Overview
Otology and neurotology encompass a broad spectrum of procedures, from minor surgical procedures performed under local anesthesia in an outpatient setting (e.g., bone-anchored hearing aid placement), to complex intracranial surgeries involving critical neurovascular structures that require ICU admission (e.g., vestibular schwannoma excision). The patient population also encompasses the entire span of life, from infants to the elderly. The heterogeneity in procedural scope and patient demographics render pain management particularly challenging and require deliberate consideration for each patient and procedure.
Opioid overuse and misuse remain a significant challenge in medicine, especially in postsurgical care. Surgeons have the second highest rate of opioid prescribing and write 37% of all prescriptions, second only to pain medicine specialists. Studies have demonstrated that surgeons poorly estimate postoperative opioid needs, with patients often using less than half of their prescribed course. The need to manage a patient’s pain postoperatively, variability in patient pain tolerance, and the broad spectrum of procedures performed make the standardization of pain medication regimens especially challenging in otology and neurotology.
Studies have evaluated trends in opioid prescribing specific to the field of otology. Gerbershagen et al. examined pain intensity the first day after surgery and found that middle and inner ear surgery ranked 155 out of 179 different procedures in terms of pain intensity. However, these surgeries were labeled as a “heterogenous surgical group,” demonstrating the variation in otologic surgery. Mohan et al. reviewed outpatient otolaryngology visits and found that although only a minority of visits resulted in the prescription of opioids, the ambulatory opioid prescription rate doubled between 2008 and 2011, with chronic otitis media and otitis externa ranking among the most common visit diagnoses associated with opioid prescription (8.7% and 6.2% of all diagnoses, respectively). Separate studies have evaluated the opioid prescribing patterns within otolaryngology for procedures including tympanoplasty and mastoidectomy and showed there is high variability in prescribing patterns, especially when comparing prescriptions written by attending versus resident physicians, suggesting the need for standardized postoperative narcotic guidelines. , A study of opioid use also revealed that while a median number of 24 (IQR [20–45]) narcotic pills were prescribed by physicians to treat postsurgical pain following an otologic procedure, only a median number of 6 (IQR [2–15]) were actually consumed by patients. This study highlighted another challenge in opioid prescribing—not only are opioids commonly overprescribed, this overprescription leads to leftover opioids that may not be disposed of properly, leading to a risk of misuse. Indeed, over 80% of respondents in this study had leftover opioids following surgery, with the majority keeping the excess instead of disposing it using designated medication boxes.
It is clear that the variability in otologic surgery mandates tailored approaches to pain. As the emphasis on reducing opioid prescriptions grows, further subspecialty data will be needed to guide analgesic principles. Furthermore, with the advent of enhanced recovery after surgery (ERAS) pathways a strong understanding of pain management principles is needed. The objective of this chapter is to provide an overview of postoperative pain management in otology and neurotology with a view toward the role of multimodal analgesia and opioid-sparing approaches.
Otologic surgery
Most otologic surgeries are conducted on an outpatient basis and include both adult and pediatric patient populations. Otologic procedures are confined to the external and/or middle ear and do not intrude into major body cavities or involve extensive soft tissue work. Consequently, postoperative pain control is seldom a major issue for patients. Although the approach to pain management in this discipline is ostensibly simpler than in neurotologic surgery, where pain control must be considered in the setting of a craniotomy, specific considerations may be required for pediatric patients and for procedures performed under conscious sedation or local anesthesia alone for certain procedures. Assessment of pain control in the pediatric population is particularly challenging due to the variety of pain scales used in this population, such as the Global Mood Scale and pain visual analog scales, which may not be adequate in capturing the subjective experience of pain.
