Perioperative Analgesia for Patients Undergoing Septoplasty and Rhinoplasty: An Evidence-Based Review

Clinical and surgical factors associated with opioid refill rates following septorhinoplasty

BACKGROUND

Septorhinoplasty is one the most common class of procedures performed worldwide, and opioids are frequently prescribed for post-operative pain [1].

OBJECTIVE

The objective of this study was to examine the rate of post-operative opioid prescription refills following septorhinoplasty.

METHODS

This study was a case-control study of patients who underwent septoplasty and other secondary concomitant procedures.

RESULTS

Of the 249 patients included in this study, the majority of patients (94.8%) were prescribed 12 tablets of hydrocodone-acetaminophen 5 mg - 325 mg and only 31 patients (13.3%) received refills. The presence of osteotomies and history of prior opioid use were associated with refills. Nasal valve repair type, open versus closed approach, and presence of autologous auricular cartilage graft harvest were not.

DISCUSSION

Our study highlights factors that surgeons should consider when prescribing opioids after septorhinoplasty. Twelve tablets of an opioid are likely sufficient for the majority of patients, but if osteotomies are performed or the patient has a history of prior opioid use, more may be indicated to avoid the need for refills. Additional narcotics are not necessary for an open approach or for patients in which auricular cartilage is needed.

Postoperative effects of bilateral sphenopalatine ganglion blockade in septorhinoplasty operations; double-blind randomized clinical trial

OBJECTIVE

We aimed to investigate the effect of bilateral sphenopalatine ganglion blockade (SPGB) on the main postoperative complications in septorhinoplasty operations.

METHODS

In this randomized, controlled, prospective study, 80 cases planned for Septorhinoplasty operations under general anesthesia were included in the study. The cases were divided into two groups; SPGB was performed with 2 mL of 0.25% bupivacaine bilaterally 15 min before the end of the operation in the SPGB group (Group S, n = 40). In the control group (Group C, n = 40), 2 mL of 0.9% NaCl solution was applied into both SPG areas. In the recovery unit after the operation; the pain and analgesic needs of the patients at 0, 2, 6 and 24 h were evaluated.

RESULTS

There was no statistically significant difference between the groups in terms of hemodynamic parameters (ASA, MBP, HR) (p > 0.05) All VAS values were statistically lower in Group S than in Group C (p < 0.05). In Group S, the need for analgesic medication was found in 5 cases between 0-2 h, whereas in Group C, this rate was found in 17 cases, and it was statistically significant (p < 0.05).

CONCLUSION

Bilateral SPGB application was determined to provide better analgesia in the early postoperative period compared to the control group, it was concluded that further studies are needed to say that there are significant effects on laryngospasm and nausea-vomiting.

LEVEL OF EVIDENCE

2, degree of recommendation B.

Is transoral sphenopalatine ganglion blockade more effective on postoperative pain than endoscopic sphenopalatine ganglion blockade?

PURPOSE

In this study, we aimed to examine and compare the effects of endoscopic SPGB and transoral SPGB on postoperative pain control and patient satisfaction in patients undergoing septoplasty.

METHODS

Participants were randomly divided into three groups, no blockade (n:20), endoscopic SPGB (n:20), and transoral SPGB (n:20). Those who had no blockage were included in the control group. Demographic data of patients, such as age and sex, VAS (visual analogue scale) and postoperative pain scores (PPS) [determined at arrival in the post-anesthesia care unit (PACU) and after 2, 6, 12, and 24 h], general analgesic use (24 and 168 h after surgery) and postoperative Quality of Recovery (QoR-15) values were recorded and compare them.

RESULTS

The PPS PACU of 2 h, 6 h, 12 h, and 24-h values of the transoral group were lower than the endoscopic and control groups (p < 0.001).The values of 24 h and 168 h of analgesic use in the transoral group were lower than in the control and endoscopic groups (p < 0.001).The average recovery QoR-15 scores at 12 h and 24 h differed according to the groups (p < 0.001) and the highest values were in the transoral group (p < 0.001).

CONCLUSION

Transoral SPGB is more effective in postoperative pain control than endoscopic SPGB, it decreases the use of postoperative analgesics and improves postoperative recovery scores.

The benefits and risks of non-steroidal anti-inflammatory drugs for postoperative analgesia in sinonasal surgery: a systematic review and meta-analysis

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.

Pain management following septorhinoplasty surgery: evidence from a systematic review

PURPOSE

We investigated recent evidence on the analgesics available for postoperative pain management among patients undergoing septoplasty or rhinoplasty surgery.

