Basics of Acute and Chronic Pain Medicine for the Otolaryngologist Yury Khelemsky, MD Assistant Professor Anesthesiology a...
Introduction <ul><li>“ an unpleasant sensory and emotional  experience  associated with actual or potential tissue damage....
Acute Pain <ul><li>Continues to be undermanaged </li></ul><ul><li>Most common concern of surgical patients </li></ul><ul><...
Benefits of Effective Postoperative Analgesia <ul><li>Reduced hospital costs </li></ul><ul><li>Reduced LOS </li></ul><ul><...
Patient Satisfaction <ul><li>Does not directly correlate to pain intensity (raw VAS) </li></ul><ul><li>Strongly linked to:...
Mechanism of Postoperative Pain <ul><li>Starts with direct nerve and tissue trauma </li></ul><ul><li>Release of inflammato...
Multimodal Analgesia Multimodal analgesia:  combination of pain medications that act on different receptors at various poi...
Preemptive Analgesia <ul><li>Drug administered prior to tissue injury  </li></ul><ul><li>speculated that alters peripheral...
Preemptive Analgesia: Local <ul><li>Preincisional local prior to pediatric tonsillectomy – decreased analgesic consumption...
Preemptive Analgesia: Systemic <ul><li>Dexamethasone </li></ul><ul><li>NSAIDS – may use Cox-2 selective agents (celecoxib,...
Perioperative Regional Anesthesia <ul><li>Infraorbital Nerve  Block: effective for maxillary sinus surgery </li></ul><ul><...
Perioperative Regional Anesthesia <ul><li>The  auricular branch  of the vagus nerve: infiltration of anesthetic posterior ...
Perioperative Analgesics Opioids <ul><li>-  development of addiction is extremely unlikely during treatment of acute pain ...
Perioperative Analgesics Opioids Opioid IV equianalgesic dose to  morphine 10mg IV  (mg) Fentanyl 0.1-0.2 Methadone 5-10 M...
Perioperative Analgesics <ul><li>Ketorolac (Toradol): only IV NSAID. 30 mg IV is equianalgesic to morphine 10mg IV. Potent...
Perioperative PO Analgesics <ul><li>Acetaminophen – use standing doses. Use in combination with NSAIDS and/or opioids  </l...
Chronic Pain Management <ul><li>Pain longer than 3 (to 6) months </li></ul><ul><li>WHO Ladder: validated in cancer pain </...
Chronic Opioid Therapy <ul><li>Chronic opioids in low back pain did not result in significant decrease of pain scores </li...
Chronic Opioid Therapy <ul><li>Decision to begin long term opioids must be weighed carefully.  </li></ul><ul><li>Monitor f...
Craniofacial Pain <ul><li>Central Facial Pain (5 Causes) </li></ul><ul><li>Peripheral Facial Pain (Neuralgias) </li></ul><...
Central Facial Pain International Classification of Headache Disorders <ul><li>1. Anesthesia dolorosa   </li></ul><ul><li>...
Central Facial Pain International Classification of Headache Disorders <ul><li>2. Central Post-Stroke Pain   </li></ul><ul...
Central Facial Pain International Classification of Headache Disorders <ul><li>3. Multiple Sclerosis   </li></ul><ul><li>m...
Central Facial Pain International Classification of Headache Disorders <ul><li>4. Persistent Idiopathic Facial Pain   </li...
Central Facial Pain International Classification of Headache Disorders <ul><li>5. Burning Mouth Syndrome </li></ul><ul><li...
Central Craniofacial Pain Interventional Therapy <ul><li>Transcutaneous electric nerve stimulation  </li></ul><ul><li>Gass...
Neuralgias Glossopharyngeal Neuralgia <ul><li>Paroxysmal, severe, stabbing pain affecting the tonsillar fossa, ear, tongue...
Neuralgias Trigeminal Neuralgia <ul><li>trigeminal neuralgia (TN) tends to occur in paroxysms and is maximal at or near on...
Neuralgias Trigeminal Neuralgia:  Interventional Treatments <ul><li>Blockade of the mandibular nerve with alcohol </li></u...
Cancer Pain <ul><li>>50% of patients with head and neck cancer experience significant pain with approximately 10% experien...
Cancer Pain <ul><li>Pain in 1 st  year of treatment is independently associated with recurrence and survival </li></ul><ul...
Sinus Headache <ul><li>Sinusitis - uncommon cause of chronic headaches </li></ul><ul><li>Many patients initially diagnosed...
Sinus Headache <ul><li>2005 multidisciplinary guidelines were published to assist in differentiation of migraine and sinus...
Sinus Headache <ul><li>referral to a headache specialist:  </li></ul><ul><li>new-onset headache, frequent (more than once ...
