Postoperative pain assessment after functional endoscopic sinus surgery (FESS) for chronic pansinusitis

A Review of Postoperative Care Following Endoscopic Sinus Surgery for Chronic Rhinosinusitis

OBJECTIVES

This study reviews current postoperative care recommendations following endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS), with the goal of optimizing recovery, minimizing complications, and reducing the risk of disease recurrence.

METHODS

A comprehensive literature review was conducted to identify studies on postoperative care following ESS for CRS. Findings were synthesized to develop evidence-based recommendations for optimal postoperative management.

RESULTS

Postoperative care following ESS for CRS requires a multifaceted approach. Pain management should prioritize acetaminophen and nonsteroidal anti-inflammatory drugs, with opioids reserved for severe pain. Nasal irrigation, topical corticosteroids, and debridement are recommended for all patients. Nasal packing and drug-eluting devices may offer additional benefits, but are not universally required. The use of antibiotics and oral corticosteroids should be selective and guided by individual patient factors and risk profiles.

DISCUSSION

While general recommendations are made, patient-specific factors such as comorbidities, financial constraints, and adherence to care must be considered. Further evaluation of these factors is essential to establish a more comprehensive and individualized standard of care for postoperative management.

CONCLUSIONS

Effective postoperative care following ESS for CRS should be individualized, multifaceted, and focused on improving recovery, minimizing complications, and ensuring the best possible patient outcomes.

Wrist and ankle acupuncture relief moderate to severe postoperative pain after functional endoscopic sinus surgery: A randomized controlled study

Introduction

The study aimed to validate the effectiveness of Wrist and Ankle Acupuncture (WAA) in attenuating moderate to severe postoperative pain following Functional Endoscopic Sinus Surgery (FESS).

Methods

Participants were randomly allocated into a treatment group (n = 57) and a control group (n = 58). The treatment group underwent WAA treatment, while the control group received sham acupuncture treatment. The Numeric Rating Scale (NRS) was employed to assess postoperative pain. The sleep efficiency, the amount of rescue medication, and the adverse events were also evaluated for both groups.

Results

A significant immediate reduction in NRS scores was observed in the treatment group (p < .01). At 2, 4, 8, 22, and 24 h after first treatment, pain intensity decreased in the WAA group compared with the control group (p < .01). Moreover, the WAA group demonstrated superior sleep efficiency relative to the control group on the night after surgery (p < .01). And the mean number of rescue tablets used on the WAA group was obviously lower than the control group (p < .01). There were no serious adverse events in both groups, and all adverse events completely disappeared within 3 days.

Conclusion

WAA effectively alleviated postoperative discomfort associated with nasal packing subsequent to FESS and enhanced sleep quality during the postoperative night. The anatomical superficiality of the acupuncture points employed reduces the risk of adverse events while yielding effective analgesic results, thus validating its suitability for clinical application.

Comparison of the effects of remimazolam and dexmedetomidine on the quality of recovery in functional endoscopic sinus surgery: a randomized clinical trial

BACKGROUND

Postoperative pain usually occur in patients who have undergone functional endoscopic sinus surgery (FESS). Remimazolam and dexmedetomidine could enhance the quality of recovery (QoR) after surgery. The aim of this study was to compare the effects of remimazolam and dexmedetomidine with respect to the QoR-40 score of patients who have undergone FESS.

METHODS

A total of 120 patients (18-65 years) scheduled for FESS were randomly allocated to Group R, Group D or Group C. Group R received 0.075 mg/kg remimazolam loading and 0.1 mg/kg/h infusion. Group D received dexmedetomidine (1.0 µg/kg loading, 0.5 µg/kg/h infusion). Group C received a placebo equal to dexmedetomidine. Anaesthesia was induced with propofol, sufentanil and cisatracurium. Anaesthesia maintenance was performed via target-controlled infusions (TCIs) of propofol and remifentanil. The primary outcome was the QoR-40 score on the day before surgery and postoperative Day 1 (POD1). The secondary outcomes were the time to return to consciousness, length of stay in the PACU, sedation score upon PACU arrival, pain, postoperative nausea and vomiting (PONV) and cumulative consumption of propofol and remifentanil. Adverse effects were recorded.

