Postoperative nausea and vomiting and pain after minor oral and maxillofacial surgery: clinical implications of a new association

Postoperative nausea and vomiting (PONV) and postoperative pain (POP) remain among the most frequent and distressing sequelae following oral and maxillofacial surgery (OMS) procedures performed under general anesthesia. Although these outcomes are traditionally discussed as distinct postoperative complications, increasing evidence suggests that they are interrelated through shared neurophysiologic and clinical pathways. In this context, Nakamura and colleagues present a retrospective cohort study evaluating whether PONV is associated with increased POP in patients undergoing minor OMS under general anesthesia (1).

Historically, POP has been conceptualized as a contributor to PONV, mediated by sympathetic activation, opioid administration, and stress-related neurohumoral responses. Early anesthesiology literature demonstrated that inadequately controlled pain increased the likelihood of postoperative emesis independent of anesthetic technique (2,3). Subsequent clinical studies reinforced this association, showing that improved analgesia, particularly opioid-sparing strategies, can reduce PONV incidence (4). However, the inverse relationship, whereby nausea and vomiting themselves may amplify pain perception, has received comparatively limited attention within OMS-focused research.

By demonstrating a statistically significant association between early PONV and increased pain intensity, Nakamura et al. challenge this unidirectional framework and suggest that PONV may function not merely as a parallel adverse event but as an active modulator of POP perception. It is critical to note however that the association demonstrated in the study was noted to be transient in nature and limited to the 2-hour post-operative mark

The interaction between pain and nausea has been recognized in perioperative medicine for decades. Foundational studies proposed that pain itself may act as a primary driver of postoperative vomiting, even in the absence of anesthetic-related triggers (2,3). More contemporary investigations have confirmed that higher pain scores are associated with increased PONV rates, particularly when opioid analgesics are required for pain control (5).

Within OMS, this relationship has been most extensively examined in the setting of major procedures, particularly orthognathic surgery. Silva and colleagues previously reported that increased POP intensity was associated with higher rates of PONV following orthognathic surgery, emphasizing the role of surgical magnitude and perioperative opioid exposure (6). More recently, Yaşlı et al. demonstrated a similar association between pain severity and nausea in the early postoperative period after orthognathic surgery (7). These studies, however, primarily framed pain as a predictor of PONV rather than as an outcome potentially influenced by nausea.

The work by Nakamura et al. extends this literature by shifting focus to minor OMS, a population often presumed to experience limited postoperative morbidity. Their reported early PONV incidence of approximately 21% is consistent with prior observational data in minor oral surgery under general anesthesia, confirming that PONV remains clinically relevant even in less invasive procedures (8). More importantly, their multivariate analysis suggests that PONV is independently associated with increased early POP, even after adjustment for demographic, anesthetic, and surgical variables (1).

The hypothesis that nausea may amplify pain perception is biologically plausible. Neuroanatomical studies have demonstrated reciprocal connections between the nucleus tractus solitarius and trigeminal sensory nuclei, providing a potential substrate for interaction between visceral discomfort and craniofacial pain processing (9). This overlap may be particularly relevant in OMS, where surgical insult occurs in highly innervated craniofacial tissues with dense sensory representation.

Clinical observations in migraine and vestibular disorders further support this concept, as nausea frequently coexists with heightened pain sensitivity and symptom severity (10). Experimental pain research suggests that nausea and visceral discomfort may lower pain thresholds and enhance central sensitization, thereby amplifying subjective pain ratings (11). In this context, PONV may represent not only a postoperative complication but also a contributor to a broader symptom cluster that shapes the early recovery experience.

From an OMS perspective, the findings of Nakamura et al. have meaningful clinical implications. Minor OMS procedures are frequently performed in ambulatory settings with expectations of rapid recovery and early discharge. Even modest increases in early POP, however, can delay discharge, increase unplanned healthcare utilization, and negatively affect patient satisfaction (12).

