Pain after Head-and-neck Cancer Surgery: The Need for Multidisciplinary Approach

Despite the substantial burden, pain after major head and neck oncological surgery has been historically overlooked and underreported in the literature.[1] This underestimation may stem from the multifaceted nature of postsurgical pain, which encompasses nociceptive, neuropathic, emotional and psychological components.[2] A holistic, multidisciplinary approach is imperative to adequately address this complex pain syndrome and its various biopsychosocial dimensions in the head and neck cancer surgery population. Postsurgical pain is highly prevalent among head and neck cancer patients, with studies indicating acute pain incidence up to 50% and chronic pain rates around 40% at 1 year and 15% at 5 years post-treatment. Over 50% of head and neck cancer patients have reported medical disability within 1 year of diagnosis, underscoring the functional impacts of unrelieved pain in this population. Quality of Life and Head-and-Neck Cancer Treatment Chronic pain after head and neck cancer treatment significantly impairs quality of life (QOL) across physical, functional, psychological, social and financial domains. Key predictors of diminished quality of life in this population include nasogastric tube placement, tracheostomy, medical comorbidities, chemoradiation, neck dissection, younger age, lower education level, and female sex. Uncontrolled chronic pain can be severely debilitating for head and neck cancer survivors, underscoring the need for proactive multimodal pain management starting in the perioperative period to optimize long-term QOL outcomes.[3] Suboptimal postoperative pain control in head and neck cancer patients undergoing extensive resection and reconstruction has been associated with impaired functional recovery, prolonged hospitalization, and progression to chronic pain. Effective management of acute postoperative pain is imperative to prevent the development of debilitating persistent pain and optimize QOL after major head and neck surgery. A multimodal analgesic approach is essential to adequately address pain and comfort in this complex patient population. PAIN MANAGEMENT IN HEAD-AND-NECK CANCER SURGERY Head-and-neck cancer treatment, involving surgery, radiation, and chemotherapy, often leads to facial disfigurement, speech and swallowing difficulties, and chronic pain in the oral cavity, such as mucositis. Resection of accessory nerves and nerves of the superficial cervical plexus during surgery can result in chronic pain syndromes. The incidence of neck and shoulder pain was found to be 33% and 37%, respectively, and myofascial pain affected 46% of patients. Additionally, 65% of patients who underwent neck dissection surgery with or without radiotherapy experienced loss of sensation at the one-year follow-up. Despite these challenges, the management of chronic pain following head-and-neck cancer surgery remains elusive and suboptimal.[2,4] OPIOID-SPARING ANALGESIA Traditionally, opioid-based patient-controlled analgesia has been the primary approach for managing postoperative pain following major head-and-neck resection. However, due to concerns about opioid-related adverse events, especially respiratory depression, there is a growing interest in opioid-sparing multimodal analgesia. This approach involves utilizing a combination of medications such as paracetamol, nonsteroidal anti-inflammatory drugs, cyclooxygenase inhibitors, lidocaine, N-methyl-d-aspartate antagonists, gabapentinoids, steroids, and alpha-2 agonists.[5] Additionally, an interdisciplinary acute pain management strategy that integrates physical and psychological therapy, transdermal drug delivery, subcutaneous infusion pumps, subperiosteal catheters, locoregional techniques, and selective nerve blocks is essential to form a part of multimodal analgesia for effective pain control in head-and-neck cancer patients. CONCLUSION We advocate for a standardized multidisciplinary approach to evaluate and manage pain in head and neck cancer patients perioperatively. Preoperative assessment should be conducted to identify high-risk individuals, provide pain education, and optimize the patient through prehabilitative strategies. Postoperative follow-up in the early recovery period is critical for pain control and to reduce risks of developing chronic pain. Eliciting pain scores may be challenging in tracheostomized patients, further emphasizing the need for preoperative counseling. Implementing a multimodal analgesia protocol that minimizes opioid exposure through an interdisciplinary acute pain service can improve pain control, reduce opioid-related adverse events, enhance functional recovery, and potentially mitigate the burden of persistent and chronic pain in this complex surgical population. Routine holistic assessment and management of pain before and after major head and neck surgery should be integrated into standard clinical practice. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.