References <ul><li>Khelemsky Y. Acute and Chronic Pain Management. In: Levine, Govindaraj, and Demaria, eds.  Anesthesiolo...
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Basics of acute and chronic pain medicine for the Otolaryngologist (ENT)

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

  1. 1. 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
  2. 2. Introduction <ul><li>“ an unpleasant sensory and emotional experience associated with actual or potential tissue damage.” </li></ul><ul><li>Acute vs. Chronic </li></ul><ul><li>Nociceptive vs. Non-nociceptive </li></ul><ul><li>New – Rapidly Evolving Field – Boards 1993, new standardized ACGME requirements 2007. </li></ul>
  3. 3. Acute Pain <ul><li>Continues to be undermanaged </li></ul><ul><li>Most common concern of surgical patients </li></ul><ul><li>Majority experience at least moderate levels of postoperative pain </li></ul>
  4. 4. Benefits of Effective Postoperative Analgesia <ul><li>Reduced hospital costs </li></ul><ul><li>Reduced LOS </li></ul><ul><li>Earlier mobilization </li></ul><ul><li>Reduced postop morbidity </li></ul><ul><li>Possibly decreases risk of development of chronic pain syndromes (persistent postoperative pain) </li></ul><ul><li>Increased patient satisfaction – critical for hospital reimbursement </li></ul>
  5. 5. Patient Satisfaction <ul><li>Does not directly correlate to pain intensity (raw VAS) </li></ul><ul><li>Strongly linked to: </li></ul><ul><li>Staff responsiveness to complaint </li></ul><ul><li>PCA over nurse bolus </li></ul><ul><li>Involvement of a dedicated acute pain medicine service </li></ul>
  6. 6. Mechanism of Postoperative Pain <ul><li>Starts with direct nerve and tissue trauma </li></ul><ul><li>Release of inflammatory mediators leads to hyperalgesia or allodynia </li></ul><ul><li>Nociceptive input to spinal cord leads to “wind up” phenomenon. </li></ul>
  7. 7. Multimodal Analgesia Multimodal analgesia: combination of pain medications that act on different receptors at various points in pain transmission.
  8. 8. Preemptive Analgesia <ul><li>Drug administered prior to tissue injury </li></ul><ul><li>speculated that alters peripheral and central nervous system processing of noxious stimuli that leading to a reduction of both hyperalgesia and allodynia </li></ul>
  9. 9. Preemptive Analgesia: Local <ul><li>Preincisional local prior to pediatric tonsillectomy – decreased analgesic consumption, more rapid return to activity </li></ul><ul><li>Addition of clonidine to local anesthetic prolongs analgesic effect </li></ul>
  10. 10. Preemptive Analgesia: Systemic <ul><li>Dexamethasone </li></ul><ul><li>NSAIDS – may use Cox-2 selective agents (celecoxib, meloxicam) if concerned about bleeding </li></ul><ul><li>Acetaminophen </li></ul><ul><li>Gabapentin and Pregabalin </li></ul><ul><li>Clonidine </li></ul><ul><li>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. </li></ul>
  11. 11. Perioperative Regional Anesthesia <ul><li>Infraorbital Nerve Block: effective for maxillary sinus surgery </li></ul><ul><li>Mandibular nerve blocks for mandibular osteotomy </li></ul><ul><li>Inferior alveolar nerve block: may use in conjunction with superficial cervical block for carotid endarterectomy in which high carotid bifurcations necessitate cranial retraction </li></ul>
  12. 12. Perioperative Regional Anesthesia <ul><li>The auricular branch of the vagus nerve: infiltration of anesthetic posterior to the tragus and can be useful for myringotomy and tympanostomy procedures </li></ul><ul><li>Superficial cervical plexus (ventral rami of C1-C4): otoplasty, cochlear implant, tympanomastoid surgery, and carotid endarterectomy, parathyroid, and thyroid surgery </li></ul>
  13. 13. Perioperative Analgesics Opioids <ul><li>- development of addiction is extremely unlikely during treatment of acute pain </li></ul><ul><li>Morphine – histamine release, caution in reactive airway disease and cardiovascular disease. M-6-G active metabolite, may accumulate in renal failure </li></ul><ul><li>Meperidine (Demerol) should be avoided due to CNS toxic metabolite </li></ul><ul><li>Use IV PCA (no basal) routinely over nurse administered boluses – anyone can order basic IV PCAs </li></ul><ul><li>Methadone is a NMDA Antagonist (in addition to opioid receptor agonist): excellent for opioid tolerant patients, pain with neuropathic features. Check QTc (Torsades) </li></ul>
  14. 14. 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