METHODS

Studies were retrieved from MEDLINE (through PubMed), Web of Science, and Embase up to 3 August 2022.

RESULTS

Forty-seven studies including 3717 patients were included. There were 45 randomized clinical trials and 2 observational cohort studies. Most of the studies were recently published and conducted in Turkey (n = 27). The majority of the studies performed the intervention preoperatively (n = 26), 11 studies postoperatively, 6 studies intraoperative, 2 studies preoperative plus intraoperative, and 2 studies performed the intervention with preoperative plus postoperative timing. The most evaluated medication was lidocaine (n = 10), followed by levobupivacaine (n = 4), and gabapentin (n = 4). Regarding post-operative pain assessment, the most used scale was the visual analog scale (VAS) (n = 36). Compared to controls, almost all interventions showed a significant benefit in managing post-operative pain. Although it should be mentioned regarding the comparison between opioids and NSAIDs consumption after surgery for pain management, most studies did not show a significant difference between the groups. No major side effects except nausea and vomiting were observed among the reviewed studies.

CONCLUSION

This study summarized the most recent options that are available to manage pain following septorhinoplasty surgery. Recent investigations showed local interventions vs pre/post-operative analgesic medications are highly suggested to be replaced with opioids and NSAIDs as they have shown prominent efficacy with no significant adverse events. Future research is advised to determine the best dosage and administration techniques.

The analgesic efficacy of ketamine for septorhinoplasty: a meta-analysis study

BACKGROUND

The analgesic efficacy of ketamine supplementation was not well-established for septorhinoplasty and this meta-analysis aimed to compare ketamine supplementation with placebo for the postoperative pain control of septorhinoplasty.

METHODS

We systematically searched several databases, including PubMed, EMbase, Web of science, EBSCO and Cochrane library databases, and included randomized controlled trials (RCTs) regarding the effect of ketamine supplementation versus placebo for pain control after septorhinoplasty. This meta-analysis was conducted by random effect model.

RESULTS

Five RCTs were included in this meta-analysis. In comparison with control group for septorhinoplasty, ketamine supplementation was associated with significantly decreased pain scores at 30 min (SMD = - 3.84; 95% CI = - 6.73 to - 0.96; P = 0.009), pain scores at 1 h (SMD = - 2.70; 95% CI = - 3.79 to - 1.61; P < 0.00001), pain scores at 2 h (SMD = - 1.83; 95% CI = - 3.01 to - 0.64; P = 0.003), rescue analgesics (OR = 0.08; 95% CI = 0.04 to 0.17; P < 0.00001), but unraveled no obvious impact on pain scores at 4 h (SMD = - 1.13; 95% CI = - 3.37 to 1.12; P = 0.32) or the incidence of nausea and vomiting (OR = 0.71; 95% CI = 0.30 to 1.72; P = 0.45).

CONCLUSIONS

Ketamine supplementation was effective to improve pain relief after septorhinoplasty.

Comparative Evaluation of Postoperative Pain Scores and Opioid Consumption in Septorhinoplasty After Administration of Single-Dose Preemptive Paracetamol and Ibuprofen: A Randomized Controlled Trial

Introduction  Septorhinoplasty operates on the nose's bone and cartilage and is ensued by severe postoperative pain. Objective  The objective of this study is to evaluate the effects of preoperative administration of intravenous (IV) paracetamol and ibuprofen on postoperative pain scores in patients undergoing septorhinoplasty. Methods  A total of 150 patients undergoing septorhinoplasty were randomly assigned into 3 groups with 50 patients in each group. The control group (group A) was administered 100 ml saline solution; the paracetamol group (group B) was administered 1,000 mg of IV paracetamol in 100 ml of saline solution; and the ibuprofen group (group C) was administered 800 mg of IV ibuprofen in 100 ml of saline solution before surgery. Opioid analgesics were employed to achieve postoperative analgesia. Postoperative pain was evaluated using the visual analogue scale (VAS). Postoperative opioid consumption and adverse effects were also recorded for each patient. Results  In comparison with group A, the score in the VAS of groups B and C was statistically lower in all the time intervals ( p  < 0.05). In the 1 st and 6 th hours postoperatively, group C's score in the VAS in was lower than that of group B ( p  < 0.05). In the control group, total opioid consumption was highest in all time intervals ( p  < 0.05). In group C, total opioid consumption was significantly lower than in group B in the 0 to 6 and 6 to 12 hours intervals. ( p  < 0.05). Conclusion  The single-dose preemptive administration of ibuprofen has a more profound postoperative analgesic effect than paracetamol in the first 6 hours after septorhinoplasty. After the first 6 hours postsurgery, there is no difference between ibuprofen and paracetamol in terms of analgesic effect.

