Basics of acute and chronic pain medicine for the Otolaryngologist (ENT)

Basics of Acute and Chronic Pain Medicine for the Otolaryngologist Yury Khelemsky, MD Assistant Professor Anesthesiology and Interventional Pain Medicine The Mount Sinai Medical Center

Introduction
“ an unpleasant sensory and emotional experience associated with actual or potential tissue damage.”
Acute vs. Chronic
Nociceptive vs. Non-nociceptive
New – Rapidly Evolving Field – Boards 1993, new standardized ACGME requirements 2007.

Acute Pain
Continues to be undermanaged
Most common concern of surgical patients
Majority experience at least moderate levels of postoperative pain

Benefits of Effective Postoperative Analgesia
Reduced hospital costs
Reduced LOS
Earlier mobilization
Reduced postop morbidity
Possibly decreases risk of development of chronic pain syndromes (persistent postoperative pain)
Increased patient satisfaction – critical for hospital reimbursement

Patient Satisfaction
Does not directly correlate to pain intensity (raw VAS)
Strongly linked to:
Staff responsiveness to complaint
PCA over nurse bolus
Involvement of a dedicated acute pain medicine service

Mechanism of Postoperative Pain
Starts with direct nerve and tissue trauma
Release of inflammatory mediators leads to hyperalgesia or allodynia
Nociceptive input to spinal cord leads to “wind up” phenomenon.

Multimodal Analgesia Multimodal analgesia: combination of pain medications that act on different receptors at various points in pain transmission.

Preemptive Analgesia
Drug administered prior to tissue injury
speculated that alters peripheral and central nervous system processing of noxious stimuli that leading to a reduction of both hyperalgesia and allodynia

Preemptive Analgesia: Local
Preincisional local prior to pediatric tonsillectomy – decreased analgesic consumption, more rapid return to activity
Addition of clonidine to local anesthetic prolongs analgesic effect

Preemptive Analgesia: Systemic
Dexamethasone
NSAIDS – may use Cox-2 selective agents (celecoxib, meloxicam) if concerned about bleeding
Acetaminophen
Gabapentin and Pregabalin
Clonidine
Take home point: Administering certain medications before surgery may decrease postoperative pain: not just by exerting a direct analgesic effect, but by decreasing peripheral and central sensitization.

Perioperative Regional Anesthesia
Infraorbital Nerve Block: effective for maxillary sinus surgery
Mandibular nerve blocks for mandibular osteotomy
Inferior alveolar nerve block: may use in conjunction with superficial cervical block for carotid endarterectomy in which high carotid bifurcations necessitate cranial retraction

Perioperative Regional Anesthesia
The auricular branch of the vagus nerve: infiltration of anesthetic posterior to the tragus and can be useful for myringotomy and tympanostomy procedures
Superficial cervical plexus (ventral rami of C1-C4): otoplasty, cochlear implant, tympanomastoid surgery, and carotid endarterectomy, parathyroid, and thyroid surgery

Perioperative Analgesics Opioids
- development of addiction is extremely unlikely during treatment of acute pain
Morphine – histamine release, caution in reactive airway disease and cardiovascular disease. M-6-G active metabolite, may accumulate in renal failure
Meperidine (Demerol) should be avoided due to CNS toxic metabolite
Use IV PCA (no basal) routinely over nurse administered boluses – anyone can order basic IV PCAs
Methadone is a NMDA Antagonist (in addition to opioid receptor agonist): excellent for opioid tolerant patients, pain with neuropathic features. Check QTc (Torsades)

Perioperative Analgesics Opioids Opioid IV equianalgesic dose to morphine 10mg IV (mg) Fentanyl 0.1-0.2 Methadone 5-10 Morphine Hydromorphone 2 Sufentanyl 0.01 Remifentanyl 0.05-0.1

