Postoperative pain after parotid surgery-comparison between superficial/total parotidectomy and extracapsular dissection: a prospective observational study.

PURPOSE: To evaluate postoperative pain and discomfort after parotid surgery with regard to different surgical approaches. METHODS: This clinical study was carried out at a single tertiary referral center (2021-2022) and included 2 groups of adult patients (mean age 56.6 ± 12.7 vs. 53.4 ± 14.1 years) following elective parotid surgery due to a parotid tumor of any entity. The first group (SP/TP group) consisted of 31 patients after superficial parotidectomy (SP) or total parotidectomy (TP) (n = 31). The second group (ECD group) included all patients who had undergone extracapsular dissection (ECD) (n = 51). Primary endpoints comprised pain on ambulation as well as maximum and minimum pain (NRS 0-10) on the first three postoperative days (PODs). A neuropathic pain component (evaluated on POD 1 and 3), the analgesic score (collected from the patient file on POD 1-3), treatment-related side-effects/pain-associated impairments, and patient satisfaction (all measured on the 1st POD) were defined as secondary endpoints. Patients were surveyed using the standardized and validated "Quality Improvement in Postoperative Pain Treatment" (QUIPS) questionnaire and the painDETECT® questionnaire. Comparisons were performed using independent t tests, Wilcoxon tests, and χ2 tests, and the respective effect sizes were calculated. RESULTS: Looking at the first postoperative day, patients of both groups (SP/TP vs. ECD) reported comparable pain on ambulation (2.8 ± 2.0 vs. 2.6 ± 1.8; p = 0.628, r = 0.063), maximum (3.5 ± 2.2 vs. 3.5 ± 2.3; p = 0.992, r = 0.002) and minimum pain (1.1 ± 1.04 vs. 1.0 ± 1.2; p = 0.206, r = 0.157). Furthermore, there were no significant differences in pain-related restrictions or pain medication requirement. The patients in both groups were equally satisfied with their pain therapy (p = 0.282, R = 0.135). The sum score of the painDETECT® questionnaire delivered clearly negative (< 12) results on average (POD1: 6.81; POD3: 6.59); no significant difference between the groups was found (p = 0.991, R2 < .001). CONCLUSION: Neither surgical technique on the parotid gland was significantly superior to the other in terms of postoperative pain perception. Overall, postoperative pain can be classified as mild to moderate following parotid surgery. A neuropathic pain component could be excluded for the acute postoperative phase. TRIAL REGISTRATION: The study was registered in the German Registry for Clinical Studies (DRKS) (application No.: DRKS00016520).

Impact of Cancer Localization on Symptom Burden and Quality of Life in Head and Neck Cancers: A Comparative Study.

Background: Head and neck cancer (HNC) is a critical concern in oncology, with notable disparities in survival rates. While the long-term symptom burden in HNC survivors and its impact on quality of life (QoL) has been explored, there is limited understanding of the influence of cancer localizations on these aspects. This study aims to elucidate the role of cancer localizations in shaping long-term outcomes in HNC patients. Methods: A cross-sectional study was conducted at the University Hospital Erlangen's Department of Otolaryngology, exploring the impact of cancer localization on symptom burden and QoL in 138 HNC patients using the University of Washington Quality of Life Questionnaire Version 4. Results: In our study of HNC patients, we investigated symptom burden across different cancer localizations, including oral cavity, oropharyngeal, hypopharyngeal, laryngeal, and cancer of unknown primary (CUP). While we found no significant variations in parameters such as pain, appearance, and activity, notable differences emerged in swallowing, speech, and salivation. Patients with oral cavity and laryngeal carcinomas had significantly higher swallowing and salivation scores compared to those with oropharyngeal carcinoma and CUP, while speech-related symptoms were lower for oral cavity and laryngeal carcinoma patients. Importantly, these symptom differences did not significantly impact health-related and overall QoL. These findings emphasize the nuanced interplay between symptomatology and QoL in different HNC cancer localizations. Conclusion: The research highlights significant disparities in post-treatment symptoms across different HNC localizations and underscores the need for personalized treatment and management strategies to address unique challenges associated with each HNC type, ultimately aiming to enhance post-treatment QoL.

Postoperative Pain Following Eye Enucleation: A Prospective Observational Study.