Comparing the Effect of Ketamine and Lidocaine on Agitation and Pain in Rhinoplasty: A Randomized Clinical Trial

Background

Emergence agitation (EA) is an important clinical problem that occurs during the initial period of recovery from anesthesia. This study aimed to determine the effects of ketamine and lidocaine administered on agitation level, postoperative pain, and hemodynamic changes in adults after rhinoplasty.

Materials and Methods

Totally 72 patients scheduled to undergo elective rhinoplasty were enrolled in this prospective study. Patients were randomly divided into three groups including control group (n = 24), ketamine group (n = 24), and lidocaine group (n = 24). Twenty minutes before surgery completion, 1 ml saline was administered intravenously to the saline group, while 0.5 mg/kg ketamine or 1.5 mg/kg lidocaine was administered to two other groups. The emergence agitation level of the patients was evaluated using the Richmond Agitation-Sedation Scale just after extubation and in the post-anesthesia care unit (PACU). Postoperative pain was evaluated by Numerical Rating Scale that scored (from 0 to 10) every 10 min until the patients were discharged from PACU.

Results

There was a significant difference between EA level between ketamine (P = 0.049) and lidocaine (P = 0.019) groups compared to the control group, and there was a significant difference between pain level between the ketamine (P = 0.008) and lidocaine (P = 0.035) groups compared the to control group, while there was no significant difference between the level of agitation (P = 0.922) and level of pain (P = 0.845) after extubation between the ketamine and lidocaine groups.

Conclusion

Ketamine and lidocaine are highly effective in preventing EA and pain control. Further studies with a greater sample size and longer follow-up period are needed to confirm the current findings.

The Efficacy of Gabapentin + Dexamethasone for Postoperative Analgesia Following Septoplasty: A Prospective Randomized Placebo-Controlled Trial

AIMS

This study aimed to compare the efficacy of gabapentin, dexamethasone, and gabapentin + dexamethasone for pain control after septoplasty.

MATERIALS AND METHODS

This prospective randomized trial included 120 patients that underwent septoplasty and were randomly divided into 4 groups: group G (preoperative gabapentin 600 mg p.o.); group D (intraoperative dexamethasone 8 mg i.v.); group GD (preoperative gabapentin 600 mg p.o. + intraoperative dexamethasone 8 mg i.v.); group C (placebo control).

RESULTS

The median VAS score was significantly lower in groups G and GD at 1, 2, 4, 6, 12, and 24 hours postsurgery than in group C (P < .008 for all). The median VAS score was significantly lower in group D than in group C at 1, 2, and 4 hours postsurgery (P < .008 for all). There weren't any significant differences in the VAS score between groups D, G, and GD at any time point. Groups G, D, and GD had a significantly lower frequency of rescue analgesic use than group C; however, there were no differences between groups G, GD, and C (P < .001 and P = .108, respectively).

CONCLUSION

Gabapentin, dexamethasone, and gabapentin + dexamethasone are equally more effective analgesics during the first 4 hours postsurgery than placebo. The addition of dexamethasone to gabapentin does not provide extra analgesia. Both gabapentin and gabapentin + dexamethasone have a more prolonged analgesic effect than dexamethasone alone.

Nonopioid perioperative analgesia in head and neck cancer surgery: A systematic review

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.

Management of postoperative pain after head and neck cancer surgery is a complex issue, requiring a careful balance of analgesia and undesired side effects.

Five studies (n = 592 patients) reported on the use of nonsteroidal anti‐inflammatory drugs, acetaminophen, anticonvulsants, local anesthetics, and corticosteroids.

Four studies described a significant decrease in overall postoperative narcotic usage though subjective pain scores widely varied.

Multimodal analgesia is a popular and effective strategy that may reduce dependence on opioids for the treatment of postoperative pain.

Are NSAIDs effective enough for postoperative pain control after functional endoscopic sinus surgery and septoplasty: A randomized controlled study

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.

