ESS, and pain appears to influence opioid use within the first 4 days after surgery. Additionally, patients with anxiety may benefit from alternative pain management strategies to mitigate opioid consumption. LEVEL OF EVIDENCE 3 Laryngoscope, 2021.
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Affiliation(s)
- Vivek C Pandrangi
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, U.S.A
| | - Brian L Scott
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, U.S.A
| | - Jasmina Pailet
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, U.S.A
| | - Jess C Mace
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, U.S.A
| | - Nyssa F Farrell
- Department of Otolaryngology-Head and Neck Surgery, Washington University in St. Louis, St. Louis, Missouri, U.S.A
| | - Mathew Geltzeiler
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, U.S.A
| | - Timothy L Smith
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, U.S.A
| | - Kara Y Detwiller
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, U.S.A
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13
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Klifto KM, Elhelali A, Payne RM, Cooney CM, Manahan MA, Rosson GD. Perioperative systemic nonsteroidal anti-inflammatory drugs (NSAIDs) in women undergoing breast surgery. Cochrane Database Syst Rev 2021; 11:CD013290. [PMID: 34753201 PMCID: PMC8577884 DOI: 10.1002/14651858.cd013290.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Breast surgery encompasses oncologic, reconstructive, and cosmetic procedures. With the recent focus on the over-prescribing of opioids in the literature, it is important to assess the effectiveness and safety of non-opioid pain medication regimens including nonsteroidal anti-inflammatory drugs (NSAIDs) or NSAID pain medications. Clinicians have differing opinions on the safety of perioperative (relating to, occurring in, or being the period around the time of a surgical operation) NSAIDs for breast surgery given the unclear risk/benefit ratio. NSAIDs have been shown to decrease inflammation, pain, and fever, while potentially increasing the risks of bleeding complications. OBJECTIVES To assess the effects of perioperative NSAID use versus non-NSAID analgesics (other pain medications) in women undergoing any form of breast surgery. SEARCH METHODS The Cochrane Breast Information Specialist searched the Cochrane Breast Cancer Group (CBCG) Specialized Register, CENTRAL (the Cochrane Library), MEDLINE, Embase, The WHO International Clinical Trials Registry Platform (ICTRP) and Clinicaltrials.gov registries to 21 September 2020. Full articles were retrieved for potentially eligible trials. SELECTION CRITERIA We considered all randomized controlled trials (RCTs) looking at perioperative NSAID use in women undergoing breast surgery. DATA COLLECTION AND ANALYSIS Two review authors independently screened studies, extracted data and assessed risk of bias, and certainty of the evidence using the GRADE approach. The main outcomes were incidence of breast hematoma within 90 days (requiring reoperation, interventional drainage, or no treatment) of breast surgery and pain intensity 24 hours following surgery, incidence rate or severity of postoperative nausea, vomiting or both, bleeding from any location within 90 days, need for blood transfusion, other side effects of NSAID use, opioid use within 24 hours of surgery, length of hospital stay, breast cancer recurrence, and non-prescribed NSAID use. Data were presented as risk ratios (RRs) for dichotomous outcomes and standardized mean differences (SMDs) for continuous outcomes. MAIN RESULTS We included 12 RCTs with a total of 1596 participants. Seven studies compared NSAIDs (ketorolac, diclofenac, flurbiprofen, parecoxib and celecoxib) to placebo. Four studies compared NSAIDs (ketorolac, flurbiprofen, ibuprofen, and celecoxib) to other analgesics (morphine, hydrocodone, hydromorphone, fentanyl). One study compared NSAIDs (diclofenac) to no intervention. NSAIDs compared to placebo Most outcomes are judged to have low-certainty evidence unless stated otherwise. There may be little to no difference in the incidence of breast hematomas within 90 days of breast surgery (RR 0.33, 95% confidence interval (CI) 0.05 to 2.02; 2 studies, 230 participants; I2 = 0%). NSAIDs may reduce pain intensity 24 (± 12) hours following surgery compared to placebo (SMD -0.26, 95% CI -0.49 to -0.03; 3 studies, 310 participants; I2 = 73%). There may be little to no difference in the incidence rates or severities of postoperative nausea, vomiting, or both (RR 1.15, 95% CI 0.58 to 2.27; 4 studies, 939 participants; I2 = 81%), bleeding from any location within 90 days (RR 1.05, 95% CI 0.89 to 1.24; 2 studies, 251 participants; I2 = 8%), or need for blood transfusion compared to placebo groups, but we are very uncertain (RR 4.62, 95% CI 0.23 to 91.34; 1 study, 48 participants; very low-certainty evidence). There may be no difference in other side effects (RR 1.12, 95% CI 0.44 to 2.86; 2 studies, 251 participants; I2 = 0%). NSAIDs may reduce opioid use within 24 hours of surgery compared to placebo (SMD -0.45, 95% CI -0.85 to -0.05; 4 studies, 304 participants; I2 = 63%). NSAIDs compared to other analgesics There is little to no difference in the incidence of breast hematomas within 90 days of breast surgery, but we are very uncertain (RR 0.33, 95% CI 0.01 to 7.99; 1 study, 100 participants; very low-certainty evidence). NSAIDs may reduce pain intensity 24 (± 12) hours following surgery (SMD -0.68, 95% CI -0.97 to -0.39; 3 studies, 200 participants; I2 = 89%; low-certainty evidence) and probably reduce the incidence rates or severities of postoperative nausea, vomiting, or both compared to other analgesics (RR 0.18, 95% CI 0.06 to 0.57; 3 studies, 128 participants; I2 = 0%; moderate-certainty evidence). There is little to no difference in the development of bleeding from any location within 90 days of breast surgery or in other side effects, but we are very uncertain (bleeding: RR 0.33, 95% CI 0.01 to 7.99; 1 study, 100 participants; other side effects: RR 0.11, 95% CI 0.01 to 1.80; 1 study, 48 participants; very low-certainty evidence). NSAIDs may reduce opioid use within 24 hours of surgery compared to other analgesics (SMD -6.87, 95% CI -10.93 to -2.81; 3 studies, 178 participants; I2 = 96%; low-certainty evidence). NSAIDs compared to no intervention There is little to no difference in pain intensity 24 (± 12) hours following surgery compared to no intervention, but we are very uncertain (SMD -0.54, 95% CI -1.09 to 0.00; 1 study, 60 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS Low-certainty evidence suggests that NSAIDs may reduce postoperative pain, nausea and vomiting, and postoperative opioid use. However, there was very little evidence to indicate whether NSAIDs affect the rate of breast hematoma or bleeding from any location within 90 days of breast surgery, the need for blood transfusion and incidence of other side effects compared to placebo or other analgesics. High-quality large-scale RCTs are required before definitive conclusions can be made.
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Affiliation(s)
- Kevin M Klifto
- Division of Plastic and Reconstructive Surgery, University of Missouri School of Medicine, Columbia, USA
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Ala Elhelali
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland
| | - Rachael M Payne
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St Louis, USA
| | - Carisa M Cooney
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Michele A Manahan
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Gedge D Rosson
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
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Abstract
PURPOSE OF REVIEW Pituitary adenoma resections comprise a large proportion of intracranial tumor surgeries. This patient population is medically and physiologically complex and requires careful perioperative planning and management on the part of the anesthesiologist. This review will summarize anesthetic considerations for pre, intra, and postoperative management of patients undergoing transsphenoidal pituitary surgery. RECENT FINDINGS An endoscopic approach is favored for patients undergoing transsphenoidal pituitary surgery. Hemodynamic monitoring is important to maintain cerebral perfusion and avoid risk of bleeding; however, 'controlled' hypotension may have adverse effects. Multimodal analgesia is effective for the management of postoperative pain and may reduce the risk of postoperative complications, including respiratory depression and postoperative nausea and vomiting. SUMMARY Transsphenoidal pituitary surgery is a preferred approach for the surgical management of nonfunctioning pituitary macroadenomas with symptoms of mass effect and functioning adenomas that cannot be otherwise managed medically. Understanding tumor pathologies and systemic effects are essential for preoperative planning and providing safe anesthetic care during the perioperative period.
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Affiliation(s)
- Kamilla Esfahani
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
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15
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Miller N, Noller M, Yang A, McCoul ED, Tolisano AM, Riley CA. Lesser Known Uses of γ-Aminobutyric Acid Analogue Medications in Otolaryngology. Laryngoscope 2021; 132:954-964. [PMID: 34536232 DOI: 10.1002/lary.29855] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/17/2021] [Accepted: 08/27/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVES/HYPOTHESIS In otolaryngology, γ-aminobutyric acid (GABA) analogues have been previously analyzed for their roles in neuropathic pain, chronic cough, tinnitus, and perioperative analgesia. The primary aim of this study is to comprehensively summarize and synthesize the existing evidence for lesser known uses of gabapentin and pregabalin in otolaryngology. STUDY DESIGN A scoping review conducted of the available English-language literature was performed by two authors through April 1, 2021. METHODS The Preferred Reporting Items for Systematic Review and Meta-Analysis criteria were followed, and a quality assessment of included studies was performed using the Methodological Index for Non-Randomized Studies. RESULTS Ten studies met inclusion criteria. Three studies found that gabapentin may reduce gastrostomy tube usage and improve swallowing function in head and neck cancer patients undergoing radiation therapy (RT). Three studies suggested that gabapentin may help reduce opiate use when used as a primary analgesic in patients with radiation-induced mucositis. One study demonstrated that pregabalin-reduced trismus severity in patients with radiotherapy-induced trismus. One study demonstrated gabapentin may be useful in patients with phonasthenia. Two studies demonstrated that GABA analogues may be a useful adjunct in patients with globus pharyngeus in the context of likely laryngeal sensory neuropathy. CONCLUSIONS The most promising potential uses for GABA analogues identified in this review are for improving swallowing, trismus, and narcotic overuse after RT. The benefit of GABA analogues for improving nonorganic voice disorders is also promising while the benefit for globus pharyngeus when possibly related to laryngeal sensory neuropathy is inconclusive. Laryngoscope, 2021.