Background and Objectives: Enucleation of an eye is the most invasive procedure in ophthalmologic surgery. It can be the result of various diseases (malignant/chronic/trauma/infection) and is nevertheless relatively rare, but leads to the loss of a strongly innervated neuronal organ. This study systematically evaluates postoperative pain levels following enucleation of the eye globe. Materials and Methods: This prospective single-center study enrolled twenty-four patients undergoing enucleation of the eye globe. Perioperatively all patients completed (preoperative day, day of surgery, 1st, 2nd, and 3rd day following surgery) standardized questionnaires concerning their pain experience and treatment-related side-effects (internal protocol, QUIPS, painDETECT®). Patients received usual pain therapy in an unstandardized individual manner. Results: Preoperatively, mean average pain intensity of all included patients was 3.29 ± 2.46 (range, 0-8), 3.29 ± 3.24 (range, 0-8) on the day of surgery, 4.67 ± 1.90 (range, 2-10) on day 1, 3.25 ± 1.39 (range, 1-6) on day 2, and 2.71 ± 1.30 (range, 1-6) on day 3 after surgery. Mean maximum pain intensity was 4.71 ± 3.28 (range, 0-10) preoperatively, 4.04 ± 3.78 (range, 0-10) on the day of surgery, 5.75 ± 2.01 (range, 2-10) on day 1, 4.25 ± 1.89 (range, 2-10) on day 2, and 3.88 ± 1.54 (range, 2-8) on day 3 after surgery. Nineteen patients (79.2%) stated that they would have preferred more pain therapy. Conclusions: Patients undergoing eye enucleation report pain sensations in need of intervention in this university hospital. Thus, effective standardized pain treatment concepts are now a high priority to be established in an interdisciplinary manner containing standardized regimens and continuous regional procedures. Awareness of this problem in the medical team should be sharpened through targeted training and information.

Analgesia after tonsillectomy with controlled intravenous morphine - overdue or exaggerated?

OBJECTIVE: To assess the value of a morphine Patient Controlled Intravenous Analgesia (PCIA) after Tonsillectomies (TE). METHODS: 30 adult patients were treated with oral analgesics (protocol group) and compared to 30 patients treated with a morphine PCIA for the first 3 Postoperative Days (PODs) after TE. Average and maximum pain severities (Numeric Rating Scale - NRS: 0-10) on PODs 1-3, analgesic score, quality of life, patient satisfaction and side effects were defined as outcome measures. RESULTS: Average pain severities of the protocol and the PCIA group were of similar magnitude (NRS) (POD1: 4.48 vs. 4.71 [p = 0.68], POD2: 4.75 vs. 4.22 [p = 0.32] and POD3: 4.44 vs. 4.25 [p = 0.71]). Maximum pain intensities on POD1 (p = 0.92), POD2 (p = 0.51) and POD3 (p = 0.36) were also comparable between both groups. Patients with a PCIA consumed significantly more opioids (p = 0.001) without significant more side-effects. CONCLUSION: The PCIA did not provide a superior pain control compared to oral analgesics. In view of the considerable effort and the high opioid consumption, it cannot be recommended as a standardized application for pain control after TE.

Analgesia after tonsillectomy with controlled intravenous morphine - overdue or exaggerated?

Abstract Objective: To assess the value of a morphine Patient Controlled Intravenous Analgesia (PCIA) after Tonsillectomies (TE). Methods: 30 adult patients were treated with oral analgesics (protocol group) and compared to 30 patients treated with a morphine PCIA for the first 3 Postoperative Days (PODs) after TE. Average and maximum pain severities (Numeric Rating Scale - NRS: 0-10) on PODs 1-3, analgesic score, quality of life, patient satisfaction and side effects were defined as outcome measures. Results: Average pain severities of the protocol and the PCIA group were of similar magnitude (NRS) (POD1: 4.48 vs. 4.71 [p = 0.68], POD2: 4.75 vs. 4.22 [p = 0.32] and POD3: 4.44 vs. 4.25 [p = 0.71]). Maximum pain intensities on POD1 (p = 0.92), POD2 (p = 0.51) and POD3 (p = 0.36) were also comparable between both groups. Patients with a PCIA consumed significantly more opioids (p = 0.001) without significant more side-effects. Conclusion: The PCIA did not provide a superior pain control compared to oral analgesics. In view of the considerable effort and the high opioid consumption, it cannot be recommended as a standardized application for pain control after TE.

