Assessment and Management of Postoperative Pain Associated with Sleep Apnea Surgery

A literature review was conducted regarding the assessment and treatment of postoperative pain following surgery for obstructive sleep apnea (OSA). Given the risks of opioid use by patients with OSA, special attention to opioid risk reduction and avoidance is warranted in this population. The results of this review demonstrate the existence of a body of evidence that supports the use of nonopioid analgesics and nonpharmacologic approaches pain management. Strategies for managing postoperative pain should emphasize the use of local anesthetic infiltration, nonsteroidal antiinflammatory drugs, acetaminophen, topical analgesics, surgical wound cooling, and when necessary, safer opioid medications, such as tramadol and intranasal butorphanol.

A Prospective Evaluation of Postoperative Opioid Use in Otologic Surgery

OBJECTIVE

To prospectively evaluate opioid consumption following adult outpatient otologic surgery.

STUDY DESIGN

Prospective observational.

SETTING

Single-tertiary referral center.

PATIENTS

Patients scheduled for otologic surgery who did not have a history of chronic opioid use were recruited between February 2018 and February 2019.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Opioid consumption was queried using telephone or in-person surveys administered between postoperative days 5 and 15. Patient demographics, surgical details, and opioid prescription patterns were abstracted from medical records. Opioid distribution was determined by querying records maintained by the California Department of Justice through a state-wide prescription drug monitoring program mandated since 2016.

RESULTS

Seventy patients were prescribed an average of 68.9 ± 31.8 mg of morphine equivalents (MME) and consumed 47.3 ± 42.9 MME over 2.4 ± 2.3 days postoperatively. Patients who received a postauricular incision were prescribed significantly more than those who underwent transcanal procedures (86.2 vs 55.9 MME; t test, p < 0.001), consumed significantly more (72.2 vs 28.6 MME; t test, p < 0.001), and for a significantly longer duration (3.4 vs 1.6 days; t test, p = 0.001). In the postauricular group, there was no significant difference in consumption between mastoidectomy and nonmastoidectomy subgroups (64.9 vs 89.2 MME; t test, p = 0.151). Eighty percent of transcanal patients consumed 50 MME (10 pills) or less, while 80% of postauricular patients consumed 80 MME (16 pills) or less.

CONCLUSIONS

Patients in our cohort consumed approximately 3/4 of the prescribed opioids. Those with postauricular incisions used significantly more than those with transcanal incisions. Postoperative opioid prescription recommendations should be tailored according to the extent of surgery.

Incidence and Predictive Factors for Additional Opioid Prescription after Endoscopic Skull Base Surgery

Introduction  Postoperative pain management and opioid use following endoscopic skull base surgery (ESBS) is not well understood. A subset of patients requires additional opioid prescription (AOP) in the postoperative period. The objective of this study is to describe the incidence of AOP, as well as evaluate patient and surgical characteristics that may predict additional pain management requirements following ESBS. Methods  A retrospective review of cases undergoing ESBS between November 2016 and August 2018 was performed. We reviewed patients' sociodemographic and clinical data, and Controlled Substance Utilization Review and Evaluation System (CURES) records. Stepwise multivariable logistic regressions were performed to evaluate the factors associated with AOP within 60 days following surgery. Results  A total of 42 patients were identified. Indications for ESBS included intracranial mass (64.2%), sinonasal malignancy (23.8%), and skull base reconstruction (9.5%). AOP were recorded in nine patients (21.4%). There were no significant differences in operative factors, including approach, lesion location, or perioperative analgesia between the two cohorts. On multivariable logistic regression, we found that younger age (odds ratio [OR]: 0.891, 95% confidence interval [CI]: 0.79-1.00, p  = 0.050), comorbid depression (OR: 86.48, 95% CI: 1.40-5,379.07, p  = 0.034), and preoperative opioid use (OR: 104.45, 95% CI: 1.41-7,751.10, p  = 0.034) were associated with additional prescriptions postoperatively. Conclusion  The requirement for extended postoperative opioid pain control is common after ESBS. Patient demographics including age and psychosocial factors, such as depression may predict the need for AOP after ESBS. These results suggest that patient-driven factors, rather than surgical characteristics, may determine the need for prolonged pain control requirements after ESBS.

Association of Perioperative Opioid Prescriptions With Risk of Complications After Tonsillectomy in Children

Importance

Practice guidelines recommend nonopioid medications in children after tonsillectomy, but to date, studies have not used recent national data to assess perioperative opioid prescribing patterns or the factors associated with these patterns in this population. Closing this knowledge gap may help in assessing whether such prescribing and prescription duration could be safely reduced.

