Postoperative pain remains a major challenge in ear, nose, and throat (ENT) surgeries, contributing to delayed recovery, unplanned admissions, and poor quality-of-life outcomes¹. ENT procedures such as tonsillectomy, septoplasty, tympanoplasty, and functional endoscopic sinus surgery (FESS) involve highly innervated and vascular areas of the upper aerodigestive tract, making postoperative pain both intense and prolonged². Inadequately managed pain can impair swallowing, oral intake, and airway protection, particularly after tonsillectomy, and may predispose to complications such as dehydration, wound infection, or secondary hemorrhage³.

Traditional reliance on opioids for perioperative analgesia is limited by side effects such as nausea, vomiting, sedation, respiratory depression, and delayed mobilization⁴. Consequently, there has been a paradigm shift toward multimodal analgesia—an approach integrating different classes of analgesics and adjuvant techniques to optimize pain control while minimizing opioid exposure⁵. This aligns with the Enhanced Recovery After Surgery (ERAS) framework, which emphasizes early mobilization, effective pain management, and reduced hospital stay⁶.

Multimodal regimens typically combine acetaminophen, NSAIDs, local anesthetic infiltration, dexamethasone, and adjuvants such as dexmedetomidine or gabapentinoids⁷. Several randomized controlled trials have demonstrated that pre-emptive administration of acetaminophen or NSAIDs significantly lowers postoperative pain scores and reduces opioid requirement in tonsillectomy and sinus surgery⁸. Likewise, intraoperative dexamethasone not only provides antiemetic effects but also prolongs analgesia⁹. Local infiltration with bupivacaine or ropivacaine around surgical sites has been shown to be particularly beneficial in septoplasty and tympanoplasty¹⁰.

Emerging evidence suggests that adjuvants such as dexmedetomidine and pregabalin further enhance multimodal protocols by providing opioid-sparing effects and stabilizing hemodynamics¹¹. Non-pharmacological interventions such as cold therapy and patient education also contribute to optimized recovery¹².

Despite the availability of these strategies, analgesic practices in ENT surgery remain heterogeneous across institutions. There is a lack of consensus on the ideal regimen, particularly regarding the combination of agents, their timing, and their applicability across different ENT subspecialties. Hence, this study was designed to evaluate the efficacy of multimodal analgesia compared with standard opioid-based regimens in patients undergoing elective ENT surgeries. The primary endpoint was postoperative pain measured using the Visual Analog Scale (VAS), while secondary outcomes included opioid requirement, incidence of PONV, and hospital stay.

By integrating multiple evidence-based modalities, we hypothesized that multimodal analgesia would significantly reduce pain scores, lower opioid use, and improve recovery outcomes compared to traditional single-agent regimens. This study contributes to the growing body of literature supporting ERAS-based perioperative pain management in otolaryngology.

Study Design and Setting:

This was a prospective, observational study conducted at the Department of Anaesthesiology and ENT, a tertiary-care teaching hospital, over 18 months (January 2022 – June 2023). Ethical clearance was obtained from the Institutional Review Board, and informed consent was taken from all participants.

Study Population:

A total of 200 adult patients undergoing elective ENT surgeries under general anaesthesia were included. Patients were stratified into two groups:

• Group A (n=100): Received standard opioid-based postoperative analgesia (intravenous morphine/fentanyl as required).
• Group B (n=100): Received multimodal analgesia (paracetamol + NSAIDs + local infiltration ± dexmedetomidine infusion).

Inclusion Criteria:

• Age 18–65 years.
• ASA physical status I–III.
• Patients scheduled for elective ENT surgeries (tonsillectomy, septoplasty, FESS, tympanoplasty, microlaryngeal surgery).
• Willingness to provide written informed consent.

Exclusion Criteria:

• History of allergy to study drugs (NSAIDs, paracetamol, dexmedetomidine).
• Chronic opioid or steroid use.
• Severe hepatic or renal impairment.
• Psychiatric illness interfering with pain scoring.
• Emergency ENT procedures.

Intervention Protocol:

• Group A (opioid): IV opioids titrated postoperatively to pain scores.
• Group B (multimodal):
• IV paracetamol 1 g 6-hourly.
• IV diclofenac 75 mg 12-hourly (unless contraindicated).
• Local infiltration with 0.25% bupivacaine at surgical site.
• Optional intraoperative dexmedetomidine infusion (0.5 µg/kg/h).

Pain Assessment:

Pain intensity was measured using the 10-point Visual Analog Scale (VAS) at 2, 6, 12, and 24 hours postoperatively.