  15. 15. Perioperative Analgesics <ul><li>Ketorolac (Toradol): only IV NSAID. 30 mg IV is equianalgesic to morphine 10mg IV. Potential for bleeding in ENT/plastics, esp. with postop thromboprophylaxis. </li></ul><ul><li>COX-2 inhibitors may be preferable (celecoxib) </li></ul><ul><li>Acetaminophen IV: just FDA approved, will be on formulary this year. </li></ul><ul><li>Ketamine – very low dose infusions </li></ul><ul><li>Lidocaine – IV infusions </li></ul>
  16. 16. Perioperative PO Analgesics <ul><li>Acetaminophen – use standing doses. Use in combination with NSAIDS and/or opioids </li></ul><ul><li>If bleeding concern – use Celebrex (celecoxib) </li></ul><ul><li>Tramadol – weak opioid agonist and SNRI, less n/v, not a controlled substance </li></ul><ul><li>Tapentadol (Nucynta) – opioid agonist and NRI. As effective as oxycodone, much less N/V. </li></ul>
  17. 17. Chronic Pain Management <ul><li>Pain longer than 3 (to 6) months </li></ul><ul><li>WHO Ladder: validated in cancer pain </li></ul>
  18. 18. Chronic Opioid Therapy <ul><li>Chronic opioids in low back pain did not result in significant decrease of pain scores </li></ul><ul><li>Higher risk of addiction in non-cancer pain </li></ul><ul><li>Aberrant drug behaviors in up to 25% of pts </li></ul><ul><li>#1 cause of accidental death 35-54 year olds (#2 of 25-34, 55-65 year olds) – more than car accidents </li></ul><ul><li>In addition to addiction and overdose - hypogonadism, decreased immune function, disruption of sleep patterns, and, paradoxically, opioid-induced hyperalgesia </li></ul>
  19. 19. Chronic Opioid Therapy <ul><li>Decision to begin long term opioids must be weighed carefully. </li></ul><ul><li>Monitor for aberrant behavior, side effects, and efficacy </li></ul><ul><li>Opioid agreements, Urine drug testing, functional assessments </li></ul><ul><li>Avoid combination with benzodiazepines (synergistic) – no role in pain medicine </li></ul><ul><li>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 </li></ul>
  20. 20. Craniofacial Pain <ul><li>Central Facial Pain (5 Causes) </li></ul><ul><li>Peripheral Facial Pain (Neuralgias) </li></ul><ul><li>Head and Neck Cancer Pain </li></ul><ul><li>Headache </li></ul><ul><li>Neck Pain </li></ul>
  21. 21. Central Facial Pain International Classification of Headache Disorders <ul><li>1. Anesthesia dolorosa </li></ul><ul><li>presents as painful anesthesia or hyperesthesia in the distribution of the occipital or trigeminal nerves. </li></ul><ul><li>most frequent cause is iatrogenic, occurring after rhizotomy or thermocoagulation performed to treat trigeminal neuralgia </li></ul><ul><li>Either TCAs or gabapentinoids can be helpful in its treatment </li></ul>
  22. 22. Central Facial Pain International Classification of Headache Disorders <ul><li>2. Central Post-Stroke Pain </li></ul><ul><li>unilateral dysesthesia and altered sensation that is not attributable to trigeminal nerve pathology. </li></ul><ul><li>etiology is a lesion of the trigeminothalamic pathway, thalamus, or thalamocortical projection. </li></ul><ul><li>TCAs first line, Gabapentin </li></ul>
  23. 23. Central Facial Pain International Classification of Headache Disorders <ul><li>3. Multiple Sclerosis </li></ul><ul><li>may result in severe unilateral or bilateral facial pain that is attributed to a demyelinating lesion of the central connections of the trigeminal nerve </li></ul><ul><li>Carbamazepine is the drug of choice; however, evidence for its use is weak </li></ul>
  24. 24. Central Facial Pain International Classification of Headache Disorders <ul><li>4. Persistent Idiopathic Facial Pain </li></ul><ul><li>not attributed to another disorder and is a diagnosis of exclusion. </li></ul><ul><li>Either TCAs or topiramate may be considered for management </li></ul>
  25. 25. Central Facial Pain International Classification of Headache Disorders <ul><li>5. Burning Mouth Syndrome </li></ul><ul><li>oral burning sensation without an identifiable pathology. </li></ul><ul><li>all potential medical or dental causes of mouth pain must be ruled out before establishing this diagnosis. </li></ul><ul><li>TCAs, clonazepam, gabapentin, and cognitive behavioral therapy may be employed in its treatment </li></ul>
  26. 26. Central Craniofacial Pain Interventional Therapy <ul><li>Transcutaneous electric nerve stimulation </li></ul><ul><li>Gasserian ganglion stimulation have been used with some success for the treatment of central craniofacial pain </li></ul><ul><li>Deep brain stimulation and other surgical therapies are used as last resorts in patients with severe disability and failure of other treatments </li></ul>
