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. INTERVENTIONSThe 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 MEASURESAverage 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 Duringpostoperative 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]; η 2 p = 0.09 [0.01-0.21]) and maximum (2.4 [2.2] vs 4.2 [2.0]; η 2 p = 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]; η 2 p = 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%]; = 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.
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.
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.
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