Pain management after tonsillectomy-by demand or by-the-clock-is there a difference?

PURPOSE: To improve pain management after tonsillectomy (TE) by comparing individual analgesic management by demand versus a fixed-scheduled analgesic treatment protocol in a prospective trial. PATIENTS AND METHODS: Forty consecutive patients received individual pain treatment by demand (control group) followed by 40 patients who were treated by a fixed-scheduled four-staged escalating analgesic protocol (intervention group) after TE. Minimum and maximum pain as well as pain on ambulation (NRS 0-10) on the first postoperative day were defined as primary objectives. Secondary endpoints comprised the analgesic score, treatment-related side effects/pain-associated impairments, wish for more pain medication, and patient satisfaction. Patients were surveyed using the standardized and validated "Quality Improvement in Postoperative Pain Treatment" (QUIPS) questionnaire. RESULTS: Patients of the control group reported comparable minimum (2.03 ± 1.42 vs 2.38 ± 1.79, P = 0.337, r = 0.110) and maximum pain (6.65 ± 2.10 vs 6.93 ± 1.86, P = 0.536, r = 0.07) and pain on ambulation (4.73 ± 2.26 vs 5.18 ± 2.19, P = 0.370, r = 0.10) compared to the intervention group. Patients in both groups were comparably well satisfied with the pain treatment (7.53 ± 2.40 vs 7.73 ± 2.30, P = 0.704, r = 0.04), experienced similar side effects and functional impairments (P > 0.050, Φ < 0.3), and did not ask for much more analgesic medication (P = 0.152, Φ = 0.160). CONCLUSION: Pain control following TE was not distinctly affected by applying a fixed-scheduled analgesic treatment protocol compared to individual analgesic therapy. In conclusion, analgesic treatment after TE remains unsatisfying. Consequently, further efforts are needed to achieve a standardized and effective approach to the underlying pathophysiological causes of pain following TE.

Factors Influencing the Outcome of Head and Neck Cancer of Unknown Primary (HNCUP).

Background: This study on patients with head and neck cancer of unknown primary (HNCUP) assesses the impact of surgical and non-surgical treatment modalities and the tumour biology on the oncological outcome. Methods: A total of 80 patients with HNCUP (UICC I−IV) were treated with simultaneous neck dissection followed by adjuvant therapy, between 1 January 2007 and 31 March 2020. As the primary objective, the influence of treatment modalities on the overall survival (OS), the disease-specific survival (DSS) and the progression-free survival (PFS) were analysed in terms of cox regression and recursive partitioning. The tumour biology served as secondary objectives. Results: The 5-year OS for the entire cohort was 67.7%, (95% CI: 54.2−81.2%), the 5-year DSS was 82.3% (72.1−92.5%) and the 5-year PFS was 72.8% (61.8−83.8%). Cox regression revealed that patients undergoing adjuvant radiotherapy only had a four times higher risk to die compared to patients receiving chemoradiation therapy (HR = 4.45 (1.40; 14.17), p = 0.012). The development of distant metastases had a significantly negative impact on OS (HR = 8.24 (3.21−21.15), p < 0.001) and DSS (HR = 23.79 (6.32−89.56), p < 0.001). Recursive portioning underlined the negative influence of distant metastases on OS (3.2-fold increase in death probability) and DSS (4.3-fold increase in death probability), while an UICC stage of IVb increased the risk for further progression of the disease by a factor of 2. Conclusions: The presence of distant metastases as well as adjuvant treatment with radiation without concomitant chemotherapy, were among others, significant predictors for the overall survival of HNCUP patients, with distant metastases being the most significant predictor.

Advance directives in patients with head and neck cancer - status quo and factors influencing their creation.

