Opioid usage and non-opioid alternatives in septorhinoplasty: a narrative review

Introduction

Background

Postoperative pain following septorhinoplasty has a large impact on patients’ overall experience and has been shown to impact perceived aesthetic and functional improvement (1). With each patient, an experienced surgeon should weigh the potential for opioid dependence with achieving adequate postoperative analgesia. There are specific patient characteristics and surgical factors that may contribute to increased post-septorhinoplasty pain levels. However, there are many alternative perioperative analgesics available to address patients’ pain levels while reducing postoperative opioid use.

Rationale and knowledge gap

Currently, there are no clinical practice guidelines for surgeons to reference when prescribing postoperative narcotics for septorhinoplasty. This may be due to the fact that each patient’s pain tolerance and sensitivity to opioids is unique and varies greatly. It may also stem from surgeons hesitating to stray from the perioperative care they learned during training. There are other review articles (2); however, the current study provides an up-to-date and more expansive review on the current state of opioid use in septorhinoplasty.

Objective

In this review, we seek to highlight trends in opioid prescribing patterns post-septorhinoplasty, illustrate patient characteristics and aspects of the surgery that may be associated with higher opioid requirements, and to discuss analgesic alternatives that have been effective in reducing opioid requirements after surgery. In doing so, this review can be used for surgeons to reflect on their own opioid prescribing patterns and consider improving their practice by reducing the number of opioids they prescribe for the indicated patients and consider exploring analgesic alternatives described. We present this article in accordance with the Narrative Review reporting checklist (available at https://joma.amegroups.com/article/view/10.21037/joma-24-35/rc).

Methods

A literature search was performed in November 20, 2024 via PubMed database. Articles included in the review were written in English or had available English translations and were published between 01/01/2004–11/20/2024. Keywords for the literature search included words and phrases such as: ‘opioid use in septorhinoplasty’, ‘pain septorhinoplasty’, ‘rhinoplasty opioids’, and ‘narcotics septorhinoplasty’. Articles were excluded if, upon review, were found to be discussing opioid use in the context of surgeries other than rhinoplasty, septoplasty, or septorhinoplasty. Articles were also excluded if their data from septorhinoplasty patient groups were not separated from data from patients who underwent other types of surgeries. This was a clear effort to isolate studies that were solely investigating opioid use in the relevant surgeries as described above. The results from all the reviewed articles were analyzed by the two authors and the following sections were created in order to organize the narrative review succinctly: opioid prescribing and consumption patterns, and analgesic alternatives. Table 1 highlights the search strategy summary.

Discussion

Opioid prescribing and consumption patterns

Physicians have increasingly been made aware of the addictive properties of narcotic pain medications. It is now required to for physicians to complete 8 hours of training on the management of opioid disorders. Surgeons have become more aware of excessive and inappropriate prescribing of opioids during the perioperative time period and have been focusing on ways to appropriately provide postoperative analgesia while minimizing risks of addiction. Septorhinoplasty is a procedure that often requires prescription strength postoperative analgesia; however, the challenge lies in prescribing enough narcotics to adequately treat postoperative pain while avoiding unused narcotics that may be abused or diverted to others (3). In a survey study sent to all members of the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) in July 2018, 89.5% of respondents reported prescribing some variation of opioids following septorhinoplasty yet 86.9% responded that they didn’t believe opioid dependence was an issue in rhinoplasty patients, despite acknowledging it as an issue in 61% of surgical patients in general. A quarter (25.1%) of these respondent physicians reported prescribing >25 tablets of opioids per rhinoplasty, with 52.4% prescribing 11–25 tablets (4).

Several studies have compared the number of opioids prescribed after septorhinoplasty to the number actually taken by the patients. Depending on the study, the average number of pills that patients report using ranges from 5.2 to 15 (5-9). A telephone interview study with 64 patients following septoplasty and/or rhinoplasty revealed that although patients were prescribed an average of 42.4 opioid tablets, they only consumed 14.7. Additionally, they reported that gender, type of procedure (septoplasty vs. rhinoplasty), and use of Doyle splints did not have an impact on the number of opioids used (10). Other studies have supported this finding of no significant difference in opioid requirement when comparing septoplasty to rhinoplasty (8).

