Combination Analgesics Provide Superior Relief in Perioperative Pain Management

by Literature Review •

In light of opioid misuse and diversion, how effective are perioperative analgesic regimens following otologic surgery?

BOTTOM LINE: There is evidence that combination analgesics, such as acetaminophen plus codeine, provide superior pain relief to monotherapy analgesics in otologic surgery perioperative pain management.

BACKGROUND: Over two million Americans suffer from prescription opioid drug abuse, and more than 115 people die each day from an opioid overdose. Recent national policy reforms make prescribing opioids more difficult, even when they are indicated. As otologic surgery is frequently outpatient, effective perioperative pain management may help reduce excessive postoperative opioid prescriptions.

STUDY DESIGN: Literature review of 23 studies of randomized control trials investigating pain management in otologic surgeries published between Jan. 1, 1947, and June 30, 2018, encompassing 1,842 patients.

SETTING: Embase, Cochrane Library, and PubMed/MEDLINE databases.

SYNOPSIS: Study results included the following: Preoperative administration of oral ketorolac, but not acetaminophen, provided better postoperative pain control than placebo in children undergoing bilateral myringotomy. Preoperative acetaminophen with codeine was superior to acetaminophen alone after bilateral myringotomy and pressure-equalizer tube placement (BM-T). Acupuncture therapy may be effective in diminishing both pain and emergence agitation in children after BM-T insertion. An intraoperative great auricular nerve (GAN) block in children undergoing tympanomastoid surgery may provide superior analgesia, although preoperative GAN block did not offer significant postoperative pain relief advantages. A combination of bupivacaine and 100 μg fentanyl for operative field infiltration was associated with better postoperative analgesia than the combination with 50 μg fentanyl. Continuous wound infusion of 0.2% ropivacaine was overall more efficacious and safer for postoperative pain management than a single intercostal nerve block with 0.75% ropivacaine after costal cartilage graft harvest for auricular reconstruction in children. Remifentanil led to a clear decrease in intra- and postoperative adverse reactions, and reduced bleeding. Dexmedetomidine was a comparable alternative to midazolam–fentanyl for sedation and analgesia in tympanoplasty surgery under local anesthesia. Limitations included heterogenous variables that made accurate comparisons difficult.

CITATION: Campbell HT, Yuhan BT, Smith B, et al. Perioperative analgesia for patients undergoing otologic surgery: an evidence-based review. Laryngoscope,