April 2020 HSC Section 4 - Plastic and Reconstructive Problems

achieve pain control in these 90% of patients (Fig. 5). Re fl ecting on our VAS pain data, the need for opioid analge- sia is most likely on the day of surgery and for 1 (septoplasty only) or 2 (rhinoplasty) days after surgery. It seems reason- able that opioids may be required for patient comfort during these time periods in many patients, and some patients may feel the need to use opioids later in the fi rst 14 postoperative days. In our study, septoplasty patients averaged 4.1 4.4 (maximum of 15) tablets, whereas rhinoplasty patients used 4.4 4.0 (maximum of 14) tablets. These groups averaged 32.0 and 28.7 MMEs. Patel et al. 19 documented an average use of 8.7 hydrocodone (5 mg)/acetaminophen (325 mg) tab- lets (43.5 MMEs); 26% of their patients used more than 15 tablets (80 MMEs or more). However, our results agree in the lack of relationship between total MMEs and the per- formance of an external approach or osteotomies. This study did not assess the effect of a comprehen- sive multimodality analgesia (MMA) regimen but rather assessed the patients ’ pain control needs in the current setting. Militsakh et al. 25 and Shindo et al. 26 found that opioid prescribing after thyroid and parathyroid surgery declined with the use of a MMA regimen. Addition of such a regimen may further reduce the need for opioids. CONCLUSION Despite the backlash against the characterization of pain as the fi fth vital sign, disproportionate postopera- tive pain can be an important sign of an atypical postop- erative course; excessive opioid prescription should be avoided for this reason, as well as the risk of opioid addiction. However, as noted by Zgierska et al., 27 the current environment in which hospitals and physicians are reviewed by patients, including questions about pain control, establishes a potential con fl ict between the need to provide adequate postoperative analgesia and conser- vative and reasoned opioid prescribing. This study es- tablishes a patient-derived benchmark against which prescription patterns can be judged, and represents part of a larger departmental initiative examining other ambulatory otolaryngology procedures.

5/325 postoperatively. Almost three-quarters of the patients reportedly used 15 tablets or less, whereas 5% required more than the 20 to 30 tablets prescribed. These authors found no difference in opioid use based on age, primary ver- sus revision surgery, or concurrent performance of osteo- tomies, septoplasty, or turbinate reduction. Sethi et al. 20 noted an average of 28 opioid tablets (range, 5 – 40) pre- scribed to 173 patients undergoing rhinoplasty, suggesting signi fi cant routine overprescribing. Patients recorded pain scores using a VAS instru- ment after septal surgery or septorhinoplasty in a study by Szychta et al. Patients who underwent septal surgery only in this study reported minimal pain, with VAS scores less than 10 at all times after surgery. 21 This dif- fers signi fi cantly from the results of our study, in which average VAS pain scores, although mild, exceeded a VAS score of 10 until POD 3. In our study, VAS scores were not signi fi cantly higher for patients undergoing rhino- plasty at any time after surgery. The appropriate VAS cutoff between mild and moderate pain, and the need for opioid analgesics, is debatable, with Bodian et al. 22 and Myles et al. 23 advocating a score of 31 or higher and Jen- sen et al. 24 using a VAS score >40. If a VAS score of 40 is used as a cutoff for mild pain, rhinoplasty, but not septo- plasty, patients in our study had, on average, moderate pain (VAS 45.8 21.3) only on the day of surgery. If a VAS of 30 or less is used as a cutoff, our rhinoplasty pa- tients had on average moderate pain on POD 1 (VAS 38.1 21.4) and POD 2 (VAS 30.0 22.3) as well; by comparison, patients undergoing septoplasty had moder- ate pain on the day of surgery (VAS 35 25.1) and POD 1 (VAS 30.0 23.3). However, when comparing septo- plasty to rhinoplasty groups, the total MMEs used, the number of opioid doses, and the mean daily VAS pain scores were not signi fi cantly different. Only the total acet- aminophen used differed signi fi cantly between the two groups, with the rhinoplasty patients averaging slightly more than 4,500 milligrams more than septoplasty patients ( P = .0112). Our study fi rmly establishes the relatively low levels of pain experienced by the average septoplasty and rhino- plasty patient. Whereas some patients experienced more severe pain or for a longer duration, the patients in this study experienced, on average, 2 to 3 days of mild pain. Even patients who reported VAS scores in the high 80s in the postoperative period were well-managed, with relatively low total daily MMEs of opioid and low numbers of doses. Pain scores of rhinoplasty patients, 86% of whom also had septoplasty, were not signi fi cantly higher than those of patients who underwent septoplasty alone. The total num- ber of doses of opioids used (4.4 4.0 vs. 4.1 4.4), the total MMEs consumed (32.0 30.2 vs. 28.7 34.1), and the number of days with VAS > 30 or 40 (2.9 2.7 and 1.9 1.9 vs. 2.8 2.6 and 1.9 1.8) did not signi fi cantly differ between the two groups. Likewise, we found no asso- ciation between open approach or nasal bone osteotomies and the degree of postoperative pain. Based on our data, adequate pain control of at least 90% of patients after either septoplasty or rhinoplasty would require 10 to 11 opioid doses of suf fi cient potency (Fig. 4). Alternatively, a total of 71 to 80 MMEs is required to

Acknowledgments The authors acknowledge the assistance of Teresa Val- derama, MPH, Charles A. Riley, MD, and Aron Kallush, BA, in the conduct of this research.

BIBLIOGRAPHY 1. CDC Opioid Prescribing Guidelines. https://www.cdc.gov/drugoverdose/pdf/ calculating_total_daily_dose-a.pdf. Accessed December 2, 2018. 2. New York State Prescription Monitoring Program Registry. https://commerce. health.state.ny.us/doh2/applinks/cspnp/PatientSearch.action. Accessed December 2, 2018. https://www.health.ny.gov/professionals/narcotic/ prescription_monitoring/docs/pmp_registry_faq.pdf 3. CDC, Drug Overdose Death Data. https://www.cdc.gov/drugoverdose/data/ statedeaths.html. Accessed December 1, 2018. 4. National Institute on Drug Abuse. https://www.drugabuse.gov/related-topics/ trends-statistics/overdose-death-rates. Accessed November 25, 2018. 5. Rudd RA, Set P, David F, Scholl L. Increases in drug and opioid-involved overdose deaths-United States, 2010-2015. MMWR Morb Mortal Wkly Rep 2016;65:1 – 8.

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Sclafani et al.: Postoperative Pain After Septorhinoplasty

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