RESULTS

The total QoR-40 scores (median, IQR) on POD1 decreased less (154.5, 152.0 -159.0) in Groups R and D (155.0, 154.8 -159.3) than in Group C (139.0, 136.8 -142.0) (P < 0.001). The time to return of consciousness and the length of stay in the PACU were significantly shorter in Groups R and C than in Group D (P < 0.001). The level of sedation upon PACU arrival (median, IQR) in Groups R (-2.0, -2.0--1.0) and D (-2.0, -3.0--2.0) was greater than that in Group C (1.0, 0.0 -1.0) (P < 0.001). The cumulative consumption rates of propofol and remifentanil in Groups R and D were lower than that in Group C (P < 0.001). Compared with that in Group C, the pain intensity was lower in Groups R and D (P < 0.001).The number of patients occurring PONV was less in Groups R (3/40) and D (4/40) than in Group C (11/40) (P = 0.024). Fifteen patients had bradycardia in Group D, whereas no bradycardia was noted in Groups R or C (P < 0.001).

CONCLUSION

Administration of remimazolam could provide a similar QoR to that of dexmedetomidine. In addition, remimazolam may be a promising option for improving the QoR of patients who have undergone FESS.

TRIAL REGISTRATION

ChiCTR2300076209. (Prospectively registered). The initial registration date was 27/9/2023.

Electroacupuncture for Pain Relief After Endoscopic Sinus Surgery: A Randomized Controlled Trial

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.

Association between preoperative serum C-reactive protein level and leukocyte count and postoperative pain after otolaryngological surgery

PURPOSE

To determine whether the preoperative inflammatory serum C-reactive protein (CRP) and leukocyte count (LEUK) are associated with postoperative pain and complaints after otolaryngological surgery.

METHODS

Retrospective evaluation of 680 patients (33% female, median age 50 years) receiving otolaryngological surgery between November 2008 and March 2017 in a tertiary university hospital. Postoperative pain on the first postoperative day was assessed using the validated questionnaire of the German-wide project Quality Improvement in Postoperative Pain Treatment (QUIPS) including a numeric rating scale for assessment of postoperative pain (NRS, 0-10). The influence of preoperative parameters including CRP and LEUK on patients' postoperative pain was estimated.

RESULTS

Mean CRP value was 15.6 ± 34.6 mg/l and mean LEUK value 7.8 ± 3.2 Gpt/l. Patients with pharyngeal surgery had the highest CRP values (34.6 ± 52.9 mg/l), highest LEUK values (9.2 ± 4.2 Gpt/l) and the highest pain levels (3.1 ± 2.4 NRS) compared to all other surgical procedures (all p < 0.05). Higher postoperative pain was associated with LEUK values > 11.3 Gpt/l (r = 0.093, p = 0.016) and higher preoperative chronic pain (r = 0.127, p = 0.001). Multivariate analysis confirmed younger age, female gender, duration of surgery, preoperative chronic pain, type of surgery, and higher LEUK values > 11.3 as independent factors for postoperative pain. Perioperative antibiotics had no effect on the postoperative pain.

CONCLUSION

Beyond known factors, preoperative LEUK as inflammation marker is an independent predictor for pain on the first postoperative day.

Postoperative Pain Assessment in Patients Undergoing Functional Endoscopic Sinus Surgery for Chronic Rhinosinusitis: A Prospective Observational Study

Post-operative pain management after functional endoscopic sinus surgery for chronic rhinosinusitis is a field with lack of proper guidance and research. Aim of this study was to study post-operative pain and its management. In this prospective observational study 52 patients undergoing functional endoscopic sinus surgery were examined using Quality Improvement in Post-operative Pain Management (QUIPS) questionnaire post-operatively on 1st day, 2nd day and day of 1st follow up permitting standard assessment of all pain related parameters, outcome, and process parameters. Pain was relatively low after surgery throughout with nominal increase on 2nd day and relatively diminishing on 1st follow up day. Positive pain counselling and many other factors affect pain and related parameters in the patients. Opioid analgesics can be effectively avoided in these patients and pain management protocol should be established for all surgeries along with judicious use of analgesics and proper use of positive pain counselling.

Rehabilitation of patients with chronic rhinosinusitis after functional endoscopic sinus surgery

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,

The efficacy of sphenopalatine ganglion block for pain management after endoscopic sinus surgery: a meta-analysis of randomized controlled studies

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.