BACKGROUND: Advance Care Planning including living wills and durable powers of attorney for healthcare is a highly relevant topic aiming to increase patient autonomy and reduce medical overtreatment. Data from patients with head and neck cancer (HNC) are not currently available. The main objective of this study was to survey the frequency of advance directives (AD) in patients with head and neck cancer. METHODS: In this single center cross-sectional study, we evaluated patients during their regular follow-up consultations at Germany's largest tertiary referral center for head and neck cancer, regarding the frequency, characteristics, and influencing factors for the creation of advance directives using a questionnaire tailored to our cohort. The advance directives included living wills, durable powers of attorney for healthcare, and combined directives. RESULTS: Four hundred and forty-six patients were surveyed from 07/01/2019 to 12/31/2019 (response rate = 68.9%). The mean age was 62.4 years (SD 11.9), 26.9% were women (n = 120). 46.4% of patients (n = 207) reported having authored at least one advance directive. These documents included 16 durable powers of attorney for healthcare (3.6%), 75 living wills (16.8%), and 116 combined directives (26.0%). In multivariate regression analysis, older age (OR ≤ 0.396, 95% CI 0.181-0.868; p = 0.021), regular medication (OR = 1.896, 95% CI 1.029-3.494; p = 0.040), and the marital status ("married": OR = 2.574, 95% CI 1.142-5.802; p = 0.023; and "permanent partnership": OR = 6.900, 95% CI 1.312-36.295; p = 0.023) emerged as significant factors increasing the likelihood of having an advance directive. In contrast, the stage of disease, the therapeutic regimen, the ECOG status, and the time from initial diagnosis did not correlate with the presence of any type of advance directive. Ninety-one patients (44%) with advance directives created their documents before the initial diagnoses of head and neck cancer. Most patients who decide to draw up an advance directive make the decision themselves or are motivated to do so by their immediate environment. Only 7% of patients (n = 16) actively made a conscious decision not create an advance directive. CONCLUSION: Less than half of head and neck cancer patients had created an advance directive, and very few patients have made a conscious decision not to do so. Older and comorbid patients who were married or in a permanent partnership had a higher likelihood of having an appropriate document. Advance directives are an essential component in enhancing patient autonomy and allow patients to be treated according to their wishes even when they are unable to consent. Therefore, maximum efforts are advocated to increase the prevalence of advance directives, especially in head and neck cancer patients, whose disease often takes a crisis-like course.

Postoperative Pain Treatment With Continuous Local Anesthetic Wound Infusion in Patients With Head and Neck Cancer: A Nonrandomized Clinical Trial.

Importance: Up to 80% of patients with head and neck cancer undergoing ablative surgery and neck dissection develop postoperative pain with detrimental effects on quality of life that also contributes to neuropathic and chronic postoperative pain. Objective: To investigate the association of continuous local anesthetic wound infusion with pain management after head and neck surgery. Design, Setting, and Participants: This prospective, longitudinal, nonrandomized clinical study carried out in a single tertiary referral center (December 1, 2015, to July 1, 2017) included 2 groups of 30 patients. Patients were consecutively enrolled and presented for ablative head and neck surgery including selective neck dissection and studied from the preoperative through the fourth postoperative day. Interventions: The control group was treated according to a standardized escalating oral treatment protocol (ibuprofen, metamizole, opioids). The intervention group was treated with an intraoperatively applied pain catheter (InfiltraLong plus FuserPump, Pajunk, ropivacaine, 0.2%, 3 mL/h) that was removed 72 hours after operating. Main Outcomes and Measures: Average and maximum pain intensities on a numeric rating scale; quality of life using the acute version of the validated 36-Item Short Form Survey; and neuropathic pain using the validated 12-Item painDETECT questionnaire. Consumption of opioid and nonopioid analgesics and evaluation of catheter-associated complications. Results: During postoperative days 1 through 4, patients of the intervention group (mean [SD] age, 63.2 [13.3 years; 9 [30%] women) experienced lower mean (SD) (1.6 [1.4] vs 2.7 [1.8]; η2p = 0.09 [0.01-0.21]) and maximum (2.4 [2.2] vs 4.2 [2.0]; η2p = 0.11 [0.01-0.24]) pain intensities compared with the control group (mean [SD] age, 62.5 [13.6] years; 5 [17%] women). The intervention group also reported less neuropathic pain (mean [SD], 5.4 [3.4] vs 7.6 [5.1]; η2p = 0.09 [0.004 - 0.22]) and higher quality of life regarding vitality (56.2 [21.5] vs 43.8 [20.9], r = 0.29; 95% CI, 0.01-0.52) and pain (66.8 [27.3] vs 49.5 [27.7], r = 0.31; 95% CI, 0.04-0.54). Patients from the intervention group requested nonopioid analgesics considerably less often (n = 17 [57% ]vs n = 29 [97%]; ϕ = 0.47; 95% CI, 0.30-0.67) associated with a noticeably lower need to escalate pain treatment (n = 3 [10%] vs n = 9 [30%]; mean [SD] ibuprofen dose: 500 [173] mg vs 1133 [650] mg; r = 0.64; 95% CI, 0.02-0.91). No catheter-associated complications were observed. Conclusions and Relevance: Continuous anesthetic wound infusion is associated with reduced postoperative pain and decreased demand for analgesics. It therefore expands the treatment options for postoperative pain in head and neck cancer. Trial Registration: German Clinical Trials Register: DRKS00009378.

