Adoption and adherence to the MMA protocol increased substantially over the study period for patients undergoing thyroid and parathyroid surgery and was associated with a simultaneous significant decline in prescription of postoperative opioid analgesics. Use of nonopioid multimodal agents, incorporating NSAIDs, was safe and did not lead to increased incidence of bleeding. Availability of effective nonopioid MMA pathways may favorably influence physician prescribing practices and avoid unnecessary opioid prescriptions.

IMPORTANCE Perioperative analgesia strategies that rely solely on narcotics may contribute to adverse effects and concerns about opioid abuse or dependence. Multimodal analgesia protocols incorporating nonnarcotic agents may reduce the need for postoperative narcotic use.OBJECTIVE To evaluate the feasibility and safety of a multimodal analgesia protocol for outpatient head and neck surgical procedures and to identify the association of the multimodal analgesia protocol with postoperative pain perception scores and patient satisfaction. DESIGN, SETTING, AND PARTICIPANTSRetrospective evaluation of prospectively collected data on adults who underwent outpatient thyroid, parathyroid, and parotid surgery between July 2016 and February 2017 at the head and neck surgery service of a tertiary care hospital using a multimodal analgesia strategy with use of immediate preoperative acetaminophen and gabapentin, and intention to treat with a nonnarcotic postoperative outpatient analgesia strategy. MAIN OUTCOMES AND MEASURESOverall patient satisfaction scores, Overall Benefit of Analgesia Score (OBAS), and median resting and peak pain scores were recorded. Incidence of reliance on a narcotic-based postoperative outpatient analgesia strategy and adverse events related to altered analgesia strategy were identified.RESULTS Sixty-four patients (48 [75%] female; mean [SD] age, 54.6 [14.3] years) underwent outpatient thyroid, parathyroid, or parotid surgery with use of a multimodal analgesia protocol. On a 10-point rating scale, patients reported low resting pain perception scores (median, 2 [range, 0-8]) and peak pain scores (median, 4 [range, 0-9]). The OBAS assessment for composite effectiveness of analgesia indicated a favorable median score of 1 (range, 0-10; permissible range, 0-28, with lower scores better). Thirty-nine (61%) patients were able to avoid postoperative narcotic use on discharge. Fifty-six (88%) patients reported "high" or "very high" satisfaction with the multimodal analgesia strategy. No complications related to bleeding, hematoma, significant adverse events, or readmissions were observed. CONCLUSION AND RELEVANCEA multimodal analgesia strategy was feasible and safe in patients undergoing outpatient head and neck surgery and may reduce the need for narcotic use. It was associated with low pain perception scores, favorable OBAS, and overall satisfaction scores. The role of multimodal analgesia needs additional evaluation through comparative effectiveness assessment vs conventional pain management strategies.

Oral cavity squamous cell carcinoma (OCSCC) has a yearly incidence of 274,000 patients. Twenty percent to 30% of patients will harbor occult regional metastases, an important feature that correlates with worse outcomes. Supraomohyoid neck dissection (SND) is the gold standard treatment, but because of recent successes of sentinel lymph node (SLN) biopsy in the management of breast cancer and melanoma, many have begun evaluating its use in head and neck mucosal cancers. SLN biopsy offers patients decreased morbidity compared with SND, and has shown reproducibly low falsenegative rates, high-negative predictive values, and high sensitivities. Limitations with floor-ofmouth primaries and delayed secondary SNDs have been described, but a new agent designed to address these shortcomings, Lymphoseek (Neoprobe Corp.; Dublin, OH), is currently under investigation. This article reviews the current literature on SLN biopsy and introduces a phase 3 study evaluating the efficacy of Lymphoseek in SLN biopsy of OCSCCs.