Perioperative Analgesics
Ketorolac (Toradol): only IV NSAID. 30 mg IV is equianalgesic to morphine 10mg IV. Potential for bleeding in ENT/plastics, esp. with postop thromboprophylaxis.
COX-2 inhibitors may be preferable (celecoxib)
Acetaminophen IV: just FDA approved, will be on formulary this year.
Ketamine – very low dose infusions
Lidocaine – IV infusions

Perioperative PO Analgesics
Acetaminophen – use standing doses. Use in combination with NSAIDS and/or opioids
If bleeding concern – use Celebrex (celecoxib)
Tramadol – weak opioid agonist and SNRI, less n/v, not a controlled substance
Tapentadol (Nucynta) – opioid agonist and NRI. As effective as oxycodone, much less N/V.

Chronic Pain Management
Pain longer than 3 (to 6) months
WHO Ladder: validated in cancer pain

Chronic Opioid Therapy
Chronic opioids in low back pain did not result in significant decrease of pain scores
Higher risk of addiction in non-cancer pain
Aberrant drug behaviors in up to 25% of pts
#1 cause of accidental death 35-54 year olds (#2 of 25-34, 55-65 year olds) – more than car accidents
In addition to addiction and overdose - hypogonadism, decreased immune function, disruption of sleep patterns, and, paradoxically, opioid-induced hyperalgesia

Chronic Opioid Therapy
Decision to begin long term opioids must be weighed carefully.
Monitor for aberrant behavior, side effects, and efficacy
Opioid agreements, Urine drug testing, functional assessments
Avoid combination with benzodiazepines (synergistic) – no role in pain medicine
Try to avoid short acting/high value street value drugs: example oxycontin is $1/mg – a year’s supply of 80mg TID is worth almost 90k on the street

Craniofacial Pain
Central Facial Pain (5 Causes)
Peripheral Facial Pain (Neuralgias)
Head and Neck Cancer Pain
Headache
Neck Pain

Central Facial Pain International Classification of Headache Disorders
1. Anesthesia dolorosa
presents as painful anesthesia or hyperesthesia in the distribution of the occipital or trigeminal nerves.
most frequent cause is iatrogenic, occurring after rhizotomy or thermocoagulation performed to treat trigeminal neuralgia
Either TCAs or gabapentinoids can be helpful in its treatment

2. Central Post-Stroke Pain
unilateral dysesthesia and altered sensation that is not attributable to trigeminal nerve pathology.
etiology is a lesion of the trigeminothalamic pathway, thalamus, or thalamocortical projection.
TCAs first line, Gabapentin

3. Multiple Sclerosis
may result in severe unilateral or bilateral facial pain that is attributed to a demyelinating lesion of the central connections of the trigeminal nerve
Carbamazepine is the drug of choice; however, evidence for its use is weak

4. Persistent Idiopathic Facial Pain
not attributed to another disorder and is a diagnosis of exclusion.
Either TCAs or topiramate may be considered for management

5. Burning Mouth Syndrome
oral burning sensation without an identifiable pathology.
all potential medical or dental causes of mouth pain must be ruled out before establishing this diagnosis.
TCAs, clonazepam, gabapentin, and cognitive behavioral therapy may be employed in its treatment

Central Craniofacial Pain Interventional Therapy
Transcutaneous electric nerve stimulation
Gasserian ganglion stimulation have been used with some success for the treatment of central craniofacial pain
Deep brain stimulation and other surgical therapies are used as last resorts in patients with severe disability and failure of other treatments

Neuralgias Glossopharyngeal Neuralgia
Paroxysmal, severe, stabbing pain affecting the tonsillar fossa, ear, tongue, or the angle of the jaw
Triggers: chewing, touch, swallowing, coughing, speaking, or yawning
Secondary causes: demyelinating lesions, cerebellopontine angle tumor, peritonsillar abscess, carotid aneurysm, and Eagle syndrome (lateral compression of CN against an ossified stylohyoid ligament
Vascular compression of CN IX and X can occur at the nerve root entry by the vertebral artery or posterior inferior cerebellar artery.
MRI and plain films