Patient-reported outcome measures in external and endonasal functional septorhinoplasty - A propensity score matching study.

PURPOSE: Patient satisfaction after functional-aesthetic SRP (faSRP) is highly influenced by the cosmetic result of the surgical procedure. Studies that directly evaluate aesthetic success after external and endonasal faSRP are scarce. The objective of this prospective propensity score matching study was to compare patient-reported satisfaction regarding aesthetic perception following faSRP using the external and endonasal approach in a single-institution single-surgeon survey. MATERIALS AND METHODS: Out of 161 patients operated by the senior author between October 2011 and March 2017, propensity score matching (PSM) computed 54 patients each following external (group 1) or endonasal faSRP (group 2). Patients reported their satisfaction with the aesthetic appearance of the nose on a visual analogue scale (VAS, 0-10) and five Likert scale questions using the Utrecht questionnaire three and twelve months after surgery. RESULTS: The mean preoperative VAS score of 3.46 ± 1.06 improved significantly in all patients after faSRP to 4.54 ± 0.38 (F(1.69;157.04) = 634.01, p < 0.001). The VAS increase did not show any correlation to the surgical approach (F(1;93) = 1.12, p = 0.293). The mean aesthetic sum score (5 = low burden up to 25 = high burden) improved significantly from 13.89 ± 3.78 to 8.46 ± 3.63 after three months (t(95) = 14.021, p < 0.001) and remained almost unchanged after 12 months (8.10 ± 3.76; t(98) = 1.450, p = 0.150) irrespective of the surgical approach (F(1,544;143,587) = 0.126, p = 0.829). CONCLUSIONS: Both the external and endonasal faSRP allowed for significant improvement in patient's aesthetic self-assessment of similar extent.

Postoperative pain after tonsillectomy - the value of standardized analgesic treatment protocols.

OBJECTIVE: To alleviate pain after tonsillectomy (TE) with escalating gradual treatment protocols in a prospective trial. MATERIALS & METHODS: Following TE, 83 consecutive adult patients were treated with two different four-staged escalating analgesic protocols. Metamizole served as basic medication in protocol 1 (PT1; n = 44), whereas with protocol 2 (PT2; n = 39) ibuprofen was applied as baseline analgesic. Both protocols were escalated according to the patient´s needs to metamizole and ibuprofen vice versa and additional weak to strong opioids. The primary efficacy endpoint was defined as the minimum and maximum pain as well as pain on ambulation (NRS, 0-10). Secondary endpoints comprised analgesic score, patient satisfaction and treatment-related side-effects. RESULTS: Both patient groups exhibited similar demographic characteristics (PT1: Ø 28.8 years; 64% ♀ and PT2: Ø 26.6 years; 56% ♀). Maximum pain (6.7 ±â€¯1.9 vs. 7.6 ±â€¯1.6, t(81) = -2.254, p = 0.027) and pain on ambulation (5.0 ±â€¯1.8 vs. 5.8 ±â€¯1.8, t(81) = -2.114, p = 0.038) were significantly higher with PT2. 68.2% of patients with PT1 needed an escalation of analgesic treatment compared to 100% with PT2 (p < 0.001). The opioid consumption was also significantly higher with PT2 (43.2% vs. 71.8%, p < 0.001). There were no significant differences regarding functional impairments, side-effects and patient satisfaction (7.0 ±â€¯2.0 vs. 7.4 ±â€¯2.4, t(79) = -0.897, p = 0.373). CONCLUSION: Both treatment protocols yielded in a high degree of patient satisfaction but dissatisfactory pain relief following TE. Metamizole can be recommended as a basic medication allowing for improved pain relief. Reported pain intensities were independent of the amount of opioid intake. Further research is mandatory to standardize and improve analgesic treatment after TE.