The procedural safety and pain levels associated with outpatient ear surgery have been previously evaluated: a recent retrospective review of 1368 patients undergoing outpatient otologic surgery showed that only 2.5% of patients required readmission or inpatient stay, mostly due to vertigo, pain, or dizziness. Although ear surgery tends to be well tolerated, patients must be counseled preoperatively on expectations for pain management and made aware that the aim of analgesia is not to eliminate the pain but to decrease it to a manageable level. In the United States, nonopioid analgesics such as acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDs) are typically used as first steps in postoperative pain control after otologic procedures and are adequate for most patients. Opioid prescriptions are commonly provided should patients find nonopioids alone to be insufficient. Qian et al. prospectively studied opioid consumption following adult outpatient otologic surgery and discovered that their patients consumed roughly 75% of their prescribed opioids, and those with postauricular incisions used significantly more opioids than those with transcanal incisions. It is important to note however, pain and analgesia have an important cultural component and in other geographical settings, opioid prescriptions are not routinely provided for otologic procedures.
A recent review of opioid stewardship in otolaryngology categorized ear surgery, including ventilation tubes, tympanoplasty, mastoidectomy, ossicular chain reconstruction, cochlear implantation, bone-anchored hearing aid implantation, and stapedectomy as typically associated with “mild pain” ( Table 6.1 ). The study authors recommended preoperative use of 1000 mg acetaminophen and 400 mg gabapentin, intraoperative use of long-acting local anesthesia, and postoperative prescription of acetaminophen 500 mg every 6 h with the use of celecoxib 200 mg every 12 h or naproxen 500 mg every 8–12 h as needed for breakthrough pain. However, for patients who had a history of chronic pain or preoperative opioid use, they also recommended a possible preoperative pain service consultation as well as continuation of previously prescribed narcotics in addition to the aforementioned regimen.
| Surgery | Analgesia under study | References |
|---|---|---|
| Common otologic surgeries (e.g., PE tube, ossicular chain reconstruction, tympanoplasty) | Recommended 500 mg acetaminophen q6h with celecoxib 200 mg q12h or naproxen 500 mg q8-12h for breakthrough pain postoperatively | Cramer et al. |
| Myringotomy with bilateral PE tube placement | Preoperative ketorolac, but not acetaminophen, provided postoperative pain control in children | Watcha et al. |
| Myringotomy with bilateral PE tube placement | Preoperative ketorolac was associated with decreased pain scores postoperatively, but imparted no clinically meaningful difference on discharge analgesic requirements | Bean-Lijewski et al. |
| Myringotomy with bilateral PE tube placement | No difference in analgesic requirements was discovered in patients receiving preoperative analgesia versus placebo | McHale et al. |
| Children undergoing tympanomastoidectomy surgery | Great auricular nerve block may reduce postoperative opioid requirements | Suresh et al. |
Several studies have examined analgesic regimens for specific otologic surgeries. For example, adults are generally counseled to take acetaminophen and ibuprofen as needed for pain related to tympanostomy tube placement, and this procedure can be performed under local analgesia, although in pediatric patients, general analgesia is used. Watcha et al. reported that administering oral ketorolac preoperatively provided superior postoperative pain control relative to acetaminophen in children undergoing bilateral tympanostomy tube placement and myringotomy. However, Bean-Lijewski et al. found that although the use of preoperative ketorolac was associated with decreased pain scores at five and 10 min postoperatively, there was no difference in discharge analgesic requirements, therefore bringing into question whether ketorolac use results in a clinically meaningful difference in pain control. The transient improvement in postoperative pain must be balanced with the risks of ketorolac, especially since in the pediatric population, tympanostomy tube placement may be performed in conjunction with adenotonsillectomy, where persistent concerns exist regarding the association between ketorolac and postoperative hemorrhage. A more recent double-blinded randomized controlled trial studied the use of preoperative analgesia versus placebo in patients undergoing bilateral myringotomy with tympanostomy tube placement. The study discovered no statistically significant difference in median pain scores at 90 min or need for additional analgesia, suggesting that preoperative analgesia in this population should not be routinely administered. Alternatives to acetaminophen for preoperative analgesia include administration of topical 2% lidocaine ear drops, which have been shown to provide comparative analgesia postoperatively. Other options include blockade of the auricular branch of the vagus nerve, which provides sensory innervation to the external auditory canal and tympanic membrane, using local bupivacaine.