Performing osteotomies during rhinoplasty has been shown to elicit higher pain responses via surgical pleth index, an objective measure of nociceptive activation utilized by anesthesia intraoperatively to guide medication dosage, in one study (11). Heart rate (HR), blood pressure (BP), and depth of anesthesia as measured by Bispectral Index (BIS) values were found to be significantly increased during osteotomies compared to both 10 minutes before and after osteotomies were completed in an additional study (12). Some studies report more postoperative opioid usage in patients who underwent osteotomies (6), while others reported no significant change in opioid use in the presence of osteotomies (7). There was also no association with increased opioid requirement or rate of refills when comparing revision cases to primary cases (7,13).

The association of gender and opioid requirements is variable. One retrospective review of a postoperative pill diary patients showed that females used on average of 7.2 opioid pills compared to males’ 4.5; however, the same study also showed males reported higher pain scores on postoperative day (POD) 1–8 than their female counterparts (9). This is in contrast to a prospective pain medication survey study that found female patients reported higher pain postoperatively (14).

Although osteotomies and patients’ gender have not proven to be consistent predictive factors for identifying which patients may require a greater than average amount of opioids, there are other factors physicians may use. Patients with a prior history of opioid use and patients who have more anxiety towards pain, as measured via the Pain Catastrophizing Scale (PCS), have been shown to have increased postoperative opioid requirements (5,6). In this study, surgical characteristics, history of anxiety, cosmetic indication, surgical revision, use of osteotomies, Doyle splints and costal or conchal cartilage grafts were not associated with increased narcotic use. The average number of 5 mg narcotic tablets taken by the patients was 7.25. Those patients using >10 tablets scored higher on the PCS, which was significantly more than patients who did not score high on the scale (10.6 vs. 4.8 pills) (5).

Two studies looked at the effect state-wide legislative changes/programs in Vermont and New York, respectively, had on post-septorhinoplasty opioid usage. The Vermont Department of Health passed legislation in 2017 that limited the number of opioids that could be prescribed for acute pain, with additional requirements that providers must adhere to when prescribing opioids such as checking the Vermont Prescription Monitoring System, providing patient education about risks of opioids, obtaining consent, and to prescribe the fewest amount and for shortest duration possible as evidenced by current literature. New York’s I-STOP program (Internet System for Tracking Over-Prescribing) requires providers to check the prescription monitoring program (PMP) registry that displays controlled substance prescription histories for their patients prior to prescribing them narcotics. Both programs appear to have been successful at curtailing excessive opioid prescriptions without subsequent increase in complaints or refill requests (15,16).

In summary, it has been difficult to predict patients’ opioid requirements following septorhinoplasty based on procedure and patient characteristics, however, it seems that patients are requiring less pills than generally prescribed and education programs for providers seems to be reducing excessive opioid prescriptions.

Non-opioid alternatives

In an effort to decrease reliance on opioids following septorhinoplasty, there have been many other alternative analgesic regimens described in the literature. The variety of interventions occur pre-operative, intraoperative, and postoperative administration, or any combination of the three. Several systematic reviews and meta-analyses conclude that nonsteroidal anti-inflammatory drugs (NSAIDs), gabapentin, ketamine, nerve blocks, and alpha agonists may effectively provide alternative analgesia post-septorhinoplasty. These studies have shown reduced post-operative pain, reduced need for rescue analgesics, increased time to first analgesic requested, and decreased total opioid usage (17-21). The overall findings are summarized below and in Table 2 based on drug class.