Objective

To assess national perioperative opioid prescribing patterns, clinical and demographic factors associated with these patterns, and association between these patterns and complications in children after tonsillectomy compared with children not using opioids.

Design, Setting, and Participants

This cohort analysis used the 2016 to 2017 claims data from the database of a large national private insurer in the United States. Opioid-naive children aged 1 to 18 years with a claims code for tonsillectomy with or without adenoidectomy between April 1, 2016, and December 15, 2017, were identified (n = 22 567) and screened against the exclusion criteria. The final sample included 15 793 children.

Main Outcomes and Measures

The percentage of children with 1 or more perioperative fills (prescription drug claims for opioids between 7 days before to 1 day after tonsillectomy) was calculated, along with the duration of perioperative prescriptions (days supplied). Linear regression was used to identify the demographic and clinical factors associated with the duration of perioperative opioid prescriptions. Logistic regression was used to assess the association between having 1 or more perioperative fills and their duration and the risk of return visits 2 to 14 days after tonsillectomy for pain or dehydration, secondary hemorrhage, and constipation compared with children not using opioids.

Results

Among 15 793 children, the mean (SD) age was 7.8 (4.2) years, 12 807 (81.1%) were younger than 12 years, 2986 (18.9%) were between 12 and 18 years of age, and 8289 (52.6%) were female. In total, 9411 (59.6%) children had 1 or more perioperative fills, and the median (25th-75th percentile) duration was 8 (6-10) days; 6382 had no perioperative fills. The probability of having 1 or more perioperative fills and the duration of prescription varied across US census divisions. Having 1 or more perioperative fills was not associated with return visits for pain or dehydration (adjusted odds ratio [AOR], 1.13; 95% CI, 0.95-1.34) or secondary hemorrhage (AOR, 0.90; 95% CI, 0.73-1.10) compared with children not using opioids, but it was associated with increased risk of return visits for constipation (AOR, 2.02; 95% CI, 1.24-3.28). Duration was not associated with return visits for complications.

Conclusions and Relevance

These findings suggest that reducing perioperative opioid prescribing and the duration of perioperative opioid prescriptions may be possible without increasing the risk of these complications.

Current Opioid Prescribing Patterns after Microdirect Laryngoscopy

Background:

The prevalence of opioid abuse has become epidemic in the United States. Microdirect laryngoscopy (MDL) is a common otolaryngological procedure, yet prescribing practices for opioids following this operation are not well characterized.

Objective:

To characterize current opioid-prescribing patterns among otolaryngologists performing MDL.

Methods:

A cross-sectional survey of otolaryngologists at a national laryngology meeting.

Results:

Fifty-eight of 205 physician registrants (response rate 28%) completed the survey. Fifty-nine percent of respondents were fellowship-trained in laryngology. Respondents performed an average of 13.3 MDLs per month. Thirty-four percent of surgeons prescribe opioids for over two-thirds of their MDLs, while only 7% of surgeons never prescribe opioids. Eighty-eight percent of surgeons prescribed a combination opioid and acetaminophen compound, hydrocodone being the most common opioid component. Many surgeons prescribe non-opioid analgesics as well, with 70% and 84% of surgeons recommending acetaminophen and ibuprofen after MDL respectively. When opioids were prescribed, patient preference, difficult exposure and history of opioid use were the most influential patient factors. Concerns of opioid abuse, the physician role in the opioid crisis, and literature about postoperative non-opioid analgesia were also underlying themes in influencing opioid prescription patterns after MDL.

Conclusions:

In this study, over 90% of practicing physicians surveyed are prescribing opioids after MDL, though many are also prescribing non-opioid analgesia as well. Further studies should be completed to investigate the needs of patients following MDL in order to allow physicians to selectively and appropriately prescribe opioid analgesia postoperatively.

Quality Assessment in Supportive Care in Head and Neck Cancer

Quality assessment is a key issue in every clinical intervention, to be periodically performed so to measure the adherence to standard and to possibly implement strategies to improve its performance. This topic is rarely discussed for what concerns supportive care; however, it is necessary to verify the quality of the supportive measures; “supportive care makes excellent cancer care possible,” as stated by the Multinational Association of Supportive Care in Cancer (MASCC). In this regard, the quality of supportive care in head and neck cancer patients is a crucial topic, both to allow administration of treatments according to planned dose intensity or surgical indications and to maintain or improve patients' quality of life. This paper aims to provide insight on state of the art supportive care and its future developments for locally advanced and recurrent/metastatic head and neck cancer, with a focus on quality assessment in relation to surgery, radiotherapy, and systemic therapy.