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Affiliation(s)
- Nathaniel Miller
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, U.S.A
| | - Michael Noller
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, U.S.A
| | - Alex Yang
- F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, U.S.A
| | - Edward D McCoul
- Department of Otorhinolaryngology-Head and Neck Surgery, Ochsner Clinic, New Orleans, Louisiana, U.S.A.,Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, Louisiana, U.S.A
| | - Anthony M Tolisano
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, U.S.A.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, U.S.A
| | - Charles A Riley
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, U.S.A.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, U.S.A
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16
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Rimmer RA, Scott B, Pailet J, Farrell NF, Mace JC, Detwiller KY, Smith TL, Dogan A, Gupta S, Andersen P, Cetas J, Geltzeiler M. Opioid use after endoscopic skull base surgery: A descriptive, prospective, longitudinal cohort study. Int Forum Allergy Rhinol 2021; 12:160-171. [PMID: 34309220 DOI: 10.1002/alr.22871] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 06/11/2021] [Accepted: 07/01/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Opioid abuse is a public health crisis and the perioperative period can be a time of first opioid exposure. Little is known about postoperative pain management after endoscopic skull base surgery (ESBS). METHODS This investigation was a single-institution, longitudinal, prospective cohort study of adult patients undergoing ESBS between November 2019 and March 2020. Participants completed preoperative questionnaires and were contacted every 48 hours postoperatively to quantify pain and opioid consumption. RESULTS A total of 33 patients were enrolled and 28 of 33 patients (85%) underwent ESBS for sellar pathology. Mean total morphine milligram equivalents (MME) consumed was 381.9 ± 476.0. History of a headache disorder (p = 0.025) and previous opioid use within 60 days preoperatively (p < 0.001) were significantly associated with greater opioid use. Mean duration of opioid use was 6.7 ± 5.1 (range, 0-20) days. Headache disorder (p = 0.01), depression (p = 0.03), anxiety (p = 0.03), age ≤46 years (p = 0.029), and previous opioid use (p = 0.008) were all associated with longer mean opioid use. Patients with headache disorder also reported higher mean postoperative pain scores. Fewer than half of the participants required opioids by postoperative day 8. Prescription of nonsteroidal anti-inflammatory drugs at discharge was significantly associated with less outpatient opioid use (p = 0.032). At 2-month follow-up, 37% of patients reported keeping excess opioids. CONCLUSION After ESBS, greater total opioid use was significantly associated with history of headaches and previous opioid use within 60 days. Overall, opioid use declined among all patients in the postoperative period, but several factors may contribute to longer duration of use.
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Affiliation(s)
- Ryan A Rimmer
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, OR
| | - Brian Scott
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, OR
| | - Jasmina Pailet
- School of Medicine, Oregon Health and Science University, Portland, OR
| | - Nyssa Fox Farrell
- Department of Otolaryngology-Head and Neck Surgery, Washington University in St. Louis, St. Louis, MO
| | - Jess C Mace
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, OR
| | - Kara Y Detwiller
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, OR
| | - Timothy L Smith
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, OR
| | - Aclan Dogan
- Department of Neurological Surgery, Oregon Health and Science University, Portland, OR
| | - Sachin Gupta
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, OR
| | - Peter Andersen
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, OR
| | - Justin Cetas
- Department of Neurological Surgery, Oregon Health and Science University, Portland, OR
| | - Mathew Geltzeiler
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, OR
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17
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Lee JT, Levine CG, Overdevest JB, Higgins TS, Manes RP, Myhill JA, Soler ZM. American Rhinologic Society expert practice statement: Postoperative pain management and opioid use after sinonasal surgery. Int Forum Allergy Rhinol 2021; 11:1296-1307. [PMID: 34251080 DOI: 10.1002/alr.22847] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 05/20/2021] [Indexed: 02/06/2023]
Abstract
The goal of this American Rhinologic Society expert practice statement (EPS) is to provide clinically applicable, evidence-based recommendations regarding pain management in sinonasal surgery. This EPS was developed following the recommended methodology and approval process as previously outlined. The topics of interest included preoperative counseling, local anesthesia, use of opioids for postoperative pain, use of nonopioid medication for postoperative pain, nonsteroidal anti-inflammatory drugs and bleeding, and use of gabapentin for pain control. Following a modified Delphi approach, 6 statements were developed, 5 of which reached consensus and 1 that did not. These statements and accompanying evidence are summarized along with an assessment of future needs.
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Affiliation(s)
- Jivianne T Lee
- Department of Head and Neck Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA
| | - Corinna G Levine
- Department of Otolaryngology-Head and Neck Surgery, University of Miami School of Medicine, Miami, FL
| | - Jonathan B Overdevest
- Department of Otolaryngology-Head and Neck Surgery, Columbia University School of Medicine, New York, NY
| | - Thomas S Higgins
- Division of Otolaryngology-Head and Neck Surgery, University of Louisville School of Medicine, Louisville, KY
| | - R Peter Manes
- Department of Otolaryngology-Head and Neck Surgery, Yale School of Medicine, New Haven, CT
| | - Jeffrey A Myhill
- Otolaryngology and Allergy, North East Arkansas Baptist Clinic, Jonesboro, AR
| | - Zachary M Soler
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
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18
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Anne S, Mims JW, Tunkel DE, Rosenfeld RM, Boisoneau DS, Brenner MJ, Cramer JD, Dickerson D, Finestone SA, Folbe AJ, Galaiya DJ, Messner AH, Paisley A, Sedaghat AR, Stenson KM, Sturm AK, Lambie EM, Dhepyasuwan N, Monjur TM. Clinical Practice Guideline: Opioid Prescribing for Analgesia After Common Otolaryngology Operations. Otolaryngol Head Neck Surg 2021; 164:S1-S42. [PMID: 33822668 DOI: 10.1177/0194599821996297] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Opioid use disorder (OUD), which includes the morbidity of dependence and mortality of overdose, has reached epidemic proportions in the United States. Overprescription of opioids can lead to chronic use and misuse, and unused narcotics after surgery can lead to their diversion. Research supports that most patients do not take all the prescribed opioids after surgery and that surgeons are the second largest prescribers of opioids in the United States. The introduction of opioids in those with OUD often begins with prescription opioids. Reducing the number of extra opioids available after surgery through smaller prescriptions, safe storage, and disposal should reduce the risk of opioid use disorder in otolaryngology patients and their families. PURPOSE The purpose of this specialty-specific guideline is to identify quality improvement opportunities in postoperative pain management of common otolaryngologic surgical procedures. These opportunities are communicated through clear actionable statements with explanation of the support in the literature, evaluation of the quality of the evidence, and recommendations on implementation. Employing these action statements should reduce the variation in care across the specialty and improve postoperative pain control while reducing risk of OUD. The target patients for the guideline are any patients treated for anticipated or reported pain within the first 30 days after undergoing common otolaryngologic procedures. The target audience of the guideline is otolaryngologists who perform surgery and clinicians who manage pain after surgical procedures. Outcomes to be considered include whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.The guideline addresses assessment of the patient for OUD risk factors, counseling on pain expectations, and identifying factors that can affect pain duration and/or severity. It also discusses the use of multimodal analgesia as first-line treatment and the responsible use of opioids. Last, safe disposal of unused opioids is discussed.This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not a comprehensive guide on pain management in otolaryngologic procedures. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experiences and assessments of individual patients. ACTION STATEMENTS The guideline development group made strong recommendations for the following key action statements: (3A) prior to surgery, clinicians should identify risk factors for opioid use disorder when analgesia using opioids is anticipated; (6) clinicians should advocate for nonopioid medications as first-line management of pain after otolaryngologic surgery; (9) clinicians should recommend that patients (or their caregivers) store prescribed opioids securely and dispose of unused opioids through take-back programs or another accepted method.The guideline development group made recommendations for the following key action statements: (1) prior to surgery, clinicians should advise patients and others involved in the postoperative care about the expected duration and severity of pain; (2) prior to surgery, clinicians should gather information specific to the patient that modifies severity and/or duration of pain; (3B) in patients at risk for OUD, clinicians should evaluate the need to modify the analgesia plan; (4) clinicians should promote shared decision making by informing patients of the benefits and risks of postoperative pain treatments that include nonopioid analgesics, opioid analgesics, and nonpharmacologic interventions; (5) clinicians should develop a multimodal treatment plan for managing postoperative pain; (7) when treating postoperative pain with opioids, clinicians should limit therapy to the lowest effective dose and the shortest duration; (8A) clinicians should instruct patients and caregivers how to communicate if pain is not controlled or if medication side effects occur; (8B) clinicians should educate patients to stop opioids when pain is controlled with nonopioids and stop all analgesics when pain has resolved; (10) clinicians should inquire, within 30 days of surgery, whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.