NSAIDs

NSAIDs are the most widely investigated alternative analgesic option. Several studies compared various NSAIDs but one must be aware of the possible adverse effects this drug class poses pertaining to peptic ulcers, elevated BP, acute renal dysfunction, and hepatotoxicity in patients with liver dysfunction. One study found lornoxicam patient-controlled analgesia (PCA) pump led to less rescue doses of pethidine, and less reported nausea when compared to dipyrone PCA pump (22). Alshehri et al. performed a prospective randomized controlled trial (RCT) where postoperative opioid usage was compared between a group receiving intraoperative intravenous (IV) ibuprofen to a second group who received intraoperative IV paracetamol and found that the ibuprofen group had significantly less opioid use in the first six hours postoperatively, but no difference existed past that time point (23). An additional study showed that preoperative intravenous (IV) ibuprofen (800 mg) given to patients led to less opioid consumption between postoperative hours 0–12 when compared to patients given preoperative paracetamol (1,000 mg) and a control group (24). A prospective RCT showed that IV ibuprofen (800 mg) administered 30 minutes preoperatively led to less postoperative PCA fentanyl when compared to control (25). Perioperative celecoxib was shown to reduce the mean postoperative hydrocodone 5 mg/acetaminophen 325 mg tablets taken, the mean hydrocodone 5 mg/acetaminophen 325 mg total dosage, and mean total oral morphine equivalent (OME) dose, in addition to reducing nausea and vomiting (26). Another prospective RCT study evaluated the effects of variably administered dexketoprofen between the following four groups, each with 25 patients: Group 1 received 50 mg dexketoprofen preoperatively; Group 2 received 50 mg dexketoprofen postoperatively; Group 3 received 25 mg dexketoprofen preoperatively and 25 mg postoperatively; Group 4 was control with no dexketoprofen given. This study found that all combinations reduced tramadol consumption when compared to the control group but found no difference in intraoperative fentanyl requirements between the groups (27).

Frants et al. conducted a prospective RCT that directly compared efficacy of NSAIDs to opioids by comparing postoperative pain scores between their opioid control group, who received hydrocodone 5 mg/acetaminophen 325 mg, and an NSAID experimental group, who received ibuprofen 400 mg. They found that NSAIDs were non-inferior to opioids as the NSAID group had lower mean pain scores and there was no significant difference in average postop day for medication cessation. However, 5 patients in the NSAID group required escalation to opioid group. Interestingly, 76% of the patients in the opioid group took <8 tablets, a similar finding to the retrospective studies described above that evaluated the number of narcotic pills taken postoperatively (28).

Pregabalin/gabapentin

Pregabalin has also garnered interest as an alternative to opioids. One prospective, double-blinded RCT reported that a single 75 mg dose of preoperative pregabalin led to a lower total dose of rescue fentanyl required, and ibuprofen administered, when compared to control (29). Pregabalin was supplemented by dexamethasone in one prospective RCT that compared the following 3 groups: control (placebo-placebo), preoperative placebo combined with intraoperative pregabalin, and lastly pregabalin 300 mg 1 hour preoperatively combined with 8 mg dexamethasone intraoperatively. They found that the pregabalin-dexamethasone group used less tramadol and pethidine at 24 hours postoperative and 81.9% less total PCA tramadol when compared to control; while the pregabalin-placebo group saw 54.5% less total tramadol PCA pump consumption compared to control (30).

An important finding related to gabapentin use is the potential for withdrawal symptoms if abruptly discontinued and dizziness. Turan et al. led a prospective study which found that although their 1,200 mg preoperative gabapentin dose was effective at significantly lowering pain scores at 1 hour postop with less frequent need for rescue analgesic (diclofenac), and increased length of time before requesting a rescue analgesic, there was an increased rate of dizziness in the gabapentin group (24%) when compared to control (4%) (31).

Ketamine

Ketamine has become increasingly popular for analgesia in addition to its utility as a dissociative anesthetic. Its possible adverse effects include nausea, vomiting, confusion and emergence phenomenon. One randomized double blinded prospective RCT compared a group of patients undergoing septorhinoplasty who received an IV bolus of 0.5 mg/kg of ketamine followed by a 0.25 mg/kg continuous intraoperative infusion with a control group who received a corresponding saline bolus and saline intraoperative infusion. Both groups were administered 50 mg of dexketoprofen trometamol thirty minutes prior to the end of surgery. The ketamine group was found to have significantly lower pain scores and postoperative rescue opioid requirements (32). An additional prospective RCT included 72 patients split into three groups based on the preoperative analgesic they were given: lidocaine group (1.5 mg/kg), ketamine group (0.5 mg/kg), and control group. Both the lidocaine and the ketamine groups had significantly less emergence agitation and pain levels postoperatively, but no significant difference was found between the two intervention groups (33).