Postoperative opioid-prescribing practices in otolaryngology: A multiphasic study

OBJECTIVES

In otolaryngology, postoperative pain management lacks evidence-based guidelines. We designed a prospective, multiphasic study aimed to develop evidence-based guidelines for postoperative pain management within our institution. In this first phase of our project, we investigated opioid prescription and consumption as well as pain trends for common otolaryngologic procedures.

METHODS

Patients (n = 161) who underwent procedures between July 2018 and February 2019 were surveyed on their postoperative opioid usage and pain from day of discharge to first clinic visit. Opioid prescriptions were converted to standardized units of morphine milligram equivalents (MME). The procedures selected for analysis were parathyroidectomy/thyroidectomy, parotidectomy, sialendoscopy, and transoral robotic surgery resection (TORS).

RESULTS

In total, 19,748 MME were prescribed: 8,588 MME (43.5%) were used, leaving 11,159 MME (56.5%) unused. TORS average MME used: 221 ± 227; total MME unused: 38%. Sialendoscopy average MME used: 31 ± 46; total MME unused: 67%. Parathyroidectomy/thyroidectomy average MME used: 30 ± 37; total MME unused: 66%. Parotidectomy average MME used: 43 ± 53; total MME unused: 65%. Male gender, smoking (current and former), and psychiatric medication use were positive predictors of opioid consumption in postoperative patients (P < 0.001).

CONCLUSION

At our institution, over 50% of prescribed postoperative opioids went unused. This was most pronounced for nonmucosal surgeries. Postoperative pain management should account for this to minimize unnecessary opioid prescriptions. Based on our findings and review of current literature, we are in the process of developing prescribing recommendations to be implemented within our institution.

LEVEL OF EVIDENCE

2 Laryngoscope, 130:659-665, 2020.

Opioid prescribing patterns within otolaryngology

Objective

Determine current opioid prescribing patterns for adult procedures within an academic Otolaryngology-Head and Neck Surgery training program in order to establish a general guideline and more uniform approach to narcotic prescribing practices.

Methods

The is a prospective, single-center pilot study. An online, anonymous survey was sent to all members of the Otolaryngology-Head and Neck Surgery training program at Medical University of South Carolina including residents, fellows, and attending surgeons, and advanced practice providers (APP). The survey consisted of questions including demographics, most commonly prescribed analgesic and the average number of opioid tablets prescribed post-operatively for eleven of the most common adult procedures within Otolaryngology.

Results

Forty-two participants responded to the survey. Of the 42 respondents, 20 were attending surgeons, 11 junior level residents (year 1–3), 6 senior level residents (year 4–5), and 5 A.P.P.s. The most commonly prescribed narcotic was hydrocodone-acetaminophen with 83.3% (35/42) of respondents prescribing this medication. Tonsillectomy or uvulopalatopharyngoplasty had the highest average number of tablets prescribed at 32.3 (Range: 5 to 90). Neck dissection, parotidectomy, and thyroidectomy procedures all averaged over 20 tablets. Direct laryngoscopy opioid dose was the lowest at 4.8 tablets (range 0–20). Opioid prescriptions by surgery were broken down by provider class with only septoplasty showing a significant difference with attending physicians prescribing an average of 20 tablets vs 14.1 tablets for residents (P = 0.034).

Conclusion

We believe there remains an unacceptably high variability in current opioid prescribing patterns within otolaryngology especially within more painful procedures. Establishment of standardized post-operative narcotic guidelines is warranted.

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.

Postoperative Opioid Use in Sinonasal Surgery

Objective

To survey patients following sinonasal surgery regarding postoperative pain and opioid use.

Study Design

Patients were surveyed for 4 days following sinus and/or nasal surgery regarding their pain level and use of prescribed opioids.

Setting

Four academic medical centers and 1 private practice institution.

Subjects

Consecutive adult patients undergoing sinonasal surgery.