Current consensus guidelines for PONV prevention emphasize risk stratification and multimodal prophylaxis, particularly in patients with established risk factors such as female sex, nonsmoking status, history of PONV, and postoperative opioid use (4). Nakamura et al. reaffirm the relevance of these risk factors in minor OMS and further suggest that failure to prevent PONV may have downstream consequences for pain control (1).

For OMS surgeons, these findings support a more integrated perioperative approach. Minimization of opioid exposure, total intravenous anesthesia when appropriate, and application of evidence-based antiemetic strategies may not only reduce nausea but also mitigate early POP. This integrated model aligns with enhanced recovery principles increasingly adopted across surgical disciplines (13).

The study provides valuable insight into symptom interaction in minor OMS; however, the absence of clearly standardized analgesic and antiemetic protocols warrants consideration. Variability in perioperative medication use may independently affect both PONV and pain outcomes, potentially influencing the strength and direction of the observed association.

Several strengths enhance the interpretability of this study. Systematic postoperative assessments at defined time points allowed the authors to demonstrate that the association between PONV and pain was most pronounced in the early postoperative period¹. The use of multivariate regression analysis further strengthens the inference that PONV may independently influence pain intensity. Nevertheless, limitations inherent to the retrospective, single-center design must be acknowledged. Variability in procedures categorized as “minor OMS” introduces heterogeneity in surgical stimulus, and perioperative administration of analgesics and antiemetics was not standardized. Additionally, reliance on Visual Analog Scale (VAS) scores measured at rest may not fully capture functional impairment or affective distress associated with postoperative symptoms (14). It is critical to note when using the VAS, higher values might be reported by patients due to generalized discomfort and the values might not exclusively represent pain in the surgical site. Prospective studies with standardized protocols and broader patient-reported outcome measures would help clarify causality and clinical significance.

An additional limitation that warrants consideration is the absence of adjustment for psychological factors, particularly preoperative anxiety, which represents a plausible unmeasured confounder. Anxiety has been shown to influence both PONV and pain perception through central mechanisms involving limbic system activation and altered autonomic responses. Elevated preoperative anxiety is associated with increased susceptibility to PONV as well as lower pain thresholds and heightened pain reporting in the postoperative period. Consequently, the observed association between PONV and increased POP may, in part, reflect an underlying predisposition among more anxious patients rather than a direct causal relationship between these symptoms. Future studies incorporating validated measures of preoperative anxiety and psychological distress are therefore needed to better delineate the independent and interactive effects of these variables on postoperative outcomes.

The findings of Nakamura et al. generate several important avenues for future investigation. Prospective trials evaluating aggressive PONV prophylaxis in minor OMS, with POP as a predefined outcome, could help determine whether reducing nausea directly improves pain outcomes. Additionally, incorporation of psychological and behavioral variables, such as anxiety and expectation, may help explain interindividual variability in symptom amplification (15). As OMS continues to adopt enhanced recovery pathways, recognizing PONV as a potential contributor to pain rather than a passive byproduct may facilitate more holistic, patient-centered perioperative care.

Nakamura and colleagues provide evidence that PONV is associated with increased early POP in patients undergoing minor OMS under general anesthesia (1). Their work challenges traditional symptom hierarchies and highlights the interconnected nature of postoperative recovery. More specifically, these findings suggest that the presence of PONV correlates with an elevated perception of pain within the first 2 hours after surgery. These results should be interpreted with caution given the observational design and the potential for unmeasured confounding factors. Nevertheless, for OMS clinicians, these findings underscore the importance of comprehensive perioperative strategies that address nausea and pain concurrently, and they reinforce the role of effective antiemetic prophylaxis in optimizing early postoperative comfort, even in procedures traditionally considered low risk.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Oral and Maxillofacial Anesthesia. The article has undergone external peer review.

Peer Review File: Available at https://joma.amegroups.com/article/view/10.21037/joma-2026-1-0006/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://joma.amegroups.com/article/view/10.21037/joma-2026-1-0006/coif). The authors have no conflicts of interest to declare.

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