Nerve blocks

Many studies were interested in the utility of preoperative nerve blocks, specifically the infraorbital and infratrochlear nerve blocks. Proper administration is vital as intra-arterial injection can lead to central nervous system toxicity, as with any local anesthetics. One prospective RCT of 52 patients split into a control group vs. a group receiving bilateral infratrochlear and infraorbital preoperative nerve blocks reported that the nerve block group consumed less dexketoprofen, experienced less emergence agitation, and obtained a longer duration of postoperative analgesia (34). Another prospective RCT comparing control vs. preoperative bilateral infratrochlear and infraorbital nerve block using 8 mL of 0.5% ropivacaine also demonstrated a reduced incidence of emergence agitation, mean remifentanil consumption, postoperative tramadol use, and median postop 0–2 hours pain scores in the nerve block group (35). Boselli et al. split 40 patients into two groups with one group receiving bilateral infratrochlear and infraorbital preoperative nerve blocks in addition to a saline infusion compared to a control group that received no nerve block but a 0.1 mL/kg morphine infusion in place of the nerve block group’s saline infusion. The nerve block group was found to have lower total perioperative morphine doses administered and less time spent in the post-anesthesia care unit (PACU) (36). A retrospective review of 40 patients, split into control vs. preoperative bilateral infratrochlear and infraorbital nerve block via 0.25% levobupivacaine, failed to show any difference in pain score or analgesia requirements (37). Sari et al. compared three groups in their prospective RCT: total nose block (involving bilateral supratrochlear nerves, infratrochlear nerves at medial epicanthal areas, injection at keystone areas, pyriform apertures, suspensory ligaments, and whole septal walls) and central facial block (a bilateral infraorbital nerve block in addition to the total nose block) and control. Each group was injected pre- and postoperatively, and they group found that both nerve block groups experienced less pain, edema, and ecchymosis postoperatively when compared to control but that the central facial block was superior to the total nose block in the same parameters listed above (38).

There were two prospective RCTs that demonstrated the effectiveness of bilateral sphenopalatine ganglion preoperative blocks. One administered the block preoperatively and found it led to lower pain scores at 1, 4, and 24 hours postop, lower intraoperative remifentanil use and postoperative analgesic consumption, and lower intraoperative HR and mean arterial pressures when compared to control (39). A separate study administered the block just prior to case cessation and found no difference in intraoperative hemodynamic parameters but less patients overall in the block group required postoperative analgesics at 0–2 hours postoperative (40). Degirmenci et al. performed a retrospective cohort study that showed a preoperative sphenopalatine ganglion block significantly decreased postoperative paracetamol, tramadol, and rescue analgesic requirements (41).

Amides

Several studies have investigated the utility of amide infusions on controlling post-septorhinoplasty pain and opioid requirements. One double blinded, prospective RCT found that preoperative intranasal 5% lidocaine in combination with naphazoline was associated with less rescue analgesic requirements and less postoperative pain compared to control (42). Ates et al. administered a 1.5 mg/kg lidocaine bolus prior to anesthesia induction, followed by a 1.5 mg/kg/h continuous infusion of lidocaine intraoperatively for 1 hour and found that these patients required less rescue analgesics and did not have any intraoperative remifentanil consumption (43). A retrospective study assessing liposomal bupivacaine administration following rhinoplasty demonstrated significantly reduced opioid consumption (lower oxycodone and OME) and lower reported pain scores compared to those who did not (44). There was significantly less postoperative pain, edema, ecchymosis, analgesic use, and increased satisfaction in a group of patients who received a 2% lidocaine with 1:100,000 adrenaline lavage, vs. saline lavage for the control group, beneath their dorsal nasal flap just prior to case completion in Gümüş et al.’s prospective RCT of 40 patients (45). Finally, Bicer et al. compared levobupivacaine and ropivacaine for preoperative surgical field local infiltration and found no difference in postoperative pain scores or hemoglobin values between the two (46).

Esmolol

Esmolol infusion, in combination with remifentanil and propofol, was compared to a combination of saline/remifentanil/propofol in one study and the esmolol group was found to require less morphine and experience less postoperative pain (from 0–3 hours recorded), along with less variation in HR and BP postoperatively (47). The addition of esmolol to remifentanil, when compared to remifentanil alone, was found to reduce intraoperative and postoperative analgesic consumption, postoperative pain, and lengthen the time to first postoperative analgesic (48).