Guided Mindfulness Meditation for Pain Control After Septorhinoplasty: A Randomized-Controlled Pilot Study

Background: Mindfulness meditation has been shown to alleviate pain and may be an appealing adjunctive pain management option. Objective: To compare measures of pain, mindfulness, and opioid usage, and collect evaluative feedback among patients undergoing septorhinoplasty with and without guided meditation. Methods: Patients undergoing septorhinoplasty were randomized to online-guided meditation postoperative days 0-3 versus standard care; all received the same pain medications. Primary outcome measures included pain intensity, opioid consumption, mindfulness scores, and evaluative feedback. Results: Twenty-one patients received guided meditation and 24 received standard care. No significant difference in opioid consumption or pain scores was seen with the exception of higher opioid use in patients with intranasal splints in the standard care group. Twenty out of 21 patients provided evaluative feedback; all recommended mindfulness meditation to friends undergoing nasal surgery, 90% reported it was beneficial, 85% believed it eased pain/discomfort, and 80% believed it aided with sleep. Conclusion: Although no objective difference was found in opioid consumption or pain scores, most patients reported that guided mindfulness meditation was beneficial to their recovery following septorhinoplasty.

Postoperative Pain Management and Perceived Patient Outcomes following Endoscopic Pituitary Surgery

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.

The Impact of Surgical Procedures During Septorhinoplasty on the Intraoperative Pain Response

BACKGROUND

During septorhinoplasty, many different surgical procedures are employed to bring the nose to the desired shape and solve breathing complaints. As a matter of course, intraoperative pain response occurs due to these procedures.

OBJECTIVES

With this study, the authors aimed to evaluate the intraoperative pain formed during septorhinoplasty surgery with numerical values and to determine which stage of surgery is more painful.

METHODS

Between April 2019 and March 2020, a total of 30 female patients who were planned to undergo septorhinoplasty were included in this prospective study. Standard anesthesia and analgesia were applied to all patients. During surgery, state entropy measure was utilized to evaluate the depth of anesthesia, and Surgical Pleth Index was employed to evaluate the response of the central nervous system to pain "nociception."

RESULTS

The age of the patients ranged from 18 to 42 years (average, 25.3 ± 6.1 years). The average value of state entropy recorded during the surgery for all patients was found to be 45.43 ± 5.37. The mean beginning Surgical Pleth Index value recoded from all of the patients was 23.4 ± 8.84 compared with the beginning value; the values recorded during periost dissection, lateral osteotomy, and lower turbinate lateralization were statistically significantly higher (P < 0.005).

CONCLUSIONS

Although sufficient depth of anesthesia and standard protocol of analgesia were applied, pain response was found to be significantly higher at some procedures during septorhinoplasty. The authors think that increasing the depth of anesthesia during these procedures will increase the comfort of this operation by inhibiting pain response.

LEVEL OF EVIDENCE: 4

Lesser Known Uses of γ-Aminobutyric Acid Analogue Medications in Otolaryngology

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.

Comparing the Effect of Gabapentin, Ketamine, Dexmedetomidine, and Entonox on Pain Control in Burn Wound Dressing

This study aimed to evaluate differences in the experience of pain, nausea, and vomiting, as well as the hemodynamic parameters including heart rate (HR) and blood pressure (BP) in burn patients across four pain treatment groups-i.e., gabapentin, ketamine, dexmedetomidine, and entonox. In a single blinded randomized comparative study, 25 burn patients with second- or third-degree burns between 20% and 50% of their body surface were assigned to different treatment groups by using block randomization, while keeping the investigator blind to the size of the block. We recorded demographics, the hemodynamics, adverse effects, and pain levels before the treatment and again 5, 10, 15, 30, 60, 120, 240, and 360 minutes postadministration of pain medication (after-treatment). Gabapentin ketamine, dexmedetomidine, and entonox had significant effects in treatment of pain in burn patients. Entonox had the best analgesic effect with the least adverse effects and hemodynamic changes. Gabapentin also had good pain management effects; however, it showed less desirable effects on hemodynamic variables. Entonox caused the least amount of hemodynamic changes and the least adverse reactions, but since the medication is delivered by a facemask it limited its application with our patients. Gabapentin offered good benefits but caused a gradual drop in BP and HR and had some unfavorable reactions. However, since it is administered orally and often is cheaper, it could be considered as the drug of choice.

Prospective Randomized Trial Comparing Opioids versus Nonsteroidal Antiinflammatory Drugs for Postoperative Analgesia in Outpatient Rhinoplasty

BACKGROUND

The misuse and abuse of opioids, including overprescription, has led to the current opioid epidemic and national crisis. There is a national effort to eliminate the unnecessary prescription of opioids for analgesia.