Pain after External and Endonasal Septorhinoplasty-A Propensity Score Matching Analysis.

Guidelines for pain management following septorhinoplasty are lacking, leading to a wide range of therapy regimes even including opioid medication. Thus, the presented study strived to investigate and compare postoperative pain intensities after external and endonasal septorhinoplasty and evaluate whether pain perception is potentially related to patient satisfaction with the aesthetic result. In addition, the effectiveness of an escalating pain treatment protocol was evaluated sparing the necessity of opioid medication. This retrospective study performed at a tertiary referral medical center includes two well-balanced groups of 54 patients each created by propensity score matching out of a total of 161 patients following external or endonasal functional septorhinoplasty performed by a single surgeon between October 1, 2011 and March 31, 2017. Pain intensity was assessed using the visual analogue scale (0-10) on the first three postoperative days (PODs) alongside with the evaluation of the analgesic score. Patients' self-reported outcome was measured with the Utrecht questionnaire, preoperatively, and 3 and 12 months, postoperatively. Postoperative mean pain sensations were similarly high following the external and endonasal approach (F (2;190) = 2.166, p = 0.118) followed by a linear decrease over the first three PODs (F (2;190) = 16.84, p < 0.001). Pain sensations were not related to the duration of surgery, gender, patients' age, revision surgery, and the preoperative and postoperative assessment of the nasal appearance. The consumption of metamizole (F (1,76;172,15) = 2.83, p = 0.065) and ibuprofen (F (2;196) = 1.037, p = 0.356) were similarly high regardless of the surgical approach. Accordingly, both the endonasal and the external approaches led to comparable postoperative pain intensities and analgesic scores. Pain was treated effectively using a standardized escalating pain treatment protocol sparing the administration of opioids. Pain was not related to patient satisfaction with the nasal appearance pre- and postsurgery.

Postoperative pain following Descemet membrane endothelial keratoplasty (DMEK): a prospective study.

PURPOSE: To evaluate postoperative pain following Descemet membrane endothelial keratoplasty (DMEK). METHODS: Seventy-one patients completed perioperatively (day before surgery, day of surgery, 1st, 2nd, and 3rd day after surgery) four different questionnaires (a hospital internal protocol, QUIPS, PainDETECT®, and SF36) regarding their pain and other clinical parameters such as constipation, tiredness, vertigo, sleep disorders, concentration disorders, nausea, and emesis. All standardised questionnaires were evaluated to quantify average pain intensity as well as maximum pain intensity (NRS, 0 [no pain] to 10 [maximal pain], respectively). Analgesic treatment and intraocular pressure (IOP) during the perioperative stay were documented. RESULTS: Mean average pain intensity was 0.70 ± 1.64 before surgery, 1.97 ± 2.05 on the day of surgery, 1.39 ± 1.68 on day 1, 0.87 ± 1.36 on day 2, and 0.81 ± 1.24 on day 3 after surgery. Maximum pain intensity was 0.65 ± 1.81 before surgery, 3.35 ± 2.98 on the day of surgery, 2.68 ± 2.99 on day 1, 1.49 ± 2.15 on day 2, and 1.26 ± 2.02 on day 3 after surgery. During the first three postoperative days, over 90% of the patients stated no or well tolerable pain. Eighty-three percent had postoperatively no need for analgesics at all. On the first two postoperative days, maximum IOP correlated significantly with reported increased maximum pain intensity (p = 0.043 and p = 0.029, respectively). All patients had very little problems with constipation, tiredness, vertigo, sleep disorder, concentration disorders, nausea, and emesis. CONCLUSIONS: DMEK is associated with low postoperative pain intensity. Strong pain increase may indicate IOP elevation and should be further investigated and treated. CLINICAL TRIAL REGISTRATION: German Clinical Trial Register (DRKS00013995).