Pain and Opioid Analgesic Use After Otorhinolaryngologic Surgery

Objective

To quantify pain and opioid use after otorhinolaryngologic surgery. To determine the effect of patient and surgical factors on primary outcomes.

Study Design

Prospective cohort.

Setting

Tertiary academic hospital.

Subjects and Methods

Patients undergoing elective otorhinolaryngologic surgery were prospectively enrolled. Patients completed demographic surveys and psychometric questionnaires assessing attitudes toward pain and baseline anxiety and depression before surgery. After surgery, patients documented peak pain levels (0-100 mm, visual analog scale) and daily prescription and nonprescription analgesic requirements over a 2-week period. Average daily and cumulative pain and opioid use were calculated and compared among patient cohorts stratified by procedure and preoperative factors.

Results

A total of 134 patients were enrolled. Total tonsillectomy was associated with significantly higher pain scores and opioid consumption, as compared to all other procedures. There was moderate correlation between average cumulative pain and opioid use. Older patients required significantly fewer doses of opioids. There was no effect of sex, marital status, or education level on postoperative pain or opioid use. Psychometric instrument scores and chronic pain or analgesic use were not associated with significant differences in pain or opioid requirements. Most patients were prescribed substantially more opioids than they actually required.

Conclusion

Postoperative pain following elective otorhinolaryngologic surgery decreases dramatically within the first week and requires only few days of opioid analgesia, with the exception of tonsillectomy. Almost all patients required fewer than 15 doses of opioids.

Postoperative pain after tonsillectomy - the value of standardized analgesic treatment protocols

OBJECTIVE

To alleviate pain after tonsillectomy (TE) with escalating gradual treatment protocols in a prospective trial.

MATERIALS & METHODS

Following TE, 83 consecutive adult patients were treated with two different four-staged escalating analgesic protocols. Metamizole served as basic medication in protocol 1 (PT1; n = 44), whereas with protocol 2 (PT2; n = 39) ibuprofen was applied as baseline analgesic. Both protocols were escalated according to the patient´s needs to metamizole and ibuprofen vice versa and additional weak to strong opioids. The primary efficacy endpoint was defined as the minimum and maximum pain as well as pain on ambulation (NRS, 0-10). Secondary endpoints comprised analgesic score, patient satisfaction and treatment-related side-effects.

RESULTS

Both patient groups exhibited similar demographic characteristics (PT1: Ø 28.8 years; 64% ♀ and PT2: Ø 26.6 years; 56% ♀). Maximum pain (6.7 ± 1.9 vs. 7.6 ± 1.6, t₍₈₁₎ = -2.254, p = 0.027) and pain on ambulation (5.0 ± 1.8 vs. 5.8 ± 1.8, t₍₈₁₎ = -2.114, p = 0.038) were significantly higher with PT2. 68.2% of patients with PT1 needed an escalation of analgesic treatment compared to 100% with PT2 (p < 0.001). The opioid consumption was also significantly higher with PT2 (43.2% vs. 71.8%, p < 0.001). There were no significant differences regarding functional impairments, side-effects and patient satisfaction (7.0 ± 2.0 vs. 7.4 ± 2.4, t₍₇₉₎ = -0.897, p = 0.373).

CONCLUSION

Both treatment protocols yielded in a high degree of patient satisfaction but dissatisfactory pain relief following TE. Metamizole can be recommended as a basic medication allowing for improved pain relief. Reported pain intensities were independent of the amount of opioid intake. Further research is mandatory to standardize and improve analgesic treatment after TE.

Patterns in Pain and Opiate Use after Endoscopic Sinus Surgery

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.

Minimally invasive surgery under local anaesthesia for chronic rhinosinusitis with nasal polyps: our experience in older adults

OBJECTIVE

This paper aims to report our experience with a minimally invasive surgical procedure for the treatment of chronic rhinosinusitis with nasal polyps, performed in a day-surgery setting under local anaesthesia.

METHODS

A retrospective study of 30 patients with chronic rhinosinusitis with nasal polyps was conducted. Sino-Nasal Outcome Test 22 and modified Lund-Kennedy scores were collected. Intra- and post-operative pain was evaluated using a 10-point visual analogue scale.