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Affiliation(s)
| | - James Whit Mims
- Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - David E Tunkel
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | | | | | - John D Cramer
- Wayne State University School of Medicine, Detroit, Michigan, USA
| | - David Dickerson
- NorthShore University Health System, Evanston, Illinois, USA.,University of Chicago Medicine, Chicago, Illinois, USA
| | | | - Adam J Folbe
- Oakland University William Beaumont School of Medicine, Royal Oak, Michigan, USA
| | - Deepa J Galaiya
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Anna H Messner
- Baylor College of Medicine/Texas Children's Hospital, Houston, Texas, USA
| | - Allison Paisley
- University of Pennsylvania Otorhinolaryngology, Philadelphia, Pennsylvania, USA
| | - Ahmad R Sedaghat
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | | | - Angela K Sturm
- Angela Sturm, MD, PLLC, Houston, Texas, USA.,University of Texas Medical Branch, Galveston, Texas, USA
| | - Erin M Lambie
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
| | - Nui Dhepyasuwan
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
| | - Taskin M Monjur
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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19
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Kühnel TS, Hosemann WG, Weber R. [Postoperative treatment following paranasal sinus surgery]. HNO 2021; 69:517-528. [PMID: 33942126 DOI: 10.1007/s00106-021-01057-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2021] [Indexed: 10/21/2022]
Abstract
Postoperative care is a crucial aspect for the success of paranasal sinus interventions. Basic procedures include saline nasal wash, which should be started on the first postoperative day, topical steroids, and antibiotics in cases of infection. Medical treatment involves aspiration of secretion in the inferior meatus during the first week. Removal of scabs in the surgical field should be carried out under endoscopic control beginning at the second week. Intervals are scheduled individually. Occlusion of the nose for the time of epithelium regeneration provides a moist space in the ethmoid, which improves wound healing.
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Affiliation(s)
- Thomas S Kühnel
- Klinik und Poliklinik für Hals-Nasen-Ohren-Heilkunde, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland.
| | - Werner G Hosemann
- Fachbereich HNO, Helios Hanseklinikum Stralsund, Große Parower Straße 47, 18435, Stralsund, Deutschland
| | - Rainer Weber
- HNO-Klinik, Städtisches Klinikum Karlsruhe, Moltkestraße 90, 76133, Karlsruhe, Deutschland
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20
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JEICAN II, TROMBITAS V, CRIVII C, DUMITRU M, ALUAȘ Maria, DOGARU G, GHEBAN D, JUNIE LM, ALBU S. Rehabilitation of patients with chronic rhinosinusitis after functional endoscopic sinus surgery. BALNEO AND PRM RESEARCH JOURNAL 2021. [DOI: 10.12680/balneo.2021.421] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction. In the case of many patients with chronic rhinosinusitis (CRS), antibiotic and steroid therapies fail, and surgery is required. The recovery of patients after surgery equally depends on the postoperative behavior of each individual patient. The paper presents the outcomes of recovery after functional endoscopic sinus surgery (FESS) in a group of 74 patients.
Methods. The study was conducted in patients undergoing surgical treatment by FESS, performed by the same surgeon. For the development of the statistical database, the clinical records were collected by the same investigator.
Results. On the day of surgery and on the first postoperative day, 72.9% of patients reported facial pain, 41.8% nausea, 9.4% nasal bleeding, 8.8% vomiting. At 6 months postoperatively, 71.6% of patients estimated that they had a better quality of life than before surgery, 64.8% mentioned an improvement of olfaction as an effect, and 6.7% developed septal turbinate synechiae.
Conclusions. No major complications were identified in the recovery of CRS patients after FESS. Postoperative facial pain was less well tolerated by young patients (18-35 years old). The improvement of smell and the increase of disease-specific quality of life are the most relevant results of recovery after FESS mentioned by the patients included in our study. The otorhinolaryngologist and the family doctor play an important role in the education of patients regarding the importance of treatment with mineral and thermal waters in post-FESS recovery.
Keywords: chronic rhinosinusitis, endoscopic sinus surgery, FESS, rehabilitation, ERAS protocols,
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Affiliation(s)
- Ionuț Isaia JEICAN
- [1] Department of Head and Neck Surgery and Otorhinolaryngology, University Clinical Hospital of Railway Company, Cluj-Napoca, Romania [2] Department of Anatomy and Embryology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Veronica TROMBITAS
- [1] Department of Head and Neck Surgery and Otorhinolaryngology, University Clinical Hospital of Railway Company, Cluj-Napoca, Romania
| | - Carmen CRIVII
- [2] Department of Anatomy and Embryology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Mihai DUMITRU
- [3] Department of Head and Neck Surgery and Otorhinolaryngology, University Emergency Hospital, Bucharest, Romania [4] Department of Anatomy and Embryology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - ALUAȘ Maria
- [5] Department of Oral Health, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Gabriela DOGARU
- [6] Department of Rehabilitation, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Dan GHEBAN
- [7] Department of Pathology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Lia Monica JUNIE
- [8] Department of Microbiology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Silviu ALBU
- Department of Head and Neck Surgery and Otorhinolaryngology, University Clinical Hospital of Railway Company, Cluj-Napoca, Romania
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21
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Orlandi RR, Kingdom TT, Smith TL, Bleier B, DeConde A, Luong AU, Poetker DM, Soler Z, Welch KC, Wise SK, Adappa N, Alt JA, Anselmo-Lima WT, Bachert C, Baroody FM, Batra PS, Bernal-Sprekelsen M, Beswick D, Bhattacharyya N, Chandra RK, Chang EH, Chiu A, Chowdhury N, Citardi MJ, Cohen NA, Conley DB, DelGaudio J, Desrosiers M, Douglas R, Eloy JA, Fokkens WJ, Gray ST, Gudis DA, Hamilos DL, Han JK, Harvey R, Hellings P, Holbrook EH, Hopkins C, Hwang P, Javer AR, Jiang RS, Kennedy D, Kern R, Laidlaw T, Lal D, Lane A, Lee HM, Lee JT, Levy JM, Lin SY, Lund V, McMains KC, Metson R, Mullol J, Naclerio R, Oakley G, Otori N, Palmer JN, Parikh SR, Passali D, Patel Z, Peters A, Philpott C, Psaltis AJ, Ramakrishnan VR, Ramanathan M, Roh HJ, Rudmik L, Sacks R, Schlosser RJ, Sedaghat AR, Senior BA, Sindwani R, Smith K, Snidvongs K, Stewart M, Suh JD, Tan BK, Turner JH, van Drunen CM, Voegels R, Wang DY, Woodworth BA, Wormald PJ, Wright ED, Yan C, Zhang L, Zhou B. International consensus statement on allergy and rhinology: rhinosinusitis 2021. Int Forum Allergy Rhinol 2021; 11:213-739. [PMID: 33236525 DOI: 10.1002/alr.22741] [Citation(s) in RCA: 408] [Impact Index Per Article: 136.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/09/2020] [Indexed: 02/06/2023]
Abstract
I. EXECUTIVE SUMMARY BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document. METHODS ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary. RESULTS ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided. CONCLUSION This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.
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Affiliation(s)
| | | | | | | | | | - Amber U Luong
- University of Texas Medical School at Houston, Houston, TX
| | | | - Zachary Soler
- Medical University of South Carolina, Charleston, SC
| | - Kevin C Welch
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | | | | | | | | | - Claus Bachert
- Ghent University, Ghent, Belgium.,Karolinska Institute, Stockholm, Sweden.,Sun Yatsen University, Gangzhou, China
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - David A Gudis
- Columbia University Irving Medical Center, New York, NY
| | - Daniel L Hamilos
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - Richard Harvey
- University of New South Wales and Macquarie University, Sydney, New South Wales, Australia
| | | | | | | | | | - Amin R Javer
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | | | | | | | | | | | | | | | - Valerie Lund
- Royal National Throat Nose and Ear Hospital, UCLH, London, UK
| | - Kevin C McMains
- Uniformed Services University of Health Sciences, San Antonio, TX
| | | | - Joaquim Mullol
- IDIBAPS Hospital Clinic, University of Barcelona, Barcelona, Spain
| | | | | | | | | | | | | | | | | | | | - Alkis J Psaltis
- University of Adelaide, Adelaide, South Australia, Australia
| | | | | | | | - Luke Rudmik
- University of Calgary, Calgary, Alberta, Canada
| | - Raymond Sacks
- University of New South Wales, Sydney, New South Wales, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | - De Yun Wang
- National University of Singapore, Singapore, Singapore
| | | | | | | | - Carol Yan
- University of California San Diego, La Jolla, CA
| | - Luo Zhang
- Capital Medical University, Beijing, China
| | - Bing Zhou
- Capital Medical University, Beijing, China
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22
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Katz AP, Misztal C, Ghiam MK, Hoffer ME. Changes in Single-Specialty Postoperative Opioid Prescribing Patterns in Response to Legislation: Single-Institution Analysis Over Time. Otolaryngol Head Neck Surg 2021; 164:774-780. [PMID: 33528299 DOI: 10.1177/0194599820986577] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To determine changes in the prescriptions of postoperative opioids in response to Florida state legislation restricting the number of days for which these medications could be prescribed to 3 days in most circumstances or 7 days at provider discretion. STUDY DESIGN A retrospective review was performed for all patients undergoing 7 common outpatient otolaryngology surgical procedures. SETTING Single-institution academic center in Florida. METHODS Query of the state's online prescription drug monitoring program was used to compare prescription habits 3 months before and after the law and then again 1 year later. RESULTS A total of 561 patients were identified meeting criteria. The number of days that opioids were prescribed decreased significantly, from 6.42 to 4.48 to 3.03 days. There was a significant decrease in the proportion of patients receiving any postoperative opioid prescription, from 0.80 to 0.52 to 0.32. The total morphine milligram equivalents prescribed decreased from 28.4 before the law to 18.4 at 1 year after. CONCLUSIONS Legislative restrictions on the length of opioid prescriptions were associated with significant decreases in the proportion of patients receiving any opioids, the number of days that opioids were prescribed, and the total morphine milligram equivalents 3 months after the law went into effect, with even more dramatic changes at the 1-year time point. We opine that these changes are due to providers learning that many procedures do not require postoperative opioids and therefore increasingly considering and utilizing nonopioid alternatives in this setting.