Results

A total of 219 subjects met criteria and were included for analysis; 134 patients (61%) took 5 or fewer combination oxycodone (5-mg) and acetaminophen (325-mg) tablets in the first 3 postoperative days, and 196 patients (89.5%) took fewer than 15. Fifty-one patients (23%) consumed no opioid pain medication. Opioid consumption was positively correlated with postoperative pain ( R2 = 0.2, P < .01) but was not correlated with the use of acetaminophen ( R2 = 0.002, P = .48). No significant difference in postoperative pain or opioid consumption was seen with respect to age, sex, specific procedures performed, postoperative steroids, or smoking history. Current smokers reported higher average pain than nonsmokers ( P < .001) and also required more postoperative opioids ( P = .02).

Conclusions

An evidence-based approach to postoperative pain control following sinonasal surgery that reduces the number of unused and potentially diverted opioids is needed. The current study suggests that 15 combination oxycodone (5-mg) and acetaminophen (325-mg) tablets provide sufficient pain control for 90% of patients in the immediate postoperative period following sinonasal surgery, irrespective of the specific procedures performed, use of acetaminophen, or use of systemic steroids. Smoking status may help surgeons predict which patients will require larger opioid prescriptions.

Pain in Head and Neck Cancer Survivors: Prevalence, Predictors, and Quality-of-Life Impact

Objectives

Pain is common among patients with cancer, stemming from both malignancy and side effects of treatment. The extent to which pain persists after treatment has received little attention. We examined the prevalence, predictors, and impact on quality of life (QOL) caused by pain among survivors of head and neck cancer.

Study Design

Cohort study.

Setting

Tertiary head and neck cancer survivorship clinic.

Subjects and Methods

We identified survivors of head and neck cancer ≥1 year after diagnosis and examined the prevalence and risk factors for development of pain. Pain and QOL were assessed with multiple QOL instruments. Ordinal regression modeling examined predictors of pain in survivors.

Results

We identified 175 patients at a median of 6.6 years after diagnosis. Among survivors, 45.1% reported pain, and 11.5% reported severe pain. Among patients with current pain, 46% reported low overall QOL versus only 12% of those without pain ( P < .001). On multivariable analysis after adjustment for age, sex, and stage of disease, pain was associated with trimodality treatment (odds ratio [OR], 3.55; 95% CI, 1.06-12.77). Multivariable analysis of QOL issues revealed that pain was associated with major depression (OR, 3.91; 95% CI, 1.68-9.11), anxiety (OR, 4.22; 95% CI, 2.28-7.81), poor recreation (OR, 3.31; 95% CI, 1.70-6.48), and low overall QOL (OR, 2.20; 95% CI, 1.12-4.34).

Conclusions

Years after head and neck cancer treatment, pain remains a significant problem and is associated with worse QOL. Future efforts should focus on preventing pain from treatment and comprehensive management.

Predictive value of SNOT-22 on additional opiate prescriptions after endoscopic sinus surgery

BACKGROUND

Endoscopic sinus surgery (ESS) is generally well tolerated, yet a subset of patients require an additional opiate prescription in the postoperative period. The purpose of this study was to quantify differences in both preoperative and immediate postoperative 22-item Sino-Nasal Outcome Test (SNOT-22) scores between patients with a single prescription and those requiring additional opiate prescriptions (AOPs).

METHODS

Patients undergoing ESS between November 2016 and August 2017 were reviewed retrospectively. The Medical and Controlled Substance Utilization Review and Evaluation System (CURES) records were reviewed; patients requiring AOP within 60 days after surgery were identified. The primary and secondary outcomes of interest were the association of baseline and first postoperative visit SNOT-22 total and domain scores with AOP.

RESULTS

A total of 121 patients were reviewed, 22 (18.2%) required AOP. Baseline SNOT-22 scores were higher in aggregate (58.7 ± 16.0 vs 46.1 ± 22.5) and ear/facial domain (11.4 ± 4.8 vs 8.5 ± 5.4) in the AOP group (p < 0.01). AOP patients also demonstrated higher scores across all SNOT-22 domains (p < 0.001) at the immediate preoperative visit. There was no difference in the absolute improvement between groups (15.5 ± 18.30 vs 12.3 ± 23.9, p = 0.54). AOP patients experienced less relative improvement (20.2% vs 34.8%, p < 0.05) and smaller mean effect size (0.57 vs 0.70, p < 0.001) after ESS.

CONCLUSION

Patients reporting increased ear and facial symptoms at baseline have an increased risk of additional opiate prescription after surgery; preoperative SNOT-22 scores may provide utility in identifying these patients. Subjects in both cohorts report symptomatic improvement after ESS; however, relative, not absolute, improvement in SNOT-22 scores is more predictive of AOP.