RESULTS

The mean Sino-Nasal Outcome Test 22 score decreased from 41.8 ± 15.8 pre-operatively to 13.3 ± 9.5 post-operatively (p < 0.001). Accordingly, the mean endoscopic score decreased from 6.8 ± 1.8 to 0.2 ± 0.7 (p < 0.001). The mean intra-operative pain score was 2.9 ± 3.2, and 29 patients (96.7 per cent) reported no pain in the post-operative period (visual analogue scale score = 0).

CONCLUSION

Our study confirms that minimally invasive surgery represents a safe, repeatable procedure that results in remarkable subjective and objective improvement, without intra- and post-operative pain or discomfort.

Multicenter study on the effect of nonsteroidal anti-inflammatory drugs on postoperative pain after endoscopic sinus and nasal surgery

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.

Factors associated with opioid use after endoscopic sinus surgery

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.

A Randomized Single-Blinded Trial of Ibuprofen- versus Opioid-Based Primary Analgesic Therapy in Outpatient Otolaryngology Surgery

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.

Postoperative Pain Control and Opioid Usage Patterns among Patients Undergoing Thyroidectomy and Parathyroidectomy

OBJECTIVES

To examine opioid-prescribing patterns after endocrine surgery. To evaluate factors associated with postoperative pain and opioid use.

STUDY DESIGN

Cross-sectional.

SETTING

Academic university health system.

SUBJECTS AND METHODS

The study sample included 209 patients who underwent total thyroidectomy, hemithyroidectomy, or parathyroidectomy by 4 surgeons between August 2015 and November 2017. Eighty-nine patients completed a phone survey about postoperative pain and opioid use. Prescription, demographic, and comorbidity data were collected retrospectively. Patient characteristics associated with opioid use, use of ≥10 opioid pills, and pain score were identified via chi-square, t test, analysis of variance, or Pearson correlation. Identified factors were further assessed with multivariable logistic and linear regression modeling.

RESULTS

The median numbers of opioid pills prescribed were 20 for total thyroidectomy, 25 for hemithyroidectomy, and 20 for parathyroidectomy, and the median numbers of pills used were 1.5, 2, and 0, respectively. Of 1947 total prescribed pills, 19.7% were reported to be taken. The number of pills meeting the opioid needs of 80% of these patients was 10. In multivariable analyses, older age was associated with lower odds of opioid use (odds ratio, 0.97; 95% CI, 0.94-0.999; P = .04) and lower pain scores (Pearson correlation coefficient, -0.05; 95% CI, -0.10 to 0.001, P = .04). Charlson Comorbidity Index score >5 was associated with use of ≥10 pills (odds ratio, 6.62; 95% CI, 1.60-27.50; P = .01).

CONCLUSION

Excess opioids are often prescribed for endocrine surgery. By using an ideal pill number and understanding predictors of postoperative pain, surgeons can more adequately treat pain and limit excess opioid prescriptions.

Opioid prescription patterns and use among patients undergoing endoscopic sinus surgery

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.

Evaluation of Preoperative Flupirtine in Ambulatory Functional Endoscopic Sinus Surgery: A Prospective, Double-Blind, Randomized Controlled Trial

Background:

Functional endoscopic sinus surgery (FESS) is the mainstay therapeutic management for nasal pathologies. We evaluated flupirtine, a centrally acting analgesic, for producing perfect perioperative conditions in FESS for adults in a day-care setting.

Materials and Methods:

Sixty-two patients (25–40 years) scheduled for FESS under general anesthesia were randomly divided into Group F (n = 31) receiving preoperative flupirtine (100 mg) and Group C (n = 31) receiving identical-looking placebo capsule per oral 60 min before induction of anesthesia. Perioperative Nasal bleeding and surgeon's satisfaction score during operation; amount and number of patients receiving fentanyl, propofol, and esmolol infusion for analgesia; maintenance of desired bispectral index (BIS) and deliberate hypotension, respectively. Postanesthesia Care Unit (PACU) and hospital stay, hemodynamic parameters, and side effects were all recorded for each patient.