METHODS

Seventy patients were randomized to receive postoperative analgesia with either 5 mg hydrocodone with 325 mg acetaminophen (opioid control group) or 400 mg of ibuprofen [nonsteroidal antiinflammatory drug (NSAID) experimental group]. Pain levels were assessed on postoperative days 1, 2, and 7. Outcome measures included numeric pain rating scores and assessments of frequency and amount of analgesic used.

RESULTS

There was no significant difference in gender (p = 0.81) or age (p = 0.61) between groups. On postoperative day 0, the NSAID group (mean ± SD, 2.54 ± 1.57) was found to be noninferior to the opioid group (mean ± SD, 3.14 ± 1.75; p = 0.003). On postoperative day 1, the NSAID group showed a lower mean pain score (mean ± SD, 1.84 ± 1.29) than the opioid group (mean ± SD, 2.46 ± 1.90; p = 0.01). However, on postoperative day 7, the difference in pain scores between the NSAID (mean ± SD, 3.29 ± 2.14) and opioid (mean ± SD, 3.14 ± 2.12; p = 0.17) groups lost statistical significance. There was no significant difference in mean day of medication cessation between the NSAID (mean ± SD, 4.73 ± 1.57) and opioid (mean ± SD, 4.28 ± 2.23; p = 0.26) groups. Seventy-six percent of patients who were prescribed opioids took fewer than eight tablets. Five patients escalated from NSAIDs to opioids. There were no adverse effects related to NSAID use.

CONCLUSIONS

NSAIDs are an acceptable and safe alternative to opioids for postoperative analgesia in rhinoplasty and potentially lead to better overall pain control in some patients. Significantly reducing or eliminating opioid prescriptions may be considered in light of the current opioid epidemic.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

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.

The Safety Profile of Liposomal Bupivacaine Use in Septorhinoplasty

Objective: To evaluate the safety profile, including adverse drug reactions and operative complications, of liposomal bupivacaine (LB) use for local anesthesia during functional septorhinoplasty. Study Design: Retrospective review. Subject and Methods: A database query was conducted for patients >18 years of age who underwent septorhinoplasty from January 1, 2019, to August 1, 2020. Adverse drug reactions and postoperative outcomes were compared between patients who received locally administered LB and patients who received standard local anesthetic at the completion of the surgery. Results: A total of 95 cases were included in our data analysis. No significant differences were found in adverse reactions overall (6.3% vs. 3.1%, p = 0.51) or complications, including rate of infection (3.2% vs. 3.1%, p = 1), cartilage warping (1.6% vs. 0%, p = 1), graft resorption (0% vs. 0%, p = 1), septal hematoma (0% vs. 0%, p = 1), and need for revision surgery (4.8% vs. 3.1%, p = 1) between LB and control groups. Conclusion: LB demonstrated an acceptable safety profile when compared with standard local anesthetics during septorhinoplasty, with no significant difference in systemic or local adverse drug reactions or postoperative complications.

Implementing a Protocol to Reduce Opioid Prescriptions in Military Otolaryngology: A Quality Improvement Initiative

INTRODUCTION

To compare pain medication refill rates for adult septoplasty and rhinoplasty patients before and after initiating a multimodal analgesic protocol for reducing opioid prescriptions (PROP).

MATERIALS AND METHODS

Data from 58 adult patients were retrieved by retrospective chart review (19 septoplasties and 10 rhinoplasties before initiating PROP in September 2018 and 21 septoplasties and 8 rhinoplasties after PROP). We selected consecutive septoplasties and rhinoplasties, at which time a new discharge order set was implemented. The new order set consisted of 10 oxycodone tabs (5 mg), 100 acetaminophen tabs (325 mg), and 28 celecoxib tabs (200 mg). The primary outcome variable was the number of initial opioid prescriptions and refills filled by any provider.

RESULTS

Among the septoplasties, there was a 46% decrease in total morphine milligram equivalent (MME) prescribed, from a mean of 202.0 mg in the non-PROP group (95% CI, 235.4, 174.6) to 108.6 mg in the PROP group (95% CI, 135.8, 81.4), with no difference in refill rates. Among the rhinoplasties, there was a 51% decrease in total MME prescribed, from a mean of 258.8 mg in the non-PROP group (95% CI, 333.4, 184.1) to 126.6 mg in the PROP group (95% CI, 168.1, 85.0) with no difference in refill rates.

