Enhanced recovery after surgery in head and neck surgery: Reduced opioid use and length of stay.

OBJECTIVES: Enhanced recovery after surgery (ERAS) protocols were first developed in colorectal surgery and sought to standardize patient care. There have been several studies in the head and neck surgical literature looking at outcomes after ERAS protocol, but no studies focusing on narcotic use and length of stay. This study aimed to evaluate narcotic usage and length of stay, in addition to several other outcomes, following the implementation of an ERAS protocol. METHODS: A head and neck-specific ERAS protocol was implemented at this tertiary care center beginning July 2017. A retrospective cohort study was performed comparing this cohort to that of a retrospective control group. Outcomes included mean morphine equivalent dose, mean pain score, and percentage of patients prescribed narcotics on discharge. Secondary outcomes included ICU and total length of stay. RESULTS: The mean morphine equivalent dose (MED) administered within 72 hours postoperatively was significantly lower in the ERAS group (17.5 ± 46.0 mg vs. 82.7 ± 116.1 mg, P < .001). Average postoperative pain scores in the first 72 hours were lower in the ERAS group (2.6 ± 1.8 vs. 3.6 ± 1.9; P < .001). The average length of stay was shorter for ERAS patients (7.8 ± 4.8 vs. 9.7 ± 4.7 days, P = .008); however, there was no significant difference in ICU length of stay. CONCLUSION: Following implementation of an ERAS protocol, patients undergoing head and neck surgery had decreased narcotic use in the immediate postoperative period and at discharge, while also demonstrating improved postoperative analgesia. LEVEL OF EVIDENCE: Level 3 Laryngoscope, 130:1227-1232, 2020.

Association of Perioperative Opioid-Sparing Multimodal Analgesia With Narcotic Use and Pain Control After Head and Neck Free Flap Reconstruction.

IMPORTANCE: An increase in narcotic prescription patterns has contributed to the current opioid epidemic in the United States. Opioid-sparing perioperative analgesia represents a means of mitigating the risk of opioid dependence while providing superior perioperative analgesia. OBJECTIVE: To assess whether multimodal analgesia (MMA) is associated with reduced narcotic use and improved pain control compared with traditional narcotic-based analgesics at discharge and in the immediate postoperative period after free flap reconstructive surgery. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study assessed a consecutive sample of 65 patients (28 MMA, 37 controls) undergoing free flap reconstruction of a through-and-through mucosal defect within the head and neck region at a tertiary academic referral center from June 1, 2017, to November 30, 2018. Patients and physicians were not blinded to the patients' analgesic regimen. Patients' clinical courses were followed up for 30 days postoperatively. INTERVENTIONS: Patients were administered a preoperative, intraoperative, and postoperative analgesia regimen consisting of scheduled and as-needed neuromodulating and anti-inflammatory medications, with narcotic medications reserved for refractory cases. Control patients were administered traditional narcotic-based analgesics as needed. MAIN OUTCOMES AND MEASURES: Narcotic doses administered during the perioperative period and at discharge were converted to morphine-equivalent doses (MEDs) for comparison. Postoperative Defense and Veterans Pain Rating Scale pain scores (ranging from 0 [no pain] to 10 [worst pain imaginable]) were collected for the first 72 hours postoperatively as a patient-reported means of analyzing effectiveness of analgesia. RESULTS: A total of 28 patients (mean [SD] age, 64.1 [12.3] years; 17 [61%] male) were included in the MMA group and 37 (mean [SD] age, 65.0 [11.0] years; 22 [59%] male) in the control group. The number of MEDs administered postoperatively was 10.0 (interquartile range [IQR], 2.7-23.1) in the MMA cohort and 89.6 (IQR, 60.0-104.5) in the control cohort (P < .001). Mean (SD) Defense and Veterans Pain Rating Scale pain scores postoperatively were 2.05 (1.41) in the MMA cohort and 3.66 (1.99) in the control cohort (P = .001). Median number of MEDs prescribed at discharge were 0 (IQR, 0-18.8) in the MMA cohort and 300.0 (IQR, 262.5-412.5) in the control cohort (P < .001). CONCLUSIONS AND RELEVANCE: The findings suggest that after free flap reconstruction, MMA is associated with reduced narcotic use at discharge and in the immediate postoperative period and with superior analgesia as measured by patient-reported pain scores. Patients receiving MMA achieved improved pain control, and the number of narcotic prescriptions in circulation were reduced. LEVEL OF EVIDENCE: 3.

The Effects of Endoscopic Sinus Surgery on Voice Characteristics in Chronic Rhinosinusitis Patients.

OBJECTIVES: Functional endoscopic sinus surgery (FESS) is a standard treatment modality for patients with chronic rhinosinusitis (CRS) who have failed appropriate medical therapy. However, FESS entails modification of the upper airway tract that may alter phonatory resonance and produce voice changes. The effects of FESS on postoperative voice characteristics in patients with CRS have yet to be quantitatively assessed. METHODS: Patients with severe CRS who underwent FESS at a tertiary care referral center between May and October 2017 were prospectively enrolled. The Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) and the Voice Handicap Index (VHI) were used to quantitatively evaluate voice characteristics and quality of life, respectively. Preoperative and postoperative CAPE-V and VHI scores were compared with postoperative scores for each patient. Sino-Nasal Outcome Test (SNOT-22) scores were also obtained to assess changes in patient symptoms. RESULTS: 18 CRS patients undergoing FESS were enrolled. The average preoperative Lund-Mackay score was 14, indicating baseline severe CRS. Postoperative assessments demonstrated a statistically significant decrease in CAPE-V (45-27, p = .005) and VHI (10-4.7, p < .001) scores. These correlated with a statistically significant decrease in SNOT-22 scores (42-13, p < .001). CONCLUSIONS: Patients with CRS experience a significant improvement in voice characteristics and vocal quality of life following FESS. Furthermore, this appears to correlate with a significant decrease in self-reported disease severity. These findings may augment the discussion of potential benefits of FESS to a new potential domain for voice quality.

Prognostic factors and survival outcomes for head and neck cutaneous adnexal cancers.

OBJECTIVES: Malignant cutaneous adnexal tumors (MCAT) are rare and comprise a heterogeneous group of cancers. There have been several studies reviewing prognostic factors of these tumors, but no studies focusing on the head and neck. This study aimed to review a large population based database to evaluate prognostic factors that could impact survival. METHODS: The Surveillance, Epidemiology, and End Results (SEER) database was utilized to identify patients with MCAT of the head and neck. Both overall and disease specific survival were the main outcome measures for the study. Univariate and multivariate analyses were performed to evaluate the association of suspected prognostic factors with survival. RESULTS: The five-year OS and DSS were 72.6 and 95.5%, respectively. A favorable factor for OS was surgical resection ([HR] 0.324; P = 0.001), while unfavorable factors for OS include older age (1.051; P < 0.001), higher tumor grade (1.254; P = 0.049), larger tumor size (1.293; P = 0.003), and positive nodal involvement (3.323; P = 0.002). A favorable factor for DSS was surgical resection (0.026; P < 0.001). Unfavorable factors for DSS include older age (1.058; P = 0.046), larger tumor size (2.528; 1.565-4.085; P < 0.001), and positive nodal involvement (4.761; P = 0.022). CONCLUSION: Review of the SEER database shows good 5-year OS and DSS rates, similar to those cited in other studies. We identified several prognostic factors associated with survival, while histologic sub-type does not seem to be associated with survival. Surgical resection is the mainstay of treatment.