Results:

Significantly, less number of patients and less dosage of esmolol were required (P = 0.0040 and 0.0001, respectively) in Group F as compared to that in Group C. Again, number of patients requiring fentanyl and dosage of the same drug was significantly lower in Group F. Dose of propofol for the maintenance of BIS was significantly lower in Group F. However, the duration of controlled hypotension was almost similar in both groups. Group F patients suffered significantly less nasal bleeding and surgeon's satisfaction score was also high in this group. Discharge time from PACU and hospital was similar between two groups without any appreciable side effects.

Conclusion:

Flupirtine as a premedication found to be providing more favorable perioperative hemodynamic conditions, analgesia and thus allowing less nasal bleeding as well as more surgeons’ satisfaction score.

Administering of pregabalin and acetaminophen on management of postoperative pain in patients with nasal polyposis undergoing functional endoscopic sinus surgery

BACKGROUND

Management of postoperative pain is a common problem in endoscopic sinus surgery. The objective of this study is the evaluation of pregabalin and acetaminophen effects on the management of postoperative pain in patients with nasal polyposis undergoing functional endoscopic sinus surgery (FESS).

MATERIALS AND METHODS

In this clinical trial, double-blinded study, 70 patients with nasal polyposis who have indication of FESS were enrolled to this study. After operation, patients were divided randomly into pregabalin and acetaminophen therapy groups. The pregabalin group (n = 35) was treated under pregabalin 50 mg TDS and the acetaminophen group (n = 35) was treated under tablet acetaminophen 500 mg/6 h. Each group was administered for 3 d. The visual analogue scale (VAS) was measured in onset, 12, 24, 48 and 72 h after surgery. All data were entered into SPSS software (SPSS Inc., Chicago, IL) and appropriate statistical tests were assessed to every relation.

RESULTS

In this study, there was no significant difference between two groups according to VAS in onset (p = .37); however, VAS in 12, 24, 48 and 72 h after operation was significantly lower in the pregabalin group compared with the acetaminophen group (p < .0001, for every four). Also in the pregabalin group, adverse effects were significantly lower than the acetaminophen group (p < .03).

CONCLUSIONS

Pregabalin has more effect, safely and usefully than acetaminophen on the management of postoperative pain in the patients with nasal polyposis undergoing functional endoscopic sinus surgery.

Influence of depression, catastrophizing, anxiety, and resilience on postoperative pain at the first day after otolaryngological surgery: A prospective single center cohort observational study

The aim was to assess the association between objectified preoperative psychological factors and postoperative pain at the first day after otolaryngological surgery in accordance with other predictors of postoperative pain. Eighty-two (82) patients (59% male, median age 56 years) were included between January and May 2015. The psychological assessment the day before surgery included the Patient Health Questionnaire (PHQ-9), pain catastrophizing scale (PCS), State-Trait Operation Anxiety (STOA) inventory, and the resilience scale (RS-13). On first postoperative day, patients were rated their pain using the questionnaires of the German-wide project Quality Improvement in Postoperative Pain Treatment (QUIPS) including a numeric rating scale (NRS, 0-10) for determination of patient's maximal pain. QUIPS allowed standardized assessment of patients' characteristics, pain parameters, and outcome. The influence of preoperative and postoperative parameters on patients' maximal postoperative pain was estimated by univariate and multivariate statistical analysis. The mean maximal pain was 3.2 ± 2.9. In univariate analysis, higher PHQ-9 score more than 4 (P = 0.010), higher STOA trait anxiety (P = 0.044), and higher STOA total score (P = 0.043) were associated to more postoperative pain. In multivariate analysis higher PHQ-9 score remained an independent predictor for severe pain (beta = 0.302; 95% confidence interval [CI]: 0.054-0.473; P = 0.014). When all parameters were included into multivariate analysis, 2 of all somatic, psychological, and treatment factors were associated with severe maximal pain: more depression (PHQ-9; beta = 0.256; 95% CI: 0.042-0.404; P = 0.017), and use of opioids in the recovery room (beta = 0.371; 95% CI: 0.108-0.481; P = 0.002). Otolaryngological surgery covers the spectrum from low to severe postoperative pain and is therefore a good model for pain management studies. A set of somatic and psychological parameters seems to allow the identification of patients with higher risk for more postoperative pain. This should help to individualize and improve the perioperative pain management.

Inter-Hospital Variability of Postoperative Pain after Tonsillectomy: Prospective Registry-Based Multicentre Cohort Study

Objectives

Although tonsillectomy is one of the most frequent and painful surgeries, the association between baseline and process parameters and postoperative pain are not fully understood.