Miscellaneous medications and proposed protocols

Lastly, there are a few analgesic alternatives that were less commonly described in the literature but still warrant discussion. Given that they do not fall under any of the previous subheadings, they are discussed here. Onal et al. gave a single preoperative dose of nebulized morphine sulfate and found that it prolonged patients’ time to first postoperative analgesia requirement (49). A 30 mg/kg IV magnesium bolus was administered following induction, with a subsequent continuous infusion of 9 mg/kg magnesium intraoperatively and was found to improve quality of recovery (QoR), measured by QoR-40, and lower pain scores up until 24 hours postoperatively (50). Two meta-analyses compared dexmedetomidine and remifentanil. The first comprised of 4 RCTs and concluded that the two drugs may be comparable for anesthesia in rhinoplasty as they achieved similar additional analgesic requirements, patient and surgeon satisfaction, and extubation and recovery time (51); while the other meta-analysis included 5 RCTs and stated that there was no difference between the two medications in terms of hemodynamics, satisfaction, pain, agitation, or recovery time (52).

Several studies offered their multi-modal analgesic protocols, including which drugs should be given at which perioperative stage. Hall et al. described their 15-component multimodal pain regimen which led to only 24% of their patients requiring an opioid prescription, those who did require opioids were described as being less adherent to the protocol (53). Neighbors et al. compared the refill rates of their septoplasty and rhinoplasty patients before and after instituting the following analgesic discharge order set: 10 oxycodone (5 mg), 100 acetaminophen (325 mg), 28 celecoxib (200 mg). They found that the septoplasty group had a 46% decrease in total morphine milliequivalents (MME) with no difference in refills, while the rhinoplasty group had a 51% decrease in total MME and no difference in refills (54).

Limitations

Our study is not without limitations. For one, the literature search was limited to one database and English, or English-translated, articles only. Additionally, our review included articles aside from meta-analyses and systematic reviews as we wanted to discuss all ongoing investigations into the topic, even if they were small prospective controlled trials or retrospective chart reviews. Although we included as many articles as the literature search resulted in, narrative reviews are inherently limited by the lack of standardization for the search and not including every possible related study.

Conclusions

It is important for surgeons to adequately treat postoperative pain following septorhinoplasty. The majority of surgeons overprescribe narcotics which introduces overuse and diversion of extra pill risks. The literature demonstrates that 8–10 5-mg oxycodone tablets is sufficient for most septorhinoplasty patients. However, surgeons should be aware that patients who have had prior opioid use or have higher anxiety towards pain may require more opioids than the average patient. In an effort to reduce opioid usage altogether following septorhinoplasty, there are a variety of alternative perioperative analgesics, such as NSAIDs, gabapentin, ketamine, nerve blocks, and a variety of topical anesthetics formulations and application that are safe and effective at reducing both the number of opioids prescribed and required.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://joma.amegroups.com/article/view/10.21037/joma-24-35/rc