CONCLUSIONS

The outcomes after PROP implementation for septoplasty and rhinoplasty at our institution suggest that opioid prescription rates can be significantly decreased to manage postoperative pain, with no difference in opioid refill rates. The results also warrant further investigation into patient pain, satisfaction, provider efficiency, and healthcare costs.

No Opioids after Septorhinoplasty: A Multimodal Analgesic Protocol

Supplemental Digital Content is available in the text.

Background:

From a public health perspective, nasal surgery accounts for many unused opioids. Patients undergoing septorhinoplasty require few opioids, and efforts to eliminate this need may benefit both patients and the public.

Methods:

A multimodal analgesic protocol consisting of 15 components encompassing all phases of care was implemented for 42 patients.

Results:

Median age and BMI were 34 years and 23, respectively. Most were women (79%), White (79%), primary surgeries (62%), and self-pay (52%). Comorbid conditions were present in 74% of the patients, with anxiety (33%) and depression (21%) being the most common. Septoplasties (67%) and osteotomies (45%) were common. The median operative time was 70 minutes. No patients required opioids in recovery, and median time in recovery was 63 minutes. Ten (24%) patients required an opioid prescription after discharge. In those patients, median time to requirement was 27 hours (range 3–81), and median total requirement was 20 mg morphine equivalents (range 7.5–85). Protocol compliance inversely correlated to opioid use (P = 0.007). Compliance with local and regional anesthetic (20% versus 63%, P = 0.030) as well as ketorolac (70% versus 100%, P = 0.011) was lower in patients who required opioids. Patients who required opioids were less likely to be administered a beta blocker (0% versus 34%, P = 0.041). Pain scores were higher in opioid users on postoperative days 1–5 (P < 0.05). No complications occurred in those requiring opioids, and satisfaction rates were equivalent between groups.

Conclusion:

This protocol allowed us to safely omit opioid prescriptions in 76% of patients following septorhinoplasty, without adverse effects on outcomes or patient satisfaction.

Perioperative Intravenous Low-Dose Ketamine Infusion to Minimize Pain for Septorhinoplasty: A Prospective, Randomized, Double-Blind Study

OBJECTIVES

Studies investigating the effects of intravenous (IV) ketamine in pain management after septorhinoplasty is limited. This study aims to evaluate the efficacy of low-dose IV infusion of ketamine on pain scores.

METHODS

This randomized, prospective, double-blind study was conducted with 48 patients who underwent septorhinoplasty. Intravenous ketamine bolus (0.5 mg/kg) was administered to the ketamine group (group K, n = 24) at anesthesia induction, and ketamine infusion was continued (0.25 mg/kg/h) during the surgery. In the control group (group C, n = 24), the same protocol was administered using saline instead of ketamine. Furthermore, 50-mg dexketoprofen trometamol was administered to both groups 30 minutes before the end of the surgery. Then it was repeated at the 12th and 24th hours postoperatively. Pain scores were evaluated with the visual analogue scale. Consumptions intraoperative of opioid and sevoflurane, rescue opioid requirement, patient satisfaction, and side effects were recorded.

RESULTS

Pain scores were significantly lower in group K at all postoperative periods (P < .05). There was no significant difference between the groups in terms of intraoperative sevoflurane and remifentanil consumptions (P > .05). Rescue opioid analgesic requirements were significantly lower in group K than group C (0/24 vs 6/24, respectively; P  = .022). Side effects were similar between the groups (P > .05).

CONCLUSION

We recommend the administration of low-dose ketamine infusion during septorhinoplasty surgery because it reduces the requirement for rescue opioid analgesia and postoperative pain scores.

Feasibility of Implementing Opioid Stewardship Recommendations for Sinonasal Surgery

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.

The relationship between the level of μ-opioid receptor (μORs) and postoperative analgesic use in patients undergoing septoplasty: a prospective randomized controlled trial

Background

In this study, the μ-Opioid receptor activity was assessed pre-operatively for its association with postoperative pain level and second analgesic requirement in patients undergoing septoplasty.

