xRead - Nasal Obstruction (September 2024) Full Articles

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used safely in most NSAID intolerant patients makes its use as first line analgesia strongly recommended. Several RCTs utilizing NSAIDs for perioperative pain control in sinonasal surgery have demonstrated reduced opioid consumption. 1861,1866–1870 Moeller et al. 1868 demon strated that IV ketorolac is an effective analgesic in the setting of sinonasal surgery with similar effects to IV fen tanyl, without increasing the risk of hemorrhage. Turan et al., 1866 meanwhile, showed that the use of pre-operative rofecoxib, a COX-2 inhibitor, resulted in decreased pain scores, reduced the use of rescue analgesia, and prolonged times to first analgesic requirement. More recently, Wu et al. 1871 performed a multicenter cohort study compar ing 2 groups of patients undergoing sinonasal surgery, 1 treated with acetaminophen/hydrocodone as the primary post-operative pain control regimen and 1 treated with ibuprofen and acetaminophen as the primary regimen with acetaminophen/hydrocodone for breakthrough pain. Total opioid use and patient reported pain scores were decreased in the group treated with Ibuprofen when com pared to the cohort treated with opioids. Several studies reported that the administration of local anesthetics in sinonasal surgery, including lidocaine and bupivacaine, as either injection or infused in post operative nasal packing led to decreased VAS scores and lower analgesic requirements. 1861,1872 Other studies have reported the use of sphenopalatine ganglion block or infraorbital nerve block to provide analgesia by targeting the sensory innervation of the nasal mucosa. 1873,1874 Dexmedetomidine, a highly selective α 2 adrenergic receptor agonist, is often utilized in the practice of anesthe sia as it produces sedation, anxiolysis, and analgesia with out causing respiratory depression. Administration prior to sinonasal surgery was found to result in significant reduc tions in VAS pain scores compared with placebo-saline solutions. 1875 Pregabalin and gabapentin are new generation anticon vulsants with anti-hyperalgesic and anti-nociceptive prop erties. Although these medications are US FDA approved for the treatment of seizures and neuropathic pain, they are frequently used off-label for the treatment of other types of acute and chronic pain, including in peri-operative pain management. The use of pre-emptive gabapentinoids in nasal surgery has been well documented in several RCTs, with the majority reporting significantly lower VAS pain scores compared to placebo. 1876–1881 In summary, there is growing evidence that opioid use after sinus surgery is decreasing and non-opioid alter natives are gaining acceptance (Tables XII-3 and XII-4). Future studies that continue to validate the use of alterna tive medications will hopefully lead to a reduction in opi oid prescription and use.

Hypotensive Anesthesia for ESS Aggregate Grade of Evidence: B (Level 1: 3 studies; level 2: 10 studies; level 3: 1 study; Table XII-2). Benefit: Controlled hypotension with MAP of between 60 and 70 mmHg improves the surgical field. Harm: MAP < 60 mmHg may result in cerebral ischemia. Cost: Minimal additional cost to achieve target MAP. Benefits-Harm Assessment: Preponderance of benefit over harm. Value Judgments: A MAP of between 60 and 70 mmHg preserves cerebral blood flow in healthy patients and improves the surgical field especially

in high disease load patients. Policy Level: Recommendation.

Intervention: Controlled hypotension (MAP between 60 and 70 mmHg) is safe and improves the surgical field.

XII.A.5 Perioperative Pain Management and Opioid Reduction According to a recent national survey, post-operative opi oid analgesics are prescribed by up to 95% of providers following sinonasal surgery. However, increasing evidence suggests that patients only require a small portion of the prescription for adequate pain control, and the majority of the medication remains unused. 1857–1859 Therefore, the judicious prescribing of opioids after rhinologic surgery coupled with adjunctive non-opioid use represents a practical opportunity for otolaryngologists to reduce the amount of opioid medication prescribed. This section will review studies of postoperative analgesia regimens as well as several reports of non-opioid adjuncts to reduce imme diate postoperative pain. 1860,1861 Pain-relieving efficacy in scheduled post-operative dosing of oral acetaminophen for analgesia after sinonasal surgery has been reported. 1862 In addition to the use of oral acetaminophen, several recent RCTs have also demon strated effectiveness in pre-operative intravenous dosing of acetaminophen. 1863–1865 Both of these interventions have demonstrated reduction in immediate postoper ative pain and decreased opioid requirements. 1863–1865 Acetaminophen’s effectiveness at controlling post operative pain, excellent safety profile, and ability to be