Peer Review File: Available at https://joma.amegroups.com/article/view/10.21037/joma-24-35/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://joma.amegroups.com/article/view/10.21037/joma-24-35/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Gadkaree SK, Shaye DA, Occhiogrosso J, et al. Association Between Pain and Patient Satisfaction After Rhinoplasty. JAMA Facial Plast Surg 2019;21:475-9. [Crossref] [PubMed]
2. Nguyen BK, Yuhan BT, Folbe E, et al. Perioperative Analgesia for Patients Undergoing Septoplasty and Rhinoplasty: An Evidence-Based Review. Laryngoscope 2019;129:E200-12. [Crossref] [PubMed]
3. Lewis ET, Cucciare MA, Trafton JA. What do patients do with unused opioid medications? Clin J Pain 2014;30:654-62. [Crossref] [PubMed]
4. Levin M, Roskies MG, Asaria J. Perspectives of Facial Plastic Surgeons on Opioid Dependence in Rhinoplasty Patients. Facial Plast Surg 2019;35:540-5. [Crossref] [PubMed]
5. Carlson KJ, Dashtizad BI, Larson MO, et al. Assessment of opioid use following septorhinoplasty and its association with pain catastrophizing. Am J Otolaryngol 2024;45:104123. [Crossref] [PubMed]
6. Park C, Reategui Via Y. Clinical and surgical factors associated with opioid refill rates following septorhinoplasty. Am J Otolaryngol 2024;45:104268. [Crossref] [PubMed]
7. Patel S, Sturm A, Bobian M, et al. Opioid Use by Patients After Rhinoplasty. JAMA Facial Plast Surg 2018;20:24-30. [Crossref] [PubMed]
8. Sclafani AP, Kim M, Kjaer K, et al. Postoperative pain and analgesic requirements after septoplasty and rhinoplasty. Laryngoscope 2019;129:2020-5. [Crossref] [PubMed]
9. Marshall RV, Rivers NJ, Manickavel S, et al. Postoperative Opioid Use in Rhinoplasty Procedures: A Standardized Regimen. Facial Plast Surg 2021;37:110-6. [Crossref] [PubMed]
10. Rock AN, Akakpo K, Cheresnick C, et al. Postoperative Prescriptions and Corresponding Opioid Consumption After Septoplasty or Rhinoplasty. Ear Nose Throat J 2021;100:462S-6S. [Crossref] [PubMed]
11. Ince B, Zuhour M, Yusifov M, et al. The Impact of Surgical Procedures During Septorhinoplasty on the Intraoperative Pain Response. Aesthet Surg J 2021;41:NP1421-6. [Crossref] [PubMed]
12. Gencay I, Muluk NB, Kilic R, et al. Effects of Osteotomy on Hemodynamic Parameters and Depth of Anesthesia in Rhinoplasty Operations. J Craniofac Surg 2020;31:1705-8. [Crossref] [PubMed]
13. Sethi RKV, Lee LN, Quatela OE, et al. Opioid Prescription Patterns After Rhinoplasty. JAMA Facial Plast Surg 2019;21:76-7. [Crossref] [PubMed]
14. Justicz N, Gadkaree SK, Yamasaki A, et al. Defining Typical Acetaminophen and Narcotic Usage in the Postoperative Rhinoplasty Patient. Laryngoscope 2021;131:48-53. [Crossref] [PubMed]
15. Aulet RM, Trieu V, Landrigan GP, et al. Changes in Opioid Prescribing Habits for Patients Undergoing Rhinoplasty and Septoplasty. JAMA Facial Plast Surg 2019;21:487-90. [Crossref] [PubMed]
16. Debick NA, Wilson D, Suryadevara A. The I-STOP Program and Narcotic Prescriptions Following Facial Reconstructive Plastic Surgeries. Laryngoscope 2024;134:1208-13. [Crossref] [PubMed]
17. Lee DJ, Grose E, Brenna CTA, et al. The benefits and risks of non-steroidal anti-inflammatory drugs for postoperative analgesia in sinonasal surgery: a systematic review and meta-analysis. Int Forum Allergy Rhinol 2023;13:1738-57. [Crossref] [PubMed]
18. He D, Li Y, Wang Y. Pregabalin supplementation for the pain relief of septorhinoplasty: a meta-analysis study. Eur Arch Otorhinolaryngol 2023;280:1201-7. [Crossref] [PubMed]
19. Liang Z, Xu Y, Xue Z. The analgesic efficacy of pregabalin versus placebo for septorhinoplasty: A meta-analysis. Medicine (Baltimore) 2023;102:e33259. [Crossref] [PubMed]
20. Zhang G, Li Q, Wang P. The analgesic efficacy of ketamine for septorhinoplasty: a meta-analysis study. Eur Arch Otorhinolaryngol 2023;280:4083-9. [Crossref] [PubMed]