Methods

In our prospective study, 120 adult patients underwent septoplasty from June 2015 to January 2019 were randomly divided into 2 pre-operative groups. The first group (n = 60) was patients given tramadol (1–2 mg/kg) for post-operative analgesia, and the second group (control group) (n = 60) was initially prescribed only fentanyl (1 μg/ kg-i.v.) in the induction. Acetaminophen with codeine analgesic 325/30 mg (p.o.) was used as an rescue painkiller in the post-operative period. The μ-Opioid receptor activity was investigated in pre-operative blood samples and compared to post-operative pain level and time required for second round of analgesic administration. The visual analogue score (VAS) was used to evaluate the post-operative pain degree (0 no pain; 10 worst pain). The patients’ post-operative VAS scores were evaluated upon arrival to recovery room, and at the 1st, 3rd, 7th, 10th, and 24th hour post-operative period.

Results

Demographic data and peri-operative variables were similar in both study group (p < 0.05).There was no significant difference between the receptor levels in both groups and the mean receptor level was 200.94 ± 15.34 pg/mL (max:489.92 ± 22.36 pg/mL, min: 94.56 ± 11.23 pg/mL).In patients who used tramadol as the levels of μ-Opioid receptors increased, VAS scores of patients and second analgesic use decreased in post-operative period.The VAS scores in patients with higher receptor levels were lower in the recovery room (p < 0.05), 1st (p < 0.05) and 3rd hours (p < 0.05).The VAS scores were lower in the tramadol group compared to the control group (p < 0.05).Number of secondary analgesic requirement was significantly lower in patients of the tramadol group with higher receptor levels compared to the ones with lower receptor (p < 0.05) for arrival at the recovery room and 1st hour. Patients in the tramadol group needed a second pain killer much later than patients in the control group.

Conclusions

Our study demonstrates that patients with higher μOR levels have a higher efficacy of opioid analgesic agents and an lesser need for additional analgesic agents.

Trial registration

This trial was registered retrospectively (The ACTRN: ACTRN12619001652167, registration date: 26/11/2019).

Nonopioid, Multimodal Analgesia as First-line Therapy After Otolaryngology Operations: Primer on Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

OBJECTIVE

To offer pragmatic, evidence-informed advice on nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line therapy after surgery. This companion to the American Academy of Otolaryngology-Head & Neck Surgery (AAO-HNS) clinical practice guideline (CPG), "Opioid Prescribing for Analgesia After Common Otolaryngology Operations," presents data on potency, bleeding risk, and adverse effects for ibuprofen, naproxen, ketorolac, meloxicam, and celecoxib.

DATA SOURCES

National Guidelines Clearinghouse, CMA Infobase, National Library of Guidelines, NICE, SIGN, New Zealand Guidelines Group, Australian National Health and Medical, Research Council, TRIP database, PubMed, Guidelines International Network, Cochrane Library, EMBASE, CINAHL, BIOSIS Previews, ISI Web of Science, AHRQ, and HSTAT.

REVIEW METHODS

AAO-HNS opioid CPG literature search strategy, supplemented by PubMed/MEDLINE searches on NSAIDs, emphasizing systematic reviews and randomized controlled trials.

CONCLUSION

NSAIDs provide highly effective analgesia for postoperative pain, particularly when combined with acetaminophen. Inconsistent use of nonopioid regimens arises from common misconceptions that NSAIDs are less potent analgesics than opioids and have an unacceptable risk of bleeding. To the contrary, multimodal analgesia (combining 500 mg acetaminophen and 200 mg ibuprofen) is significantly more effective analgesia than opioid regimens (15 mg oxycodone with acetaminophen). Furthermore, selective cyclooxygenase-2 inhibition reliably circumvents antiplatelet effects.

IMPLICATIONS FOR PRACTICE

The combination of NSAIDs and acetaminophen provides more effective postoperative pain control with greater safety than opioid-based regimens. The AAO-HNS opioid prescribing CPG therefore prioritizes multimodal, nonopioid analgesia as first-line therapy, recommending that opioids be reserved for severe or refractory pain. This state-of-the-art review provides strategies for safely incorporating NSAIDs into acute postoperative pain regimens.

Nonopioid Adjuncts and Alternatives

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.

Acute Pain Management Following Facial Plastic Surgery

Facial plastic surgery, including septorhinoplasty, aging face procedures, otoplasty, and oculoplastic procedures, has varying levels of evidence for the management of acute pain after surgery. This article discusses the available evidence in these procedures and discusses the authors' recommendations for the treatment of postoperative pain, with a focus on decreasing the reliance on opioid pain medication.

Defining Typical Acetaminophen and Narcotic Usage in the Postoperative Rhinoplasty Patient

OBJECTIVE

To characterize the acetaminophen and narcotic use pattern of the postoperative rhinoplasty patient. To describe a pain level and pain medication usage pattern of the typical post-rhinoplasty patient and identify demographic considerations.