Methods

A multicentre prospective cohort study using a web-based registry enrolled 1,527 women and 1,008 men aged 4 to 85 years from 52 German hospitals between 2006 and 2015. Maximal pain (MP) score the first day after surgery on a numeric rating scale (NRS) from 0 (no pain) to 10 (MP) was the main outcome parameter.

Results

The mean maximal pain score was 5.8±2.2 (median 6). Multivariable analysis revealed that female gender (Odds ratio [OR] = 1.33; 95% confidence interval [CI] = 1.12 to 1.56; p = 0.001), age <20 years (OR = 1.56; CI = 1.27 to 1.91; p<0.0001), no pain counselling (OR = 1.78; CI = 1.370 to 2.316; p<0.001), chronic pain (OR = 1.34; CI = 1.107 to 1.64; p = 0.004), and receiving opioids in recovery room (OR = 1.89; CI = 1.55 to 2.325; p<0.001) or on ward (OR = 1.79; CI = 1.42 to 2.27; p<0.001) were independently associated with higher experienced maximal postoperative pain (greater the median of 6). The effect of age on pain was not linear. Maximal pain increased in underage patients to a peak at the age of 18 to 20 years. From the age of ≥20 years on, maximal pain after tonsillectomy continuously decreased. Even after adjustment to all statistically important baseline and process parameters, there was substantial variability of maximal pain between hospitals with a heterogeneity variance of 0.31.

Conclusion

Many patients seem to receive insufficient or ineffective analgesia after tonsillectomy. Further research should address if populations at risk of higher postoperative pain such as females, younger patients or those with preexisting pain might profit from a special pain management protocol. Beyond classical demographical and process parameters the large variability between different hospitals is striking and indicates the existence of other unknown factors influencing postoperative pain after tonsillectomy.

Endoscopic sphenopalatine ganglion blockade efficacy in pain control after endoscopic sinus surgery

BACKGROUND

The objective of this study was to evaluate the efficacy of bilateral endoscopic injection of lidocaine with epinephrine in the sphenopalatine ganglion at the end of endoscopic sinus surgery (ESS) in controlling postoperative pain and rescue analgesic requirements.

METHODS

A prospective, double blinded, placebo-controlled clinical trial of 60 patients with chronic rhinosinusitis (CRS) undergoing general anesthesia for ESS was undertaken. Patients were randomized to receive injection of 2 mL of 2% lidocaine with epinephrine or 2 mL saline at the end of surgery. Postoperatively, patients were observed for 24 hours. Pain severity was reported immediately, 6 hours, and 24 hours after surgery using a 10-cm visual analog scale (VAS). The need of rescue analgesia was recorded and compared between the 2 groups.

RESULTS

The 2 groups were matched in demographic and intraoperative details. Postoperative pain severity average was 3.4, 3.0, and 1.6 in the saline group compared to 1.6, 1.7, and 1.0 in the lidocaine group. These differences reached statically significant for the first 2 follow-up intervals. Also, there was significant difference in the whole-day postoperative average score between the 2 groups (2.6 vs 1.4). Twelve patients in the saline group required rescue analgesia compared to 5 in the lidocaine group. The average rescue analgesia dose was 27.5 mg of tramadol in the saline group vs 11.6 in the lidocaine group. These differences were statistically significant. No complications were reported in either group.

CONCLUSION

Sphenopalatine ganglion injection of lidocaine at the end of surgery is safe, simple, noninvasive, and an effective method of short-term pain control after sinus surgery.

Medicolegal Implications of Common Rhinologic Medications

As otolaryngologists, we prescribe many medications to our patients. The objective of this article is to review the potential side effects and medicolegal risks of the common medications used to treat chronic rhinosinusitis. The authors evaluate some of the common side effects as well as the published literature on the lawsuits associated with those medications. Finally, the authors review the informed consent discussion and opportunities to improve patient care and decrease the risk of litigation.

The first postoperative day: prospective evaluation of pain in adult otorhinolaryngologic surgery

OBJECTIVES

The aim of the study was to assess postoperative pain within the first 24 hours after otorhinolaryngologic surgery and to identify factors influencing postoperative pain.