Neuralgias Trigeminal Neuralgia
trigeminal neuralgia (TN) tends to occur in paroxysms and is maximal at or near onset
described as "electric shock-like" or "stabbing."
many cases are caused by vascular compression of the trigeminal nerve proximally to its exit from the brain stem
PHN – pain after zoster outbreak. Vaccine, antivirals, prophylaxis with TCAs .
Up to 5% of patients with multiple sclerosis will develop TN
carbamazepine is the drug of choice
Oxycarbazepine can be used if carbamazepine is not well tolerated
Baclofen
Gabapentin and Pregabalin?

Neuralgias Trigeminal Neuralgia: Interventional Treatments
Blockade of the mandibular nerve with alcohol
Sphenopalatine ganglion (SPG) block
Percutaneous, controlled radiofrequency trigeminal rhizotomy (RF-TR)
microvascular decompression and gamma knife radiosurgery

Cancer Pain
>50% of patients with head and neck cancer experience significant pain with approximately 10% experiencing severe pain
Pain in patients who have cancer may be due to direct effects of the tumor (i.e. invasion of bone, compression of nerves, etc.), by complications of therapy (i.e. radiation fibrosis, chemotherapy-induced neuropathy, etc.), or it can be unrelated to the disease or its treatment

Cancer Pain
Pain in 1 st year of treatment is independently associated with recurrence and survival
1/3 of head and neck cancer patients have a mood disorder in the first year of treatment. Use of prophylactic antidepressants has been advocated in this population.
Medication management – WHO Ladder
Interventions: Blockade of the mandibular nerve (with and without an indwelling catheter), Sphenopalatine (pterygopalatine) ganglion (and maxillary nerve), trigeminal ganglion, glossopharyngeal nerve, and the occipital nerve (and neurolysis of these structures)
Intrathecal infusion of local anesthetic and/or opioid

Sinus Headache
Sinusitis - uncommon cause of chronic headaches
Many patients initially diagnosed with sinus headache actually suffer from migraine
True acute sinus headache occurs in conjunction with acute sinusitis, fever, and purulent discharge
usually presents as a pressure-like or dull bilateral periorbital sensation - associated with nasal congestion
Unilateral pain: patients with middle or inferior turbinate hypertrophy, deviated septum, or unilateral sinus disease
nausea, photophobia, or hearing sensitivity unusual
Severity or location of mucosal disease on imaging studies does not correlate with sinus related pain

Sinus Headache
2005 multidisciplinary guidelines were published to assist in differentiation of migraine and sinus headache:
a stable pattern of recurrent headaches that interfere with daily function is most likely migraine
recurrent self-limited headaches associated with rhinogenic symptoms are most likely migraine
prominent rhinogenic symptoms with headache as one of several symptoms should be evaluated carefully for otolaryngologic conditions (nasal endoscopy preferred or alternatively with magnetic resonance imaging (MRI) or CT
headache associated with fever and purulent nasal discharge is likely rhinogenic in origin

Sinus Headache
referral to a headache specialist:
new-onset headache, frequent (more than once a week) headache, headache associated with neurologic symptoms or signs, or headache that does not respond adequately to conventional therapy
patients with migraine with no evidence of infection should be given a trial of migraine-specific medication and seen for a follow-up evaluation
patients with noninfectious rhinogenic symptoms who have headache as a minor symptom should be given nasal glucocorticoids and/or selective nasal antihistamines

References
Khelemsky Y. Acute and Chronic Pain Management. In: Levine, Govindaraj, and Demaria, eds. Anesthesiology and Otolaryngology. New York, NY: Springer 2011, p. TBD.

Basics of acute and chronic pain medicine for the Otolaryngologist (ENT)

by yury on Feb 22, 2011

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Basics of acute and chronic pain medicine for the Otolaryngologist (ENT) Presentation Transcript