The pain associated with mastoid surgery is also typically categorized as mild. A recent systematic review of pain management in otology reported five randomized controlled trials studying perioperative pain management for tympanomastoid surgery. Two of these studies reported the effect of block of the great auricular nerve in children, with one study finding a benefit to intraoperative blockade of the nerve 1 h before the end of the surgery with reductions in postoperative opioid requirements, while another study found no benefit. , A separate study examined the combination of bupivacaine and 100 μg fentanyl compared to bupivacaine and 50 μg fentanyl for local analgesia and found that the higher fentanyl dosing led to lower pain scores for patients undergoing modified radical mastoidectomy. Lastly, a randomized controlled trial examined three interventions (acetaminophen, acetaminophen plus codeine, and ibuprofen plus midazolam) and their effect on pain control in pediatric patients undergoing tympanocentesis. Results showed that children treated with acetaminophen alone had the highest peak heart rates and pain scores suggesting that acetaminophen alone may not be effective in reducing pain.
Similarly, the pain associated with cochlear implantation is typically mild and lasts for less than 1 week. Persistent pain following cochlear implantation is rare, and previous studies have found this affects only 1%–3% of patients. , Mahairas et al. studied opioid prescribing patterns and usage following cochlear implant surgery and reported that hydrocodone 5 mg was the most frequently prescribed opioid, with opioids prescribed for on average 5.5 days. Furthermore, they noted that each additional tablet of hydrocodone or oxycodone beyond 8 and 5 tablets per day, respectively, increased the likelihood of becoming a recurrent user of opioids by 15% and 22.5%. They concluded that limiting the total amount of opioids prescribed per day to no more than 40 morphine milligrams equivalents may be effective in decreasing the number of recurrent opioid users postoperatively.
Neurotology
Neurotologic, or lateral skull base surgeries, can cause significant postoperative pain due to the need for a craniotomy and more extensive tissue manipulation. Contrary to popular belief, pain after craniotomy can be severe in up to 90% of patients within days of surgery, with as many as 30% developing a chronic headache. Pain control in these patients can be particularly challenging due to the need for reliable neurologic examinations in the postoperative period to ensure patient safety. These competing demands may lead to the undertreatment of postoperative pain following intracranial surgery.
Multiple approaches are used to access the cerebellopontine angle for acoustic neuroma surgery, including the retrosigmoid, translabyrinthine, and middle cranial fossa approaches. Several sources of pain following craniotomy have been described and include neck pain due to patient positioning, scalp pain, and postoperative pain due to dural irritation. The diversity of approaches to the skull base warrants individualized management of pain for patients undergoing these surgeries. For example, retrosigmoid craniotomies may be associated with a higher incidence of postoperative nausea, vomiting, and headache due to manipulation of the occipital nerve extracranially, and the cerebellum and brainstem intracranially. ,
A variety of approaches to pain control have been proposed for postoperative pain after intracranial surgery ( Table 6.2 ). Patient-controlled analgesia (PCA) has been found to improve pain and lead to lower opioid use. Jellish et al. reported a dosing protocol of 1.5 mg morphine/dose with an 8-min lockout period such that the total dose of morphine over 4 h does not exceed 40 mg following skull base surgery. Nausea and vomiting should also be managed vigilantly as they can lead to increased intracranial pressures and other complications. Ondansetron may be used in combination with patient-controlled morphine for postoperative pain and emesis. However, studies have shown that patient control of ondansetron administration in addition to patient-controlled morphine increased the cost of the PCA almost tenfold with no statistically significant difference in nausea or vomiting for patients undergoing infratentorial skull base resections.