21. Kim DH, Park JB, Kim SW, et al. Effect of Infraorbital and/or Infratrochlear Nerve Blocks on Postoperative Care in Patients with Septorhinoplasty: A Meta-Analysis. Medicina (Kaunas) 2023;59:1659. [Crossref] [PubMed]
22. Sener M, Yilmazer C, Yilmaz I, et al. Patient-controlled analgesia with lornoxicam vs. dipyrone for acute postoperative pain relief after septorhinoplasty: a prospective, randomized, double-blind, placebo-controlled study. Eur J Anaesthesiol 2008;25:177-82. [Crossref] [PubMed]
23. Alshehri AA. Comparative Evaluation of Postoperative Pain Scores and Opioid Consumption in Septorhinoplasty After Administration of Single-Dose Preemptive Paracetamol and Ibuprofen: A Randomized Controlled Trial. Int Arch Otorhinolaryngol 2023;27:e471-7. [Crossref] [PubMed]
24. Çelik EC, Kara D, Koc E, et al. The comparison of single-dose preemptive intravenous ibuprofen and paracetamol on postoperative pain scores and opioid consumption after open septorhinoplasty: a randomized controlled study. Eur Arch Otorhinolaryngol 2018;275:2259-63. [Crossref] [PubMed]
25. Gozeler MS, Sakat MS, Kilic K, et al. Does a single-dose preemptive intravenous ibuprofen have an effect on postoperative pain relief after septorhinoplasty? Am J Otolaryngol 2018;39:726-30. [Crossref] [PubMed]
26. Newberry CI, McCrary HC, Cerrati EW. The Efficacy of Oral Celecoxib Following Surgical Rhinoplasty. Facial Plast Surg Aesthet Med 2020;22:100-4. [Crossref] [PubMed]
27. Ozer AB, Erhan OL, Keles E, et al. Comparison of the effects of preoperative and intraoperative intravenous application of dexketoprofen on postoperative analgesia in septorhinoplasty patients: randomised double blind clinical trial. Eur Rev Med Pharmacol Sci 2012;16:1828-33. [PubMed]
28. Frants A, Garber D, Lafer MP, et al. Prospective Randomized Trial Comparing Opioids versus Nonsteroidal Antiinflammatory Drugs for Postoperative Analgesia in Outpatient Rhinoplasty. Plast Reconstr Surg 2021;147:56-62. [Crossref] [PubMed]
29. Pourfakhr P, Khajavi MR, Jalali A, et al. Low-dose preoperative pregabalin improves postoperative pain management in septorhinoplasty surgery: a double-blind randomized clinical trial. Eur Arch Otorhinolaryngol 2019;276:2243-9. [Crossref] [PubMed]
30. Demirhan A, Tekelioglu UY, Akkaya A, et al. Effect of pregabalin and dexamethasone addition to multimodal analgesia on postoperative analgesia following rhinoplasty surgery. Aesthetic Plast Surg 2013;37:1100-6. [Crossref] [PubMed]
31. Turan A, Memiş D, Karamanlioğlu B, et al. The analgesic effects of gabapentin in monitored anesthesia care for ear-nose-throat surgery. Anesth Analg 2004;99:375-8. table of contents. [Crossref] [PubMed]
32. Ates I, Aydin ME, Celik EC, et al. Perioperative Intravenous Low-Dose Ketamine Infusion to Minimize Pain for Septorhinoplasty: A Prospective, Randomized, Double-Blind Study. Ear Nose Throat J 2021;100:254-9. [Crossref] [PubMed]
33. Omidvar S, Ebrahimi F, Amini N, et al. Comparing the Effect of Ketamine and Lidocaine on Agitation and Pain in Rhinoplasty: A Randomized Clinical Trial. J Cutan Aesthet Surg 2023;16:107-13. [Crossref] [PubMed]
34. Kaçar CK, Uzundere O, Salık F, et al. Effects of Adding a Combined Infraorbital and Infratrochlear Nerve Block to General Anaesthesia in Septorhinoplasty. J Pain Res 2020;13:2599-607. [Crossref] [PubMed]
35. Choi H, Jung SH, Hong JM, et al. Effects of Bilateral Infraorbital and Infratrochlear Nerve Block on Emergence Agitation after Septorhinoplasty: A Randomized Controlled Trial. J Clin Med 2019;8:769. [Crossref] [PubMed]
36. Boselli E, Bouvet L, Augris-Mathieu C, et al. Infraorbital and infratrochlear nerve blocks combined with general anaesthesia for outpatient rhinoseptoplasty: A prospective randomised, double-blind, placebo-controlled study. Anaesth Crit Care Pain Med 2016;35:31-6. [Crossref] [PubMed]
37. Elsayed M, Alosaimy RA, Ali NY, et al. Nerve Block for Septorhinoplasty: A Retrospective Observational Study of Postoperative Complications in 24 Hours. Cureus 2020;12:e6961. [Crossref] [PubMed]
