Approach to pain management in otology and neurotology

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.