STUDY DESIGN

Prospective cohort study at a tertiary care center.

METHODS

Rhinoplasty patients were given standardized perioperative pain instructions and narcotic medication (18 tabs oxycodone) along with a pain medication use survey. Postoperatively, survey and tracking information was collected regarding narcotic and acetaminophen use at their first postoperative appointment. Patients were asked about non-steroidal anti-inflammatory drug, aspirin, and chronic opioid use. Narcotic and acetaminophen use along pain levels (1-10) at time of use were recorded by patients at 4-hour increments postoperatively until their first postoperative visit.

RESULTS

Pain medication usage (oxycodone and acetaminophen) peaked on (postoperative day 1) POD1. Pain was significantly higher in younger patients (30 years old or younger), female patients, and primary rhinoplasty patients. Pain was correlated with acetaminophen and oxycodone use for women, and acetaminophen used for men. Autologous rib grafting was not correlated with higher narcotic use.

CONCLUSION

Describing a pain medication usage pattern for the typical post-rhinoplasty patient provides both patients and clinicians important knowledge of postoperative pain expectations and has the potential to reduce both the amount of narcotic prescribed by providers and the amount of narcotic used by patients.

LEVEL OF EVIDENCE

4 (Case Series) Laryngoscope, 131:48-53, 2021.

Postoperative Prescriptions and Corresponding Opioid Consumption After Septoplasty or Rhinoplasty

The objective of our study was to assess the relationship between postoperative opioid prescribing patterns and opioid consumption among patients who underwent septoplasty or rhinoplasty. A chart review of patients who underwent either septoplasty or rhinoplasty by 3 surgeons between July 2016 and June 2017 was performed, and pertinent clinical data were collected including the amount of narcotic pain medications prescribed. A telephone interview was then conducted to assess opioid usage and pain control regimen postoperatively. The number of opioid tablets prescribed and the number consumed were converted to total morphine milligram equivalent (MME) for uniform comparison. A total of 75 patients met the inclusion criteria, and 64 completed the telephone survey. Among these 64 patients, the mean (standard deviation [SD]) prescribed MME was 289.7 (101.3), and the mean (SD) consumed MME was 100.6 (109). Similarly, the mean (SD) number of opioid tablets prescribed was 42.4 (9.7), and the mean number of tablets consumed was 14.7 (16.3). Gender, procedure performed (septoplasty or rhinoplasty), use of Doyle splints, and surgeon were not associated with the amount of opioids prescribed or used. Subjective pain control was the only factor associated with an increase in opioid use (P = .0288). There was an overabundance of opioid pain medications prescribed compared to the amount consumed for pain control after septoplasty or rhinoplasty. Abuse of prescription opioids represents an important component of the nation's opioid crisis. Surgeons must be cognizant of the problem and adjust prescribing practices accordingly.

The effectiveness of endoscopic sphenopalatine ganglion block in management of postoperative pain after septal surgery

BACKGROUND

This study evaluated the effect of bilateral endoscopic sphenopalatine ganglion block (SPGB) for management of postoperative pain in patients undergoing septoplasty.

METHODS

Sixty septoplasty patients (51.7% male, 48.3% female, aged 18 to 45 years) were randomly assigned to general anesthesia (GA) alone (control) (n = 30) or GA plus endoscopic SPGB (n = 30). Demographic data, duration of surgery, blood loss, postoperative visual analogue scale (VAS) pain scores (upon arrival at the postanesthesia care unit [PACU] and 2, 6, 12, and 24 hours after surgery), overall analgesic usage (end of 24 and 168 hours after surgery), overall satisfaction with the pain control (end of 24 and 168 hours after surgery), and complications (bleeding, nausea and vomiting, and visual disturbance) were recorded.

RESULTS

Pain scores upon arrival to the PACU and 2, 6, 12, and 24 hours after surgery were significantly lower in the SPGB group compared to the control group (p < 0.001). Moreover, the SPGB group had significantly lower analgesic requirements and higher satisfaction scores with their pain control at the end of 24 and 168 hours after surgery compared to the control group (p < 0.001). The 2 groups significantly differed in terms of intraoperative blood loss (p = 0.024), and surgery time was longer in the SPGB group compared to the control group (p < 0.001).

CONCLUSION

SPGB with bupivacaine is a safe and effective method to reduce pain after septoplasty, and it is a cost-effective alternative to high doses of analgesics.