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Affiliation(s)
- Andrew P Katz
- Department of Otolaryngology, Miller School of Medicine, The University of Miami, Miami, Florida, USA
| | - Carly Misztal
- Department of Otolaryngology, Miller School of Medicine, The University of Miami, Miami, Florida, USA
| | - Michael K Ghiam
- Department of Otolaryngology, Miller School of Medicine, The University of Miami, Miami, Florida, USA
| | - Michael E Hoffer
- Department of Otolaryngology, Miller School of Medicine, The University of Miami, Miami, Florida, USA.,Department of Neurological Surgery, Miller School of Medicine, The University of Miami, Miami, Florida, USA
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23
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Wang P. The efficacy of sphenopalatine ganglion block for pain management after endoscopic sinus surgery: a meta-analysis of randomized controlled studies. Eur Arch Otorhinolaryngol 2021; 278:2681-2687. [PMID: 33388988 DOI: 10.1007/s00405-020-06484-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 09/25/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The efficacy of sphenopalatine ganglion (SPG) block for pain control after endoscopic sinus surgery remains controversial. We conduct a systematic review and meta-analysis to explore the influence of SPG block on pain intensity after endoscopic sinus surgery. METHODS We search PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through June 2019 for randomized controlled trials (RCTs) assessing the efficacy of SPG block for pain management after endoscopic sinus surgery. This meta-analysis is performed using the random-effect model. RESULTS Six RCTs are included in the meta-analysis. Overall, compared with control group for endoscopic sinus surgery, SPG block is associated with the decrease in pain scores at 6 h (Std. MD = - 0.71; 95% CI = - 1.08 to - 0.34; P = 0.0002) and 24 h (Std. MD = - 0.51; 95% CI = - 0.87 to - 0.14; P = 0.006), the number of rescue analgesics (RR = 0.26; 95% CI = 0.16 to 0.42; P < 0.00001) and incidence of nausea and vomiting (RR = 0.52; 95% CI = 0.30-0.89; P = 0.02), but demonstrate no obvious impact on pain scores at 2 h (Std. MD = - 0.99; 95% CI = - 2.80-0.83; P = 0.29) or headache (RR = 1.30; 95% CI = 0.38-4.46; P = 0.67). CONCLUSIONS SPG block can provide additional benefits for pain management after endoscopic sinus surgery.
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Affiliation(s)
- Ping Wang
- Otolaryngology Department, The First People's Hospital of Chongqing Liangjiang New Areas, No. 199, Renxing Road, Renhe Street, Chongqing, 401121, China.
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24
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Jordan JW, Spankovich C, Stringer SP. Feasibility of Implementing Opioid Stewardship Recommendations for Sinonasal Surgery. Otolaryngol Head Neck Surg 2020; 164:895-900. [PMID: 33138720 DOI: 10.1177/0194599820969155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The objective of our study was to review the current literature pertaining to perioperative opioids in sinus surgery and to determine the effects of implementing opioid stewardship recommendations in the setting of endoscopic sinonasal surgery. STUDY DESIGN Single-institution retrospective case-control study. SETTING Academic medical center outpatient area. METHODS This retrospective review comprised 163 patients who underwent routine functional endoscopic sinus surgery, septoplasty, and/or inferior turbinate reduction before and after implementation of a standardized pain control regimen based on published opioid stewardship recommendations. The regimen consisted of an oral dose of gabapentin (400 mg) and acetaminophen (1000 mg) at least 30 minutes prior to surgery, absorbable nasal packing soaked in 0.5% tetracaine intraoperatively, and a postoperative regimen of acetaminophen and nonsteroidal anti-inflammatory medications. Tramadol tablets (50 mg) were prescribed postoperatively for breakthrough pain. The primary outcome measure for the study was the average number of hydrocodone equivalents (5 mg) prescribed before and after the new protocol. RESULTS The average number of opioid medications prescribed, measured as hydrocodone equivalents (5 mg), decreased from 24.59 preprotocol to 18.08 after the initiation of the new perioperative regimen (P < .001). There was no significant difference between the periods (P > .05) in number of postoperative phone calls regarding pain or in patient satisfaction scores. CONCLUSION Opioid stewardship recommendations can be instituted for sinonasal surgery, including multimodal perioperative pain management and substitution of tramadol for breakthrough pain, as a method to decrease the volume of opioids prescribed, without increasing patient phone calls or affecting the likelihood of physician recommendation Press Ganey scores.
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Affiliation(s)
- Jaxon W Jordan
- Department of Otolaryngology and Communicative Sciences, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Christopher Spankovich
- Department of Otolaryngology and Communicative Sciences, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Scott P Stringer
- Department of Otolaryngology and Communicative Sciences, University of Mississippi Medical Center, Jackson, Mississippi, USA
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25
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Preoperative Gabapentin Administration and Its Impact on Postoperative Opioid Requirement and Pain in Sinonasal Surgery. Otolaryngol Head Neck Surg 2020; 164:889-894. [DOI: 10.1177/0194599820952805] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Objective To determine the efficacy of preoperative gabapentin on patient-reported pain levels and postoperative opioid requirements following sinonasal surgery. Study Design Retrospective review. Setting Academic institution. Methods Patients undergoing sinonasal surgery between July 2019 and January 2020 were followed. Groups were divided into those that received 600 mg of oral gabapentin 1 hour preoperatively (gabapentin) and those that did not (control). Postoperatively, each patient was counseled to use acetaminophen, ibuprofen, and oxycodone as needed for pain control. Patients completed a daily postoperative pain and medication log. Pain was measured by the visual analog scale (VAS) and opioid use by morphine equivalent dose (MED). Chi-square test and Wilcoxon test were used for data analysis. Results Fifty-seven patients were included (control, n = 28; gabapentin, n = 29). There was no significant difference in age, sex, or baseline Sinonasal Outcome Test–22 scores between the groups. The total MED, postoperative day (POD) 1-2 MED, POD 3-4 MED, and POD 5-6 MED did not differ significantly between the control (17.9, 12.2, 4.6, 1.5) and gabapentin (19.0, 8.9, 7.2, 3.5) groups ( P = .98, .25, .16, .44). The mean daily VAS score did not differ significantly between the control (3.1) and gabapentin (2.8) groups ( P = .81). The mean daily VAS score decreased significantly in both groups with each successive POD ( P = .004). Conclusion Preoperative gabapentin did not significantly reduce postoperative pain or opioid use. Postoperative discomfort following sinonasal surgery is mild, and opioid intake is minimal.
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26
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Nguyen BK, Svider PF, Hsueh WD, Folbe AJ. Perioperative Analgesia for Sinus and Skull-Base Surgery. Otolaryngol Clin North Am 2020; 53:789-802. [PMID: 32771245 DOI: 10.1016/j.otc.2020.05.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Perioperative analgesic management is multifaceted, and an individualized approach should be taken with each patient. Preoperative discussion of the plan for pain control and the patient's postoperative expectations is a necessary facet for optimal outcomes of analgesia. There is the potential for significant abuse and development of dependence on opioids. Nonopioids, such as nonsteroidal anti-inflammatory drugs, acetaminophen, and gabapentinoids, provide reliable alternatives for analgesic management following sinus and skull-base surgery. There is a paucity of literature regarding perioperative pain regimens for sinus and skull-base surgery, and the authors hope that this review serves as a valuable tool for otolaryngologists.
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Affiliation(s)
- Brandon K Nguyen
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Peter F Svider
- Hackensack Meridian Health, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Wayne D Hsueh
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Adam J Folbe
- Department of Otolaryngology, William Beaumont Hospital, Royal Oak, MI, USA; Barbara Ann Karmanos Cancer Institute, Detroit, MI, USA.
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27
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Husain Q, Banks C, Gray ST. Nonopioid Adjuncts and Alternatives. Otolaryngol Clin North Am 2020; 53:831-842. [PMID: 32682534 DOI: 10.1016/j.otc.2020.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Multimodality nonopioid analgesia can be effective for pain control. Balancing risks and benefits of treatment should guide the appropriateness of opioid versus nonopioid pain control.
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Affiliation(s)
- Qasim Husain
- Hackensack Meridian School of Medicine at Seton Hall University, Coastal Ear, Nose, and Throat, 100 Commons Way, Suite 210, Holmdel, NJ 07733, USA.
| | - Catherine Banks
- Department of Otolaryngology-Head and Neck Surgery, Prince of Wales Hospital, University of New South Wales, Sydney, Australia
| | - Stacey T Gray
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, 243 Charles Street, Boston, MA 02114, USA
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28
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Leung RM, Smith TL, Kern RC, Chandra RK, Schlosser RJ, Harvey RJ, Conley DB, Lee JM. Should Oral Corticosteroids be Used in Medical Therapy for Chronic Rhinosinusitis? A Risk Analysis. Laryngoscope 2020; 131:473-481. [PMID: 32633822 DOI: 10.1002/lary.28843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 04/28/2020] [Accepted: 05/18/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVES Oral corticosteroid (OCS) as a part of appropriate medical therapy (AMT) (formerly maximal medical therapy) in chronic rhinosinusitis remains controversial. While the risks of OCS are well known, the benefit remains unclear due the absence of a standardized prescribing regimen. Consequently, it is difficult to characterize whether the risks of OCS and its ability to avert endoscopic sinus surgery (ESS) are helpful in AMT. When OCS is highly effective at averting surgery, the lesser risks of OCS would be justified because it can avoid the greater risks of ESS. When OCS is poorly effective at averting ESS, the risks of OCS would not be justified because many patients will be exposed to both risks. This study seeks to identify the threshold effectiveness of OCS at averting ESS that would minimize risk exposure to patients. METHODS A probabilistic risks-based decision analysis was constructed from literature reported incidences and impacts of adverse events of OCS and ESS. Monte Carlo analysis was performed to identify the minimum effectiveness required to avoid further intervention (MERAFI) for chronic sinusitis without nasal polyp (CRSsNP) and chronic sinusitis with nasal polyp (CRSwNP). RESULTS The analysis showed MERAFI results of 20.8% (95% CI 20.7-20.9%) for CRSsNP and 16.8% (95% CI 16.7-16.9%) for CRSwNP. CONCLUSIONS Given reported OCS effectiveness in the range of 34-71% in CRSsNP and 46-63% in CRSwNP, this analysis suggests that the inclusion of OCS in AMT may be the lower risk strategy. LEVEL OF EVIDENCE N/A Laryngoscope, 131:473-481, 2021.
