HSC Section 3 - Trauma, Critical Care and Sleep Medicine

Otolaryngology–Head and Neck Surgery 158(5)

Table 1. Categories of Otolaryngology–Head and Neck Procedures Based on Pain Level. a

Pain Level

Type of Surgery

Recommended Pain Strategy

Mild pain

Endoscopic laryngeal surgery, including laryngoscopy and esophagoscopy

Preoperative: acetaminophen 1000 mg once, gabapentin 400 mg once Intraoperative: long-acting local anesthesia if possible Postoperative: acetaminophen 500 mg Q6 scheduled, add celecoxib 200 mg Q12 or naproxen 500 mg Q8-Q12 if needed for breakthrough pain Preoperative: acetaminophen 1000 mg once, gabapentin 400 mg once, celecoxib 400 mg once Intraoperative: long-acting local anesthesia if possible Postoperative: acetaminophen 500 mg Q6 scheduled, celecoxib 200 mg Q12 or naproxen 500 mg Q8-Q12, consider gabapentin 400 mg Q12, add tramadol 50 mg Q6 if needed for breakthrough pain Preoperative: acetaminophen 1000 mg once, gabapentin 400 mg once, celecoxib 400 mg once Intraoperative: long-acting local anesthesia if possible Postoperative: acetaminophen 500 mg Q6 scheduled, celecoxib 200 mg Q12 or naproxen 500 mg Q8-Q12, consider gabapentin 400 mg Q12, oxycodone 5 mg Q4 for breakthrough pain Consider preoperative pain service consultation Continue narcotic previously prescribed plus above multimodal nonopioid pain regimen If severe pain, consider consulting pain service

Ear surgery, including ventilation tubes, tympanoplasty, mastoidectomy, ossicular chain reconstruction, cochlear implantation, bone- anchored hearing aid, or stapedectomy Nasal surgery, including endoscopic sinus

surgery, septoplasty, repair of septal perforation, open rhinoplasty, or septorhinoplasty

Intermediate pain

Neck surgery, including selective, modified radical or radical neck dissection, excision of branchial cleft cyst, thyroidectomy, parathyroidectomy, wide local excision, or sentinel lymph node biopsy Salivary gland surgery, including parotidectomy and submandibular gland excision Oral or pharyngeal surgery, including tonsillectomy, uvulopalatopharyngoplasy, transoral robotic surgery of the oropharynx, laser excision of the hypopharynx, partial glossectomy, and neck dissection Major oncologic surgery, including free or regional tissue transfer and total laryngectomy

High pain

Chronic pain or chronic opioid use preoperatively

Any type of surgery

a Do not use celecoxib if patients have a history of cardiovascular disease.

appropriately. 46 The FDA recommends disposal at Drug Enforcement Administration–approved collection sites or other community take-back programs if available. 47 If no take-back program is available, then the FDA recommends flushing strong opioids down the toilet or mixing weaker opioids with compostable material and placing in a sealable plastic bag. 47 Special Populations When Prescribing Opioids When prescribing opioids, several populations are at an increased risk of adverse events and deserve special atten- tion. Opioids worsen obstructive sleep apnea and are associ- ated with postoperative re-intubation. 48 Patients with a history of cardiopulmonary disease are at increased risk of respiratory depression with opioids. 49 The elderly are

databases to monitor drugs of abuse, including opioids. PDMPs have been enacted in 49 states. Use of PDMPs is associated with a decrease in multiple opioid prescribers and opioid-related deaths. 44 If a pattern of opioid use is identified, it is important to stress that the purpose of screening for abuse is not to deprive patients with acute pain of opioid therapy. Rather, the purpose is to avoid dupli- cate prescribing and identify those at risk for overdose so that they can be provided with treatment to reduce adverse outcomes. 45 Opioid Disposal Patients must also be counseled on the proper disposal of unused opioids. Despite the high rate of unused opioid pre- scriptions, few opioids are stored or disposed of

155