METHODS

A total of 8447 patients from 65 German hospitals were included in a prospective evaluation using a web-based multicenter registry. On the first postoperative day, patients were asked to rate their pain using the questionnaires of the German-wide project Quality Improvement in Postoperative Pain Treatment including numeric rating scales (0 to 10) for the determination of patients' pain on ambulation, maximal pain, and minimal pain. Quality Improvement in Postoperative Pain Treatment allowed a standardized assessment of patients' characteristics, pain parameters, outcome, and process parameters. The influence of these parameters on the patients' postoperative pain was estimated by univariate and multivariate statistical analysis.

RESULTS

The mean pain on ambulation, the maximal pain, and minimal pain were 3.2±2.3, 4.3±2.7, and 1.6±1.6, respectively. Oral surgery, especially the subgroup of patients receiving a tonsillectomy, was related to the highest pain scores (all Ps<0.05): pain on ambulation: 4.3±2.1; maximal pain: 5.6±2.3; minimal pain: 2.4±1.6. Several factors were independently associated with more maximal pain: female sex, younger age, chronic pain, type of surgery, no pain counseling, no usage of a sedative and/or a nonopioid as premedication, usage of a nonopioid in the recovery room and/or ward, and usage of a cold pack on ward.

DISCUSSION

Analgesia and perioperative pain management in otorhinolaryngologic surgery seems to be highly variable. After otorhinolaryngologic surgery many patients seem to receive less analgesia than needed or ineffective analgesic drug regimes.

Pain on the first postoperative day after head and neck cancer surgery

Postoperative pain within the first 24 h after head and neck cancer (HNC) surgery was assessed. Factors influencing postoperative pain were identified. In a prospective cohort single center study 145 HNC patients rated their pain on the first postoperative day using questionnaires of the German-wide project Quality Improvement in Postoperative Pain Treatment (QUIPS) including numeric rating scales (NRS, 0-10) for the determination of patient's pain on ambulation, his maximal and minimal pain. QUIPS allowed a standardized assessment of patients' characteristics and pain-related parameters. The influence of these parameters on the patients' postoperative pain was estimated by univariate and multivariate statistical analysis. One-third had already pain prior to the surgical intervention. Overall, the mean pain on ambulation, maximal pain and minimal pain were 2.55 ± 2.36, 3.18 ± 2.86, and 1.38 ± 2.86 (NRS), respectively. 53 % of the patients had maximal pain scores >3. Multivariate analysis revealed independent predictors for more postoperative pain on ambulation: intensity of chronic preoperative pain, usage of non-opioids on ward, and existence of pain documentation on ward. Intensity of chronic preoperative pain and usage of non-opioids on ward were independent risk factors for more maximal pain. Intensity of chronic preoperative pain was independently associated to more minimal pain. Concerning pain management side effects, the risk for drowsiness increased with longer time of surgery. Postoperative pain after HNC surgery is highly variable and seems often to be unnecessarily high. Many patients seem to receive less analgesia than needed or ineffective analgesic drug regimes.

Pain after pediatric otorhinolaryngologic surgery: a prospective multi-center trial

The purpose of this study was to describe postoperative pain within the first day after pediatric otorhinolaryngologic surgery and to identify factors influencing postoperative pain. Using a prospective evaluation and a Web-based multi-center registry, children ≥4 years of age (n = 365) rated their pain using questionnaires of the project Quality Improvement in Postoperative Pain Treatment for Children including faces numeric rating scales (FNRS, 0-10) for the determination of patient's pain on ambulation and his/her maximal and minimal pain within 8 h after day case surgery or at the first postoperative day for inpatient cases. Additionally, functional interference and therapy-related side effects were assessed. Half of the children were 4 or 5 years of age. The predominant types of surgery were adenoidectomy and tonsillectomy ± ear ventilation tubes. Although analgesics were applied preoperatively, intraoperatively, in the recovery room and on ward, maximal pain within the first day after surgery reached 4.4 ± 3.3 (FNRS). Pain was highest after oral surgery, especially after tonsillectomy and nose surgery. 39% of the children reported pain interference with breathing (39%). The most frequent side effect was drowsiness (55%). Multivariate analysis revealed that maximal pain was independently associated with the non-standardized use of opioids in the recovery room, or use of non-opioid or opioids on ward. Analgesia and perioperative pain management in pediatric otorhinolaryngologic surgery seems to be highly variable. Tonsillectomy and nose surgery are very painful. After otorhinolaryngologic surgery many children seem to receive less analgesia than needed or ineffective analgesic drug regimes.