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Affiliation(s)
- Randy M Leung
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Timothy L Smith
- Department of Otolaryngology, Oregon Health & Science University, Portland, Oregon, U.S.A
| | - Robert C Kern
- Department of Otolaryngology, Northwestern University, Chicago, Illinois, U.S.A
| | - Rakesh K Chandra
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - Rodney J Schlosser
- Department of Otolaryngology, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Richard J Harvey
- Department of Otolaryngology, University of New South Wales and Macquarie University, Darlinghurst, New South Wales, Australia
| | - David B Conley
- Department of Otolaryngology, Northwestern University, Chicago, Illinois, U.S.A
| | - John M Lee
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
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Maroda AJ, Coca KK, McLevy-Bazzanella JD, Wood JW, Grissom EC, Sheyn AM. Perioperative Analgesia in Pediatric Patients Undergoing Otolaryngologic Surgery. Otolaryngol Clin North Am 2020; 53:819-830. [PMID: 32622548 DOI: 10.1016/j.otc.2020.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This article reviews the evidence regarding current perioperative pain management strategies in pediatric patients undergoing otolaryngologic surgery. Pediatric otolaryngology is a broad field with a wide variety of surgical procedures that each requires careful consideration for optimal perioperative pain management. Adequate pain control is vital to ensuring patient safety and achieving successful postoperative care, but many young children are limited in their capacity to communicate their pain experience. Current literature holds a disproportionate amount of focus on pain management for certain procedures, whereas there is a paucity of evidence-based literature informing most other procedures within the field.
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Affiliation(s)
- Andrew J Maroda
- Department of Pediatric Otolaryngology, Le Bonheur Children's Hospital, Memphis, TN, USA; Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Kimberly K Coca
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jennifer D McLevy-Bazzanella
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Joshua W Wood
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Erica C Grissom
- Department of Anesthesiology, Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Anthony M Sheyn
- Department of Pediatric Otolaryngology, Le Bonheur Children's Hospital, Memphis, TN, USA; Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, 910 Madison Avenue, Suite 400, Memphis, TN 38163-2242, USA; Department of Pediatric Otolaryngology, St. Jude Children's Research Hospital, Memphis, TN, USA.
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Hanson M, Li H, Geer E, Karimi S, Tabar V, Cohen MA. Perioperative management of endoscopic transsphenoidal pituitary surgery. World J Otorhinolaryngol Head Neck Surg 2020; 6:84-93. [PMID: 32596652 PMCID: PMC7296486 DOI: 10.1016/j.wjorl.2020.01.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 01/19/2020] [Indexed: 11/12/2022] Open
Abstract
The contemporary embrace of endoscopic technology in the approach to the anterior skull base has altered the perioperative landscape for patients requiring pituitary surgery. Utility of a multi-disciplinary unit in management decisions facilitates the delivery of optimal care. Evolution of technology and surgical expertise in pituitary surgery mandates ongoing review of all components of the care central to these patients. The many areas of potential variability in the pre, intra and post-operative timeline of pituitary surgery are readily identifiable. Core undertakings and contemporary controversies in the peri-operative management of patients undergoing endoscopic transsphenoidal pituitary surgery are assessed against the available literature with a view to providing guidance for the best evidence-based practice.
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Affiliation(s)
- Martin Hanson
- Multidisciplinary Pituitary and Skull Base Tumour Program, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, USA
| | - Hao Li
- Multidisciplinary Pituitary and Skull Base Tumour Program, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, USA
| | - Eliza Geer
- Multidisciplinary Pituitary and Skull Base Tumour Program, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, USA
| | - Sasan Karimi
- Multidisciplinary Pituitary and Skull Base Tumour Program, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, USA
| | - Viviane Tabar
- Multidisciplinary Pituitary and Skull Base Tumour Program, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, USA
| | - Marc A Cohen
- Multidisciplinary Pituitary and Skull Base Tumour Program, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, USA
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Zheng Z, Riley CA, Kim M, Sclafani A, Tabaee A. Opioid prescribing patterns and usage after rhinologic surgery: A systematic review. Am J Otolaryngol 2020; 41:102539. [PMID: 32451289 DOI: 10.1016/j.amjoto.2020.102539] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 04/30/2020] [Accepted: 05/03/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Judicious management of analgesics following rhinologic surgery is important for curtailing over-prescription of opioids. Limited data exists defining expected pain levels and appropriate opioid requirements after rhinologic surgery. METHODS A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. PubMed, Embase, Ovid MEDLINE, Cochrane Library databases were queried, and relevant articles were identified. RESULTS A total of 405 articles were identified, of which 13 met final inclusion criteria. Significant heterogeneity existed regarding type and quantity of opioid medication prescribed. Eight studies utilized a subjective patient-reported pain score as an outcome measure and reported mild to moderate postoperative pain that diminished over the first 3-6 days. Eight studies reported over-prescription of opioid medications with inappropriate storage of excess pills at home. Several factors were associated with an increased opioid requirement, including concurrent septoplasty, younger age, and current smoking status. CONCLUSION Rhinologic surgery is well tolerated with mild to moderate, short-lived postoperative pain. A limited amount and duration of opioid medications is required for routine management. Patients are frequently prescribed more opioids than is necessary for expected pain level, resulting in the potential for opioid misuse, abuse, and diversion. Current evidence is limited by a predominance of level 4 studies. Larger, higher quality studies with standardized reporting of pain score and opioid prescription quantity are needed.
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Affiliation(s)
- Zhong Zheng
- Department of Otolaryngology - Head and Neck Surgery, New York Presbyterian Hospital - Weill Cornell Medicine, New York, NY, USA
| | - Charles A Riley
- Department of Otolaryngology - Head and Neck Surgery, Fort Belvoir Community Hospital and Walter Reed National Military Medical Center, Fort Belvoir, VA, USA
| | - Matthew Kim
- Department of Otolaryngology - Head and Neck Surgery, New York Presbyterian Hospital - Weill Cornell Medicine, New York, NY, USA
| | - Anthony Sclafani
- Department of Otolaryngology - Head and Neck Surgery, New York Presbyterian Hospital - Weill Cornell Medicine, New York, NY, USA
| | - Abtin Tabaee
- Department of Otolaryngology - Head and Neck Surgery, New York Presbyterian Hospital - Weill Cornell Medicine, New York, NY, USA.
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Bhoja R, Ryan MW, Klein K, Minhajuddin A, Melikman E, Hamza M, Marple BF, McDonagh DL. Intravenous vs oral acetaminophen in sinus surgery: A randomized clinical trial. Laryngoscope Investig Otolaryngol 2020; 5:348-353. [PMID: 32596476 PMCID: PMC7314478 DOI: 10.1002/lio2.375] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 02/06/2020] [Accepted: 02/17/2020] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Multimodal perioperative analgesia including acetaminophen is recommended by current guidelines. The comparative efficacy of intravenous vs oral acetaminophen in sinus surgery is unknown. We aimed to determine whether intravenous or oral acetaminophen results in superior postoperative analgesia following sinus surgery. METHODS This was a prospective randomized trial with blinded endpoint assessments conducted at a single large academic medical center. Subjects undergoing functional endoscopic sinus surgery were randomized to intravenous vs oral acetaminophen in addition to standard anesthetic and surgical care. The primary outcome was visual analogue scale pain score at 1 hour postoperatively. RESULTS One hundred and ten adult patients were randomized; 9 were excluded from the data analysis. Fifty patients were assigned to intravenous acetaminophen and 51 to oral acetaminophen. Postoperative pain scores at 1 hour (primary endpoint) were not significantly different between the intravenous and oral acetaminophen groups. Similarly, there was no significant difference in pain scores at 24 hours postoperatively. Finally, there was no significant difference in postoperative opioid usage in the postanesthesia care unit or over the first 24 hours postoperatively. CONCLUSIONS This is the first comparative efficacy trial of oral vs intravenous acetaminophen in sinus surgery. There was no significant difference in pain scores at 1 or 24 hours postoperatively, and no difference in postoperative opioid use. Intravenous acetaminophen offers no apparent advantage over oral acetaminophen in patients undergoing sinus surgery. LEVEL OF EVIDENCE 1b.