  27. 27. Neuralgias Glossopharyngeal Neuralgia <ul><li>Paroxysmal, severe, stabbing pain affecting the tonsillar fossa, ear, tongue, or the angle of the jaw </li></ul><ul><li>Triggers: chewing, touch, swallowing, coughing, speaking, or yawning </li></ul><ul><li>Secondary causes: demyelinating lesions, cerebellopontine angle tumor, peritonsillar abscess, carotid aneurysm, and Eagle syndrome (lateral compression of CN against an ossified stylohyoid ligament </li></ul><ul><li>Vascular compression of CN IX and X can occur at the nerve root entry by the vertebral artery or posterior inferior cerebellar artery. </li></ul><ul><li>MRI and plain films </li></ul>
  28. 28. Neuralgias Trigeminal Neuralgia <ul><li>trigeminal neuralgia (TN) tends to occur in paroxysms and is maximal at or near onset </li></ul><ul><li>described as &quot;electric shock-like&quot; or &quot;stabbing.&quot; </li></ul><ul><li>many cases are caused by vascular compression of the trigeminal nerve proximally to its exit from the brain stem </li></ul><ul><li>PHN – pain after zoster outbreak. Vaccine, antivirals, prophylaxis with TCAs . </li></ul><ul><li>Up to 5% of patients with multiple sclerosis will develop TN </li></ul><ul><li>carbamazepine is the drug of choice </li></ul><ul><li>Oxycarbazepine can be used if carbamazepine is not well tolerated </li></ul><ul><li>Baclofen </li></ul><ul><li>Gabapentin and Pregabalin? </li></ul>
  29. 29. Neuralgias Trigeminal Neuralgia: Interventional Treatments <ul><li>Blockade of the mandibular nerve with alcohol </li></ul><ul><li>Sphenopalatine ganglion (SPG) block </li></ul><ul><li>Percutaneous, controlled radiofrequency trigeminal rhizotomy (RF-TR) </li></ul><ul><li>microvascular decompression and gamma knife radiosurgery </li></ul>
  30. 30. Cancer Pain <ul><li>>50% of patients with head and neck cancer experience significant pain with approximately 10% experiencing severe pain </li></ul><ul><li>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 </li></ul>
  31. 31. Cancer Pain <ul><li>Pain in 1 st year of treatment is independently associated with recurrence and survival </li></ul><ul><li>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. </li></ul><ul><li>Medication management – WHO Ladder </li></ul><ul><li>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) </li></ul><ul><li>Intrathecal infusion of local anesthetic and/or opioid </li></ul>
  32. 32. Sinus Headache <ul><li>Sinusitis - uncommon cause of chronic headaches </li></ul><ul><li>Many patients initially diagnosed with sinus headache actually suffer from migraine </li></ul><ul><li>True acute sinus headache occurs in conjunction with acute sinusitis, fever, and purulent discharge </li></ul><ul><li>usually presents as a pressure-like or dull bilateral periorbital sensation - associated with nasal congestion </li></ul><ul><li>Unilateral pain: patients with middle or inferior turbinate hypertrophy, deviated septum, or unilateral sinus disease </li></ul><ul><li>nausea, photophobia, or hearing sensitivity unusual </li></ul><ul><li>Severity or location of mucosal disease on imaging studies does not correlate with sinus related pain </li></ul>
  33. 33. Sinus Headache <ul><li>2005 multidisciplinary guidelines were published to assist in differentiation of migraine and sinus headache: </li></ul><ul><li>a stable pattern of recurrent headaches that interfere with daily function is most likely migraine </li></ul><ul><li>recurrent self-limited headaches associated with rhinogenic symptoms are most likely migraine </li></ul><ul><li>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 </li></ul><ul><li>headache associated with fever and purulent nasal discharge is likely rhinogenic in origin </li></ul>
  34. 34. Sinus Headache <ul><li>referral to a headache specialist: </li></ul><ul><li>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 </li></ul><ul><li>patients with migraine with no evidence of infection should be given a trial of migraine-specific medication and seen for a follow-up evaluation </li></ul><ul><li>patients with noninfectious rhinogenic symptoms who have headache as a minor symptom should be given nasal glucocorticoids and/or selective nasal antihistamines </li></ul>
  35. 35. References <ul><li>Khelemsky Y. Acute and Chronic Pain Management. In: Levine, Govindaraj, and Demaria, eds. Anesthesiology and Otolaryngology. New York, NY: Springer 2011, p. TBD. </li></ul>

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