Pain Management Following Otological Surgery: A Prospective Study of Different Strategies

Prednisone Decreases Opioid Use in Adults Undergoing Benign Oropharyngeal Surgery

OBJECTIVE

This study sought to analyze the efficacy and safety of postoperative prednisone to reduce reliance on opioids in adult benign oropharyngeal surgery.

STUDY DESIGN

Prospective cohort study.

SETTING

Single tertiary-care facility.

METHODS

Patients undergoing tonsillectomy (T), tonsillectomy and adenoidectomy (T&A), and/or modified uvulopalatopharyngoplasty (UPPP) from December 2020 to January 2023 received the standard of care postoperative management. A prednisone taper was dependent on surgeon preference. Cohorts were based on the prescription of postoperative steroids. Patients completed a survey to assess opioid usage, pain scores, and steroid compliance.

RESULTS

Seventy-two patients were included. The nonsteroid cohort (N = 29) received an average of 467 ± 94.1 morphine milligram equivalents (MME), and the steroid cohort (N = 43) received an average of 285 ± 128 MME (P < 0.001). The nonsteroid cohort consumed 1.62 times more opioids than the steroid cohort (P < 0.002). There were no significant differences in complication or refill rates between treatment groups. There were no significant differences in pain scores on the day of surgery or postoperative days 1, 5, or 10 (P = 0.34, P = 0.66, P = 0.62, and P = 0.22, respectively). Patients undergoing T&A (p = 0.019) or who had current psychiatric medication use (P < 0.006) consumed significantly more opioids. Patients who received a total opioid prescription of >300 MME (40 5-mL doses of 5 mg/5 mL liquid oxycodone) consumed 2.27 times more postoperative opioids than patients with opioid prescriptions ≤300 MME (P < 0.001).

CONCLUSION

Patients who did not receive steroids consumed 1.62 times more postoperative opioids compared to those who completed a steroid taper. Corticosteroid use was not associated with changes in pain scores, refill rates, or complication rates and may be considered in a multimodal approach to pain management in adults undergoing benign oropharyngeal surgery, although further study is warranted.

Postoperative opioid use following head and neck endocrine surgery: A multi-center prospective study

Background

Opioid abuse is widespread in North America and the over-prescription of opioids are a contributing factor. The goal of this prospective study was to quantify over-prescription rates, evaluate postoperative experiences of pain, and understand the impact of peri-operative factors such as adequate pain counseling and use of non-opioid analgesia.

Methods

Consecutive recruitment of patients undergoing head and neck endocrine surgery was undertaken from January 1st 2020 to December 31st 2021 at four Canadian hospitals in Ontario and Nova Scotia. Postoperative tracking of pain levels and analgesic requirements were employed. Chart review and preoperative and postoperative surveys provided information on counseling, use of local anesthesia, and disposal plans.

Results

A total of 125 adult patients were included in the final analysis. Total thyroidectomy was the most common procedure (40.8%). Median use of opioid tablets was 2 (IQR 0-4), with 79.5% of prescribed tablets unused. Patients who reported inadequate counseling (n = 35, 28.0%) were more likely to use opioids (57.2% vs. 37.8%, p < .05) and less likely to use non-opioid analgesia in the early postoperative course (42.9% vs. 63.3%, p < .05). Patients who received local anesthesia peri-operatively (46.4%, n = 58) reported less severe pain on average [2.86 (2.13) vs. 4.86 (2.19), p < .05] and used less analgesia on postoperative day one [0 MME (IQR 0-4) vs. 4 MME (IQR 0-8), p < .05].

Conclusion

Over-prescription of opioid analgesia following head and neck endocrine surgery is common. Patient counseling, use of non-opioid analgesia, and peri-operative local anesthesia were important factors in narcotic use reduction.

Level of evidence

Level 3.

Preoperative Anxiety Levels and Postoperative Middle Ear Surgery Pain Levels

OBJECTIVE

This study aimed to characterize self-reported postoperative pain after tympanoplasty and tympanomastoidectomy and correlate pain severity with the patient's preoperative anxiety state.

STUDY DESIGN

Prospective cohort study.

SETTING

Tertiary referral medical center.

PATIENTS

Adult patients undergoing any middle ear surgery between July 2018 and July 2019.

MAIN OUTCOME MEASURES

Patient responses to an otology questionnaire (OQ) for scoring pain intensity on a visual analog scale preoperatively and on postoperative days (PODs) 1-4, 21, and 63. The responses were correlated with anxiety state (assessed by State-Trait Personality Inventory [STPI] scores) and clinical and operative data, including surgical technique-related details.

RESULTS

Sixty patients were enrolled (mean age ± standard deviation, 40 ± 19.7 yr, 26 men). Their median preoperative (baseline) visual analog scale pain score was 6 on POD1, 5 on POD3, and 1 at 3 and 7 weeks. Their median preoperative OQ score was 32 of 70 (45.7%), 37 of 70 (52.8%) on POD1, 33 of 70 (47.1%) on POD3, 6 of 70 (8.5%) at 3 weeks, and 6 of 70 at 7 weeks. Their overall mean preoperative anxiety level (STPI score) was 2.63 ± 1.50. STPI scores were significantly higher among patients who reported OQ scores equal to or higher than the median during PODs 1 to 4 in comparison to patients who reported OQ scores lower than the median. The α Cronbach correlation between anxiety and postoperative pain scores on POD1 was 0.97.

CONCLUSION

Preoperative anxiety levels are closely associated with postoperative pain levels after any middle ear surgery. Measures to control preoperative anxiety are warranted to alleviate postoperative pain.

Multimodal Analgesia and Patient Education Reduce Postoperative Opioid Consumption in Otology

OBJECTIVE

This study sought to validate alternative pain management strategies that can reduce reliance on opioids for postoperative pain management in otology.

STUDY DESIGN

Prospective cohort study.

SETTING

Single tertiary-care facility.

METHODS

Adult patients who underwent outpatient otologic surgery from September 2021 to July 2022 were randomized into treatment cohorts. The opioid monotherapy cohort received a standard opioid prescription. The multimodal analgesia cohort received the same opioid prescription, prescriptions for acetaminophen and naproxen, and additional pain management education with a flyer on discharge. All patients completed a questionnaire 1 week after surgery to evaluate opioid usage and pain scores.

RESULTS

Eighty-six patients completed the study. The opioid monotherapy cohort (n = 42) and multimodal analgesia cohort (n = 44) were prescribed an average of 42.1 ± 20.4 morphine milligram equivalents (MME) and 38.4 ± 5.7 MME, respectively (p = 0.373). Four patients (9.52%) in the opioid monotherapy cohort required opioid refills compared to 1 patient (2.27%) in the multimodal analgesia cohort (p = 0.156). Multivariate analysis demonstrated that the multimodal analgesia cohort consumed significantly fewer opioids on average than the opioid monotherapy cohort (11.9 ± 15.9 MME vs 22.8 ± 28.0 MME, respectively). There were no significant differences in postoperative rehospitalizations (p = 0.317) or Emergency Department visits (p = 0.150). Pain scores on the day of surgery, postoperative day (POD) 1, POD3, and POD7 were not significantly different between cohorts (p = 0.395, 0.896, 0.844, 0.765, respectively).

CONCLUSION

The addition of patient education, acetaminophen, and naproxen to postoperative opioid prescriptions significantly reduced opioid consumption without affecting pain scores, refill rates, or complication rates after otologic surgery.