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Affiliation(s)
- Ravi Bhoja
- Department of Anesthesiology and Pain ManagementThe University of Texas SouthwesternDallasTexasUSA
| | - Matthew W. Ryan
- Department of OtolaryngologyThe University of Texas SouthwesternDallasTexasUSA
| | - Kevin Klein
- Department of Anesthesiology and Pain ManagementThe University of Texas SouthwesternDallasTexasUSA
| | - Abu Minhajuddin
- Department of Anesthesiology and Pain ManagementThe University of Texas SouthwesternDallasTexasUSA
| | - Emily Melikman
- Department of Anesthesiology and Pain ManagementThe University of Texas SouthwesternDallasTexasUSA
| | - Mohamed Hamza
- Department of Anesthesiology and Pain ManagementThe University of Texas SouthwesternDallasTexasUSA
| | - Bradley F. Marple
- Department of OtolaryngologyThe University of Texas SouthwesternDallasTexasUSA
| | - David L. McDonagh
- Department of Anesthesiology and Pain ManagementThe University of Texas SouthwesternDallasTexasUSA
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Ndon S, Spock T, Torabi SJ, Manes RP. Patterns in Pain and Opiate Use after Endoscopic Sinus Surgery. Otolaryngol Head Neck Surg 2020; 162:969-978. [PMID: 32284006 DOI: 10.1177/0194599820915472] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To evaluate postoperative opiate use and patients' opinions regarding pain management after endoscopic sinus surgery (ESS). STUDY DESIGN Case series with planned data collection. SETTING Tertiary referral medical center. SUBJECTS AND METHODS We prospectively evaluated postoperative opiate utilization in adults undergoing ESS over a 2-year period at an academic medical facility. Exclusion criteria included use of nasal packing, intracranial or orbital procedures, tumor surgery, and any use of endoscopic drills. All patients underwent bilateral maxillary antrostomy, total ethmoidectomy, sphenoidotomy, and frontal sinusotomy with or without septoplasty. Patients were discharged with 30 oxycodone-acetaminophen (5-325 mg) and a survey assessing pain and narcotic/nonnarcotic use on postoperative days 0 to 7. RESULTS A total of 64 patients completed surveys. Mean ± SD narcotic use over the 7-day postoperative period was 7.7 ± 7.6 pills. Patients with high narcotic use (>6 pills total) had no differences in demographic or surgical factors from those with low use (≤6 pills) but did report a higher level of postoperative day 1 pain (4.8 ± 1.1 vs 2.0 ± 1.4, P < .001). Narcotic use declined during this period, with <30% of patients requiring narcotics by postoperative day 3. CONCLUSION Our results support reduced opiate prescription and encouragement of nonnarcotic use after ESS without compromising effective pain management.
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Affiliation(s)
- Sifon Ndon
- Department of Otolaryngology, UCSF School of Medicine, San Francisco, California, USA
| | - Todd Spock
- Department of Otolaryngology, Mount Sinai Health, New York, New York, USA
| | - Sina J Torabi
- Section of Otolaryngology, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - R Peter Manes
- Section of Otolaryngology, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
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Miller C, Humphreys IM, Davis GE. Effect of Over the Counter Ibuprofen Dosing after Sinus Surgery for Chronic Rhinosinusitis: A Prospective Cohort Pilot Study. Ann Otol Rhinol Laryngol 2020; 129:677-683. [PMID: 32028782 PMCID: PMC10163897 DOI: 10.1177/0003489420906179] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Introduction: Management of pain following endoscopic sinus surgery (ESS) often involves intermittent use of opioid medications. Given the current opioid crisis, many surgeons aim to minimize opioid prescriptions. However, surgeons often avoid the use of NSAIDs following ESS out of concern for increased bleeding risk. We sought to evaluate the effectiveness and safety of over the counter dosing of ibuprofen on pain and bleeding rates following ESS. Methods: Prospective cohort pilot study of patients undergoing ESS. Patients self-selected either control arm (acetaminophen and PRN oxycodone) or intervention arm (alternating ibuprofen with acetaminophen, and PRN oxycodone). Outcome measures included pain (10-point visual analog scale [VAS]), bleeding rate (10-point VAS), and number of opiate pills consumed. Results: Thirty-nine patients completed the study (15 control and 24 intervention). Overall, patients in the intervention arm reported decreased pain levels at days 1 (−0.9 [95%CI: −2.2, 0.5], 3 (−0.9 [95%CI: −2.3, 0.5]), and 7 (−0.6 [95%CI: −1.8, 0.6]), as well as decreased postoperative bleeding at those same days −0.9 [95%CI: −2.1, 0.4], −0.9 [95%CI: −2.1, 0.4], and −0.7 [95% CI: −1.2, −0.7], compared to controls. Opiate consumption was similar between groups with patients consuming on average four opiate pills (oxycodone 5 mg). Conclusions: Over the counter dosing of ibuprofen along with acetaminophen may yield better pain control after sinus surgery compared to acetaminophen alone. Additionally, there was no significant difference in epistaxis in the ibuprofen cohort compared to the cohort who did not take ibuprofen. Furthermore, this study showed very few opioid pills were consumed after routine ESS regardless of pain regimen prescribed. A larger trial is needed to make definitive statements on safety and efficacy. Level of Evidence: 2b
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Affiliation(s)
- Craig Miller
- Department of Otolaryngology—Head & Neck Surgery, University of Washington, Seattle, WA, USA
| | - Ian M. Humphreys
- Department of Otolaryngology—Head & Neck Surgery, University of Washington, Seattle, WA, USA
| | - Greg E. Davis
- Department of Otolaryngology—Head & Neck Surgery, University of Washington, Seattle, WA, USA
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Wu AW, Walgama ES, Genç E, Ting JY, Illing EA, Shipchandler TZ, Higgins TS. Multicenter study on the effect of nonsteroidal anti-inflammatory drugs on postoperative pain after endoscopic sinus and nasal surgery. Int Forum Allergy Rhinol 2019; 10:489-495. [PMID: 31834679 DOI: 10.1002/alr.22506] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 11/14/2019] [Accepted: 11/15/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND The taboo of avoiding nonsteroidal anti-inflammatory drugs (NSAIDs) after functional endoscopic sinus surgery (FESS) has been waning. The impetus to reduce opioid prescriptions in view of the opioid epidemic led the authors to change their practices to include NSAIDs after sinus surgery. This study's aim was to analyze the differences between patients before and after we began recommending NSAIDs after FESS. METHODS A prospective cohort study was performed on patients undergoing FESS or other endoscopic nasal surgeries at 3 institutions, by 5 rhinologists and 1 facial plastic surgeon. Before introducing NSAIDs, all patients were given a prescription for hydrocodone-acetaminophen 5/325 mg and also recommended preferentially to use acetaminophen 325 mg. After the addition of NSAIDs, ibuprofen 200 mg and acetaminophen 325 mg were recommended preferentially, using the narcotic as a rescue medication. Patients kept a pain diary and medication log, and gave a visual analog scale (VAS) score for overall pain. Demographics, surgical variables, and comorbidities were also analyzed. RESULTS One hundred sixty-six total patients were recruited and had data that could be analyzed (65 without NSAIDs, 101 with NSAIDs). Overall, mean pain VAS score was 3.12 ± 1.95 for the non-NSAID group and 2.33 ± 2.30 for the NSAID group (p value = 0.006). The day with the highest mean pain was the first postoperative day. The mean number of total opioid pills taken was 6.94 ± 6.85 without NSAIDs vs 3.77 ± 4.56 with NSAIDs (p = 0.018). Age and gender were found to be the only consistently significant patient variables to affect pain. There were no bleeding complications. CONCLUSION NSAID use was introduced into the practices of 5 practicing rhinologists and 1 facial plastic surgeon. No bleeding complications were seen. Both pain and overall opioid usage were reduced significantly.
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Affiliation(s)
- Arthur W Wu
- Division of Otolaryngology-Head & Neck Surgery Cedars-Sinai Medical Center, Los Angeles, CA
| | - Evan S Walgama
- Division of Otolaryngology-Head & Neck Surgery Cedars-Sinai Medical Center, Los Angeles, CA
| | - Ege Genç
- Hacettepe University School of Medicine, Ankara, Turkey
| | - Jonathan Y Ting
- Department of Otolaryngology-Head & Neck Surgery, Indiana University, Indianapolis, IN
| | - Elisa A Illing
- Department of Otolaryngology-Head & Neck Surgery, Indiana University, Indianapolis, IN
| | - Taha Z Shipchandler
- Department of Otolaryngology-Head & Neck Surgery, Indiana University, Indianapolis, IN
| | - Thomas S Higgins
- Rhinology, Sinus & Skull Base, Kentuckiana Ear, Nose, & Throat, Department of Otolaryngology-Head & Neck Surgery, University of Louisville, Louisville, KY
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Newberry CI, Casazza GC, Pruitt LC, Meier JD, Skarda DE, Alt JA. Prescription patterns and opioid usage in sinonasal surgery. Int Forum Allergy Rhinol 2019; 10:381-387. [PMID: 31693311 DOI: 10.1002/alr.22478] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 09/29/2019] [Accepted: 10/16/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND Excess opioid use after surgery contributes to opiate misuse and diversion. Understanding opioid prescribing and utilization patterns after sinonasal surgery is critical in designing effective practice protocols. In this study we aim to identify factors associated with variable opioid usage and further delineate optimal prescription patterns for sinonasal surgery. METHODS All patients undergoing sinonasal surgery within a single health-care system from March 2017 to August 2018 were sent electronic postoperative surveys. Data were collected on the amount of opioid required, pain control, presurgical opiate use, and narcotic disposal. Additional data collected from the electronic medical record included demographics, type of surgery performed, and total amount of opioid prescribed, including refills. RESULTS Three-hundred sixty four patients were included. A mean number of 25.3 tablets were prescribed per patient, yet the mean taken was just 11.8 tablets. Excess opioids were prescribed 84.9% of the time with a mean excess narcotic in oral morphine equivalents of 152.5. Among patients, 11.8% reported using no opioids, whereas 52.1% used <50% and 36.1% used >50% of their narcotic prescription. Patients used 9.3% of their full prescription and only 2.6% required a refill. The amount used was not associated with complexity of endoscopic sinus surgery, type of opiate prescribed, gender, distance living from hospital, or current opioid usage before surgery (p > 0.05). The addition of septoplasty and/or turbinoplasty was associated with variation in opioid usage (p < 0.001). A total of 76.1% of patients incorrectly discarded/stored excess opiates. CONCLUSION Opioids are overprescribed after sinonasal surgery. The amount of postoperative opiate prescribed should be greatly reduced and may be based on the specific procedures performed. Improved patient education regarding disposal of excess narcotics may help to curtail future opioid diversion.