38. Sari E, Simsek G. Comparison of the Effects of Total Nasal Block and Central Facial Block on Acute Postoperative Pain, Edema, and Ecchymosis After Septorhinoplasty. Aesthetic Plast Surg 2015;39:877-80. [Crossref] [PubMed]
39. Tosun Söner H, Haznedar B, Söner S, et al. Effect of non-invasive bilateral sphenopalatine ganglion block on postoperative pain in patients undergoing septorhinoplasty surgery: a randomized controlled study. Minerva Anestesiol 2024;90:989-96. [Crossref] [PubMed]
40. Gökçek E, Kozan G. Postoperative effects of bilateral sphenopalatine ganglion blockade in septorhinoplasty operations; double-blind randomized clinical trial. Braz J Otorhinolaryngol 2024;90:101373. [Crossref] [PubMed]
41. Degirmenci N, Ozdem A, Uysal H, et al. The Effect of Sphenopalatine Ganglion Block on the Postoperative Pain in Patients Undergoing Septorhinoplasty. Ann Otol Rhinol Laryngol 2020;129:722-6. [Crossref] [PubMed]
42. Granier M, Dadure C, Bringuier S, et al. Intranasal lidocaine plus naphazoline nitrate improves surgical conditions and perioperative analgesia in septorhinoplasty surgery. Can J Anaesth 2009;56:102-8. [Crossref] [PubMed]
43. Ates İ, Aydin ME, Ahiskalioglu A, et al. Postoperative analgesic efficacy of perioperative intravenous lidocaine infusion in patients undergoing septorhinoplasty: a prospective, randomized, double-blind study. Eur Arch Otorhinolaryngol 2020;277:1095-100. [Crossref] [PubMed]
44. Alameddine KO, Richards BA, Vyas K, et al. Evaluating the Efficacy of Liposomal Bupivacaine in Postoperative Pain Management for Rhinoplasty: A Retrospective Study. Aesthetic Plast Surg 2024;48:1722-7. [Crossref] [PubMed]
45. Gümüş N. Lavage With Lidocaine and Adrenaline Mixture Reduces the Early Side Effects of Septorhinoplasty. Ann Plast Surg 2020;84:e29-32. [Crossref] [PubMed]
46. Bicer C, Eskıtascıoglu T, Aksu R, et al. Comparison of preincisional infiltrated levobupivacaine and ropivacaine for acute postoperative pain relief after septorhinoplasty. Curr Ther Res Clin Exp 2011;72:13-22. [Crossref] [PubMed]
47. Vahabi S, Rafieian Y, Abbas Zadeh A. The Effects of Intraoperative Esmolol Infusion on the Postoperative Pain and Hemodynamic Stability after Rhinoplasty. J Invest Surg 2018;31:82-8. [Crossref] [PubMed]
48. Celebi N, Cizmeci EA, Canbay O. Infusão intraoperatória de esmolol reduz o consumo pós-operatório de analgésicos e o uso de anestésico durante a septorrinoplastia: estudo randômico Rev Bras Anestesiol 2014;64:343-9. [Intraoperative esmolol infusion reduces postoperative analgesic consumption and anaesthetic use during septorhinoplasty: a randomized trial]. [Crossref] [PubMed]
49. Onal SA, Keleş E, Toprak GC, et al. Preliminary findings for preemptive analgesia with inhaled morphine: efficacy in septoplasty and septorhinoplasty cases. Otolaryngol Head Neck Surg 2006;135:85-9. [Crossref] [PubMed]
50. Kilic K, Sakat MS, Sahin A, et al. Efficacy of intravenous magnesium sulfate infusion on postoperative pain and quality of recovery for septorhinoplasty: a randomized controlled study. Acta Otolaryngol 2023;143:979-83. [Crossref] [PubMed]
51. Yang J, Wu X, Nie J. Comparative study between remifentanil (or fentanyl) and dexmedetomidine for the analgesia of rhinoplasty: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2024;103:e37020. [Crossref] [PubMed]
52. Janipour M, Bastaninejad S, Mohebbi A, et al. Dexmedetomidine versus remifentanil in nasal surgery: a systematic review and meta-analysis. BMC Anesthesiol 2024;24:194. [Crossref] [PubMed]
53. Hall BR, Billue KL, Hon H, et al. No Opioids after Septorhinoplasty: A Multimodal Analgesic Protocol. Plast Reconstr Surg Glob Open 2020;8:e3305. [Crossref] [PubMed]
54. Neighbors CP, Noller MW, Avillion MP, et al. Implementing a Protocol to Reduce Opioid Prescriptions in Military Otolaryngology: A Quality Improvement Initiative. Mil Med 2022;187:e154-9. [Crossref] [PubMed]