Myriam Loyo Li

Importance: The current opioid abuse epidemic in the United States requires evaluation of prescribing practices within all medical specialties. This examination includes a review of postoperative pain management for patients undergoing major head and neck procedures. Objective: To report differences in postoperative pain regimens between an international and domestic head and neck surgical program. Design, Setting, and Participants: Pain management patterns after head and neck surgery in the programs at Chinese University of Hong Kong (CUHK) and Oregon Health and Science University (OHSU) were compared with a focus on opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen or paracetamol, and anxiolytics. Cases from July 1, 2013, through August 31, 2017, were reviewed. Standing medication orders the day before surgery (PRE1), postoperative day 6 (POD6), and postoperative day 14 (POD14) were compared between institutions. Exposures: Head and neck surgery. Results: A total of 253 cases from CUHK and 567 cases from OHSU were analyzed (mean [SD] age, 59.4 [14.3] and 60.1 [16.4] years, respectively). Patients from OHSU had a significantly higher frequency of opioid orders on PRE1 (15.3% vs 1.6%; odds ratio [OR], 11.3; 95% CI, 4.09-31.10), POD6 (86.8% vs 0.4%; OR, 1653.12; 95% CI, 228.51-11 959.01), and POD14 (71.4% vs 0.8%; OR, 313.75; 95% CI, 77.12-1276.52). There were no significant differences in acetaminophen or paracetamol, NSAID, or anxiolytic orders between institutions. Institution was the most significant indicator for the presence of opioid orders on POD6 (OR, 4271.10; 95% CI, 380.04-47 999.70) and POD14 (OR, 330.35; 95% CI, 79.67-1369.82). In addition to treating institution, multivariate analysis showed that PRE1 opioid orders indicated a significant increase in likelihood of opioid orders on POD6 (OR, 4.77; 95% CI, 1.23-18.57) but not POD14. POD6 anxiolytic orders remained a significant indicator of opioid orders for POD6 (95% CI, 1.49-113.10) and POD14 (95% CI, 1.17-5.03), respectively. Conclusions and Relevance: A significantly lower frequency of postoperative opioid orders was observed from CUHK compared with OHSU across similar major head and neck procedures. This contrast encourages a careful examination of (1) cultural and patient expectations of pain control, (2) the metrics by which control is assessed, (3) industry and economic drivers of opioid use, and (4) alternatives to opioid pain regimens. A thoughtful shift in postoperative pain protocols that deemphasizes opioid use may be an opportunity to counter the epidemic of opioid abuse in the United States.

OBJECTIVES: Neuritis ossificans is a rare condition involving heterotopic ossification of nerves, usually affecting major peripheral nerves. Two cases involving cranial nerves are documented, with none affecting the facial nerve. The aim of this report is to present the first documented case of neuritis ossificans involving the facial nerve (CN VII), with a review of clinical, radiologic, and histologic findings. METHODS: An 88-year-old male with a history of radiation therapy for right ear basal cell carcinoma presented with 18 months of progressive right-sided facial weakness, resulting in complete flaccid paralysis. MRI revealed subtle enhancement of the right trigeminal nerve. He underwent facial nerve exploration. Intraoperatively, a large segment of the facial nerve appeared grossly abnormal, and biopsy revealed small rounded and linear mineral deposits with concentric internal structuring, lined focally by collections of histiocytes. This is a single case report with literature review. RESULTS: Histopathology confirmed the absence of malignancy and identified mineral deposits consistent with neuritis ossificans. Given the extensive nerve damage, nerve transfers were not feasible, leading to the decision to proceed with static suspension surgery. CONCLUSION: This case is the first known instance of neuritis ossificans affecting the facial nerve, emphasizing the diagnostic challenge in this rare condition. Histopathological evaluation was critical for diagnosis, informing the decision for static suspension surgery due to irreversible paralysis.