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Affiliation(s)
- Christopher I Newberry
- Department of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Geoffrey C Casazza
- Department of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Liese C Pruitt
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Jeremy D Meier
- Department of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - David E Skarda
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Jeremiah A Alt
- Department of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, Utah
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Patel A, Levi JR, Brook CD. Should Excess Topical Decongestant Use Raise a Red Flag? Rhinitis Medicamentosa and Opioid Use Disorder. Ann Otol Rhinol Laryngol 2019; 129:164-169. [PMID: 31581795 DOI: 10.1177/0003489419880576] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The objective of this study was to determine whether patients with rhinitis medicamentosa (RM) have an increased odds of having an opioid use disorder (OUD) and which characteristics may predict this association. METHODS The authors conducted a retrospective case control study of patients 18 years and older who presented to the otolaryngology clinic at an academic medical center from January 2013 through December 2017. Cases, defined as patients who presented with excessive decongestant nasal spray usage based on history, were matched to control patients who presented with chronic rhinitis and did not report regular nasal decongestant usage. The charts were reviewed for patients that carried a problem of opioid abuse, identified using ICD-9 codes 304.XX or ICD-10 codes F11.XX. The primary outcome of this study was the odds of having an OUD. Secondary outcomes were assessed by summary statistics. RESULTS One hundred and thirty-one cases of RM were matched to 1871 controls of chronic rhinitis. Seven cases (5.3%) and 24 (1.3%) controls had a diagnosis of OUD, consistent with an odds ratio of 3.98 for opioid abuse in patients with RM (95% CI: 1.47-9.71). Oxymetazoline was used by 85.5% (n = 112) of patients with RM. Thirty-six patients (27.1%) with RM underwent nasal surgery following a diagnosis of RM, of which twenty patients (55.6%) were prescribed opioids following the procedure. CONCLUSIONS RM is associated with increased odds of having an OUD.
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Affiliation(s)
- Aneesh Patel
- Boston University School of Medicine, Boston, MA, USA
| | - Jessica R Levi
- Boston University School of Medicine, Boston, MA, USA.,Department of Otolaryngology, Boston University Medical Center, Boston, MA, USA
| | - Christopher D Brook
- Boston University School of Medicine, Boston, MA, USA.,Department of Otolaryngology, Boston University Medical Center, Boston, MA, USA
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Badash I, Lui CG, Hur K, Acevedo JR, Ference EH, Wrobel BB. Quantifying the use of opioids in the immediate postoperative period after endoscopic sinus surgery. Laryngoscope 2019; 130:1122-1127. [DOI: 10.1002/lary.28178] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 06/02/2019] [Accepted: 06/19/2019] [Indexed: 12/23/2022]
Affiliation(s)
- Ido Badash
- Keck School of MedicineUniversity of Southern California Los Angeles California U.S.A
| | - Christopher G. Lui
- Keck School of MedicineUniversity of Southern California Los Angeles California U.S.A
| | - Kevin Hur
- Caruso Department of Otolaryngology–Head and Neck SurgeryUniversity of Southern California Los Angeles California U.S.A
| | - Joseph R. Acevedo
- Caruso Department of Otolaryngology–Head and Neck SurgeryUniversity of Southern California Los Angeles California U.S.A
| | - Elisabeth H. Ference
- Caruso Department of Otolaryngology–Head and Neck SurgeryUniversity of Southern California Los Angeles California U.S.A
| | - Bozena B. Wrobel
- Caruso Department of Otolaryngology–Head and Neck SurgeryUniversity of Southern California Los Angeles California U.S.A
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Klifto KM, Major MR, Leto Barone AA, Payne RM, Elhelali A, Seal SM, Cooney CM, Manahan MA, Rosson GD. Perioperative systemic nonsteroidal anti-inflammatory drugs (NSAIDs) in women undergoing breast surgery. Hippokratia 2019. [DOI: 10.1002/14651858.cd013290] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Kevin M Klifto
- Johns Hopkins University School of Medicine; Department of Plastic and Reconstructive Surgery; 601 N. Caroline Street Baltimore USA 21287
| | - Melanie R Major
- Johns Hopkins University School of Medicine; Department of Plastic and Reconstructive Surgery; 601 N. Caroline Street Baltimore USA 21287
| | - Angelo A Leto Barone
- Johns Hopkins University School of Medicine; Department of Plastic and Reconstructive Surgery; 601 N. Caroline Street Baltimore USA 21287
| | - Rachael M Payne
- Washington University School of Medicine; Division of Plastic and Reconstructive Surgery, Department of Surgery; St Louis USA
| | - Ala Elhelali
- National University of Ireland; Department of Nursing and Midwifery; Aras Moyola, National University of Ireland Galway Galway Ireland
| | - Stella M Seal
- Johns Hopkins University School of Medicine; Welch Medical Library; 2024 E. Monument St. Baltimore USA 21287
| | - Carisa M Cooney
- Johns Hopkins University School of Medicine; Department of Plastic and Reconstructive Surgery; 601 N. Caroline Street Baltimore USA 21287
| | - Michele A Manahan
- Johns Hopkins University School of Medicine; Department of Plastic and Reconstructive Surgery; 601 N. Caroline Street Baltimore USA 21287
| | - Gedge D Rosson
- Johns Hopkins University School of Medicine; Department of Plastic and Reconstructive Surgery; 601 N. Caroline Street Baltimore USA 21287
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Raikundalia MD, Cheng TZ, Truong T, Kuchibhatla M, Ryu J, Abi Hachem R, Jang DW. Factors associated with opioid use after endoscopic sinus surgery. Laryngoscope 2019; 129:1751-1755. [PMID: 30861579 DOI: 10.1002/lary.27921] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVES/HYPOTHESIS Responsible prescribing of postoperative pain medications is necessary in combatting the current opioid epidemic in the United States. The goal of this study was to determine which clinical factors affect opioid usage following functional endoscopic sinus surgery (FESS). STUDY DESIGN Retrospective medical records study. METHODS This is a single-institution retrospective study of subjects undergoing FESS by the senior author between September 2016 and December 2017. Opioid usage was assessed for each patient at the first postoperative visit. Univariate and multivariable analyses were performed to investigate factors associated with pain medication usage. Patients using opioids prior to surgery were excluded. RESULTS A total of 136 patients were stratified into three groups based on number of opioid tablets taken during the first week after surgery: 31 patients (23%) took no opioids, 61 patients (45%) took one to five tablets, and 44 patients (32%) took more than five tablets. Gender, extent of surgery, revision surgery, polyp status, and cystic fibrosis did not significantly vary between the three groups. Multinomial logistic regression analysis with backward stepwise variable selection method revealed that those who had septoplasty (odds ratio [OR]: 4.84, 95% confidence interval [CI]: 1.68-13.98; P < .01) or were of younger age (OR 0.96, 95% CI: 0.93-0.99; P = .01) had significantly higher odds of taking >5 tablets. CONCLUSIONS The majority of patients undergoing FESS did not take more than 5 opioid tablets after surgery. Concurrent septoplasty and younger age were associated with increased opioid usage. Knowledge of such factors can help surgeons to assess opioid prescribing patterns and to counsel their patients on postoperative pain. Laryngoscope, 129:1751-1755, 2019.
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Affiliation(s)
- Milap D Raikundalia
- Division of Head and Neck Surgery and Communication Sciences, Department of Surgery, Duke University, Durham, North Carolina
| | - Tracy Z Cheng
- Duke University School of Medicine, Durham, North Carolina
| | - Tracy Truong
- Duke Translational Medicine Institute Biostatistics Core, Durham, North Carolina
| | | | - Jiyoung Ryu
- MedRehab Specialists of North Carolina, Charlotte, North Carolina, U.S.A
| | - Ralph Abi Hachem
- Division of Head and Neck Surgery and Communication Sciences, Department of Surgery, Duke University, Durham, North Carolina
| | - David W Jang
- Division of Head and Neck Surgery and Communication Sciences, Department of Surgery, Duke University, Durham, North Carolina
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Nguyen KK, Liu YF, Chang C, Park JJ, Kim CH, Hondorp B, Vuong C, Xu H, Crawley BK, Simental AA, Church CA, Inman JC. A Randomized Single-Blinded Trial of Ibuprofen- versus Opioid-Based Primary Analgesic Therapy in Outpatient Otolaryngology Surgery. Otolaryngol Head Neck Surg 2019; 160:839-846. [DOI: 10.1177/0194599819832528] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Objective To compare the efficacy of pain control and opioid consumption between patients who receive opioid as primary analgesic therapy and those who receive ibuprofen. Study Design Prospective randomized trial. Setting Tertiary care academic hospital. Subject and Methods Adult patients undergoing outpatient otolaryngology surgery were assigned to take hydrocodone/acetaminophen or ibuprofen for postoperative analgesia. Patient-recorded pain scores and analgesic consumption were analyzed. Results Out of 185 recruits, 108 (58%) completed responses. Fifty-six patients (52%) received opioid medication for primary analgesic treatment versus 52 (48%) who received ibuprofen. There was no difference in reported pain scores between the treatment groups. Those who received ibuprofen as primary therapy reported a significantly lower consumption of opioid medication at 2.04 tablets/pills (95% CI, 0.9-3.1) versus 4.86 (3.6-6.1; P = .001). Based on multivariate analysis, male sex and older age exhibited lower reported pain scores, while older age and use of ibuprofen as primary therapy exhibited lower opioid requirements. Conclusion For postoperative pain management in outpatient otolaryngology procedures, ibuprofen as primary therapy can provide equally effective pain control as compared with hydrocodone/acetaminophen while decreasing overall opioid requirement. Prescription pill counts are further described to help guide physician practices in the era of an opioid epidemic.