Relative frequency of chronic postoperative pain in patients operated for chronic otitis media

Chronic postoperative pain may lead to physical disability and psychosocial distress. In this longitudinal observational study, for the first time we evaluated the relative frequency of chronic postoperative pain in patients operated for chronic otitis media (COM) at two university hospitals. Patients were questioned about pain at the site of the surgical incision 3-6 months after the operation, and again 3 months after the first visit. Pain intensity was quantified by visual analogue scale (VAS). T test, Chi-square test, and logistic regression were used for analyzing data and multivariate analysis. In 155 patients (42 male, 113 female, mean age: 38.57 ± 10.66 years), chronic postoperative pain was observed in 50 cases (32.3 %). A significant decrease in the average score of VAS was observed from 5.18 to 2.64 within 3 months (P = 0.0001). Statistically significant correlation was observed between chronic postoperative pain and age, sex, acute postoperative pain and history of Irritable Bowel Syndrome or migraine, but after multivariate analysis, only the age group and severe acute post-operation pain were effective on incidence of chronic post-operative pain. In conclusion, surgery for COM is followed by chronic pain in about 32 % of patients, and some risk factors for the development of chronic postoperative pain after this surgery exist, including age and severe acute post-operation pain.

Topical Levobupivacaine Efficacy in Pain Control after Functional Endoscopic Sinus Surgery

Objective

The aim of this study was to find out the efficacy of a polyvinyl alcohol (PVA) sponge (Merocel Kennedy; Medtronic Xomed, Jacksonville, Florida) sinus pack soaked with levobupivacaine hydrochloride to control postoperative pain and analgesic need following functional endoscopic sinus surgery (FESS).

Study Design

The study was designed as a prospective, double-blind, randomized, controlled study. Forty-one patients who underwent FESS were included in the analysis.

Setting

A tertiary referral hospital in Turkey.

Materials and Methods

Patients who underwent FESS were divided into 2 groups. The PVA sponge sinus packs were soaked with 5 mL of levobupivacaine hydrochloride (chirocaine 25 mg/10 mL; Abbott, Nycomed Pharma AS, Elverum, Norway) in group I and with 5 mL of saline in group II.

Main Outcome Measures

Postoperative pain levels were recorded using a visual analog scale (VAS score, 0-100) at 30 minutes and 1, 2, 8, 12, and 24 hours.

Results

There were no statistically significant differences between groups regarding age, sex, and American Society of Anesthesiologists status. Postoperative VAS values at 30 minutes and 1, 2, 8, 12, and 24 hours were significantly lower in group I than in group II ( P < .05). Supplemental analgesia amount was significantly lower in group I than in group II ( P = .003).

Conclusion

Using levobupivacaine-soaked PVA sponge sinus packs after FESS is an effective, easy, and quick method to control postoperative pain, and it improves patient comfort and tolerability.

[Postoperative pain assessment after middle ear surgery]

BACKGROUND

The purpose of this work was to assess postoperative pain management after middle ear surgery.

MATERIALS AND METHODS

In a prospective clinical study, 73 adults were evaluated on the first postoperative day after middle ear surgery using the questionnaire of the Germany-wide project QUIPS (quality improvement in postoperative pain management). The main outcome measures were patients' characteristics, pain parameters, outcome, and pain therapy process parameters.

RESULTS

Overall, pain on the first postoperative day was mild. Pain management consisted predominately of premedication with midazolam, remifentanil intraoperatively, metamizole in the recovery room and on the ward. Otherwise healthy patients suffered significantly more from pain than patients with reduced general condition in univariate and multivariate analyses. About half of the patients demanded pain relief on the ward. Despite immediate pain management with nonopioids and/or opioids, these patients had significantly more maximal pain and were less satisfied with overall pain therapy than patients not demanding pain therapy.

DISCUSSION

QUIPS is a simple tool to evaluate the quality of in-hospital postoperative pain management following ear surgery. Pain on the first postoperative day seems to be moderate but should be improved for patients demanding more analgetics despite baseline pain therapy on the ward.