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Affiliation(s)
- Khanh K. Nguyen
- Department of Otolaryngology–Head and Neck Surgery, Loma Linda University Health System, Loma Linda, California, USA
| | - Yuan F. Liu
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Crystal Chang
- School of Medicine, Loma Linda University, Loma Linda, California, USA
| | - Jaimie J. Park
- School of Medicine, Loma Linda University, Loma Linda, California, USA
| | - Cherine H. Kim
- Department of Otolaryngology–Head and Neck Surgery, Loma Linda University Health System, Loma Linda, California, USA
| | - Brian Hondorp
- Department of Otolaryngology–Head and Neck Surgery, Loma Linda University Health System, Loma Linda, California, USA
| | - Christopher Vuong
- Department of Otolaryngology–Head and Neck Surgery, Loma Linda University Health System, Loma Linda, California, USA
| | - Helen Xu
- Department of Otolaryngology–Head and Neck Surgery, Loma Linda University Health System, Loma Linda, California, USA
| | - Brianna K. Crawley
- Department of Otolaryngology–Head and Neck Surgery, Loma Linda University Health System, Loma Linda, California, USA
| | - Alfred A. Simental
- Department of Otolaryngology–Head and Neck Surgery, Loma Linda University Health System, Loma Linda, California, USA
| | - Christopher A. Church
- Department of Otolaryngology–Head and Neck Surgery, Loma Linda University Health System, Loma Linda, California, USA
| | - Jared C. Inman
- Department of Otolaryngology–Head and Neck Surgery, Loma Linda University Health System, Loma Linda, California, USA
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Nguyen BK, Yuhan BT, Folbe E, Eloy JA, Zuliani GF, Hsueh WD, Paskhover B, Folbe AJ, Svider PF. Perioperative Analgesia for Patients Undergoing Septoplasty and Rhinoplasty: An Evidence-Based Review. Laryngoscope 2018; 129:E200-E212. [PMID: 30585326 DOI: 10.1002/lary.27616] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/17/2018] [Indexed: 12/17/2022]
Abstract
OBJECTIVES/HYPOTHESIS Opioid misuse and diversion is a pressing topic in today's healthcare environment. The objective of this study was to conduct a review of non-opioid perioperative analgesic regimens following septoplasty, rhinoplasty, and septorhinoplasty. STUDY DESIGN Evidence-based systematic review. METHODS PubMed, MEDLINE, Cochrane Library, and Embase databases were reviewed for articles related to perioperative analgesic use in septoplasty, rhinoplasty, and septorhinoplasty. Quality of studies were assessed via the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) criteria, Jadad scores, and the Cochrane bias tool. Patient demographic data and clinical outcomes, including medication type, dose, administration time, pain scores, and adverse events, were obtained from included studies. Summary tables detailing the benefits and harms of each investigated regimen are included. RESULTS Thirty-seven studies met inclusion criteria for this evidence-based review. The quality of the studies was determined to be of moderate quality based off of GRADE standardized criteria with a mean Jadad score of 3.1. A preponderance of evidence showed reduced perioperative pain scores and rescue analgesic requirements, supporting the use of local anesthetics for analgesic control. Nonsteroidal anti-inflammatory drugs (NSAIDs) demonstrated similar decreased visual analog scores and postoperative analgesic demand; however, increased adverse events in this class warrant caution. CONCLUSIONS Contemporary literature supports the use of NSAIDs, gabapentin, local anesthetics, and α-agonists as effective perioperative analgesic opioid alternatives for septoplasty and septorhinoplasty. Local anesthetic use is a cost-effective option resulting in decreased postoperative pain scores and rescue analgesic requirements. Further large-scale, multi-institutional, controlled studies are needed to provide definitive recommendations. LEVEL OF EVIDENCE NA Laryngoscope, 129:E200-E212, 2019.
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Affiliation(s)
- Brandon K Nguyen
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan.,Department of Otolaryngology, William Beaumont Hospital, Royal Oak, Michigan
| | - Brian T Yuhan
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan.,Department of Otolaryngology, William Beaumont Hospital, Royal Oak, Michigan
| | - Elana Folbe
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan
| | - Jean Anderson Eloy
- Department of Otolaryngology-Head and Neck Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey.,Department of Ophthalmology and Visual Science, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey.,Department of Neurological Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Giancarlo F Zuliani
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan.,Zuliani Facial Aesthetics, Bloomfield Hills, Michigan
| | - Wayne D Hsueh
- Department of Otolaryngology-Head and Neck Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Boris Paskhover
- Department of Otolaryngology-Head and Neck Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Adam J Folbe
- Department of Otolaryngology, William Beaumont Hospital, Royal Oak, Michigan.,Barbara Ann Karmanos Cancer Institute, Detroit, Michigan, U.S.A
| | - Peter F Svider
- Department of Otolaryngology-Head and Neck Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey
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Sethi RKV, Miller AL, Bartholomew RA, Lehmann AE, Bergmark RW, Sedaghat AR, Gray ST. Opioid prescription patterns and use among patients undergoing endoscopic sinus surgery. Laryngoscope 2018; 129:1046-1052. [PMID: 30582624 DOI: 10.1002/lary.27672] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 10/04/2018] [Accepted: 10/15/2018] [Indexed: 12/18/2022]
Abstract
OBJECTIVES/HYPOTHESIS Opioid-related deaths in the United States have increased 200% since 2000, in part due to prescription diversion from patients who had a surgical procedure. The purpose of this study was to characterize provider prescription patterns and assess patient-reported opioid use after endoscopic sinus surgery (ESS). STUDY DESIGN Retrospective chart review. METHODS Patients who underwent ESS between May 2017 and May 2018 were included. Opioid prescription, operative details, and postoperative opioid use data were extracted. The Massachusetts Prescription Awareness Tool (MassPAT) was queried to determine if patients filled their prescription. RESULTS One hundred fifty-five patients were included. Nearly all patients received an opioid prescription (94.8%). An average of 15.6 tablets was prescribed per patient. Among 116 patients with MassPAT data, 91.4% filled their prescription. Among 67 patients who reported the number of tablets they had used at the time of first follow-up appointment, 73.1% reported taking no opioids. Mean number of tablets prescribed was significantly greater among patients who underwent primary versus revision surgery (16.5 vs. 13.5, P = .0111) and those who had splints placed (21.5 vs. 15.1, P = .0037). Predictors of opioid use included concurrent turbinate reduction (58.3% vs. 14.3%, P < .0001) and concurrent septoplasty (45.5% vs. 21.6%, P = .039). CONCLUSIONS Nearly all patients who underwent ESS were prescribed an opioid, and nearly all patients filled their prescription. However, the vast majority of patients did not require any opioid medication for postoperative pain control. As the opioid epidemic continues to persist, these findings have immediate relevance to current prescribing patterns and pain management practices. LEVEL OF EVIDENCE 4 Laryngoscope, 129:1046-1052, 2019.
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Affiliation(s)
- Rosh K V Sethi
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts.,Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
| | - Ashley L Miller
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts.,Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
| | | | - Ashton E Lehmann
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts.,Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
| | - Regan W Bergmark
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts.,Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Boston, Massachusetts, U.S.A.,Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, U.S.A
| | - Ahmad R Sedaghat
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts.,Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
| | - Stacey T Gray
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts.,Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
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Gray ML, Fan CJ, Kappauf C, Kidwai S, Colley P, Iloreta AM, Govindaraj S. Postoperative pain management after sinus surgery: a survey of the American Rhinologic Society. Int Forum Allergy Rhinol 2018; 8:1199-1203. [PMID: 30019397 DOI: 10.1002/alr.22181] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 05/22/2018] [Accepted: 05/31/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND Postoperative pain management is controversial as there are no current guidelines to direct clinical practice. The purpose of this study was to demonstrate prescribing patterns for pain management after functional endoscopic sinus surgery (FESS). METHODS A 15-item web-based survey was electronically distributed to 1770 members of the American Rhinologic Society (ARS). Linear regression analysis was used to determine associations between providers and prescribing patterns. RESULTS The survey was completed by 168 members (9.49%), representing all regions of the United States. The most commonly prescribed medications were opioid/non-opioid combination pills. One hundred fifty-seven of 168 members (94.05%) prescribed at least one kind of opioid after FESS, with an average of 27.38 pills. The majority of surveyed members worked in private or academic settings. Academic physicians were less likely to prescribe ibuprofen (p = 0.0407), and nonsteroidal anti-inflammatory drugs (NSAIDs) in general (p = 0.032). Physicians in private practice were less likely to refer patients to pain management (p = 0.0117), but more likely to refer patients to nontraditional forms of pain management (p = 0.0164). Academic physicians were more likely to refer patients to pain management (p = 0.00121). There was no association between perception of pain control and the prescription of NSAIDs or with number of opioid pills prescribed. CONCLUSION Most providers prescribed opioids after FESS. There was no significant difference in the number of opioids prescribed based on geography or practice setting. There was significant heterogeneity in the adjuvant pain management strategy between academic and private practitioners. Most members provided patient education and few reported poor pain control. However, there was a gap in understanding of appropriate medication disposal and evidence-based postoperative pain management.
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Affiliation(s)
- Mingyang L Gray
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Caleb J Fan
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Catharine Kappauf
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sarah Kidwai
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Patrick Colley
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alfred Marc Iloreta
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Satish Govindaraj
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
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45
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Wise SK. A focus on quality. Int Forum Allergy Rhinol 2018; 8:767-768. [DOI: 10.1002/alr.22170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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