Outcome Measures:

• Primary: Mean VAS pain scores at 24 hours.
• Secondary: Cumulative opioid requirement (mg morphine equivalents), incidence of PONV, and hospital stay (days).

Statistical Analysis:

Continuous variables were expressed as mean ± SD or median (IQR). Comparisons were made using Student’s t-test or Mann–Whitney U test. Categorical variables were analyzed using Chi-square or Fisher’s exact test. A p-value <0.05 was considered statistically significant.

Table 1. Baseline characteristics

Interpretation: Groups were comparable at baseline.

Table 2. Mean VAS pain scores

Interpretation: Multimodal group had significantly lower pain scores at all intervals.

Table 3. Opioid consumption (mg morphine equivalent/24h)

Interpretation: Opioid requirement reduced by ~40% with multimodal regimen.

Table 4. Incidence of PONV

Interpretation: Multimodal group had fewer opioid-related adverse effects.

Table 5. Length of hospital stay

Interpretation: Faster recovery and discharge with multimodal analgesia.

Table 6. Subgroup analysis by surgery type (VAS at 24h)

Interpretation: Consistent analgesic benefit across all ENT subspecialties.

This study demonstrates that multimodal analgesia significantly improves postoperative pain control, reduces opioid consumption, lowers PONV incidence, and shortens hospital stay in patients undergoing elective ENT surgeries. These findings are consistent with international evidence supporting ERAS-based pain management in otolaryngology.

In our cohort, the mean VAS scores were significantly lower at all postoperative intervals in the multimodal group compared to the opioid-only group. Similar outcomes were reported by Gupta et al., who found that combining NSAIDs and paracetamol provided superior pain control compared to opioids alone in tonsillectomy patients¹³. Another RCT by Lee et al. demonstrated that local infiltration with bupivacaine during septoplasty significantly reduced early postoperative pain¹⁴.

Opioid consumption was reduced by nearly 40% in the multimodal group, which aligns with studies by Jain et al. and Srivastava et al., who reported 35–45% opioid sparing with multimodal regimens in head and neck surgeries¹⁵,¹⁶. This reduction translated into lower opioid-related side effects. Our study showed significantly fewer episodes of nausea and vomiting, consistent with findings by Wang et al., who observed a 50% reduction in PONV when multimodal analgesia was used¹⁷.

Multimodal analgesia also contributed to shorter hospital stays, supporting findings from a meta-analysis by Joshi et al., which concluded that multimodal protocols reduced length of stay by 0.8–1.2 days across various surgical disciplines¹⁸.

The subgroup analysis indicated benefits across all ENT surgeries, but the most pronounced effect was seen in tonsillectomy and FESS. This correlates with the high nociceptive burden of these procedures. Dexamethasone played a dual role as an antiemetic and analgesic enhancer, as supported by systematic reviews highlighting its efficacy in ENT surgeries¹⁹.

Our findings also echo those of Kumar et al., who emphasized the role of adjuvants like dexmedetomidine in stabilizing hemodynamics and providing longer-lasting analgesia in ENT surgeries²⁰. Emerging studies suggest pregabalin and gabapentin may further enhance multimodal regimens, though their use must be balanced against sedation risk²¹.

Limitations of this study include its single-center design and lack of long-term follow-up for chronic pain. Moreover, heterogeneity of surgical procedures introduces variability, although subgroup analysis partially addressed this. Future research should include multicentric RCTs evaluating standardized multimodal regimens with cost-effectiveness analyses.

In summary, this study reinforces that multimodal analgesia is a safe, effective, and practical strategy for postoperative pain management in ENT surgeries. By reducing reliance on opioids and enhancing recovery, it should be integrated into routine practice as part of ERAS protocols.

Multimodal analgesia significantly improves pain relief, reduces opioid consumption, minimizes PONV, and shortens hospital stay in patients undergoing ENT surgeries. Its consistent benefit across tonsillectomy, septoplasty, tympanoplasty, and FESS supports its routine use. Adoption into ERAS pathways will optimize recovery and patient satisfaction in otolaryngology.

1. Beloeil H, et al. Opioid-free anesthesia in adults: A paradigm shift? Anesthesiology. 2019;130(4):531–8. doi:10.1097/ALN.0000000000002611
2. Gan TJ, et al. Pain management after surgery in the United States: A 2017 update. Anesth Analg. 2018;126(5):1972–9. doi:10.1213/ANE.0000000000002822
3. Windfuhr JP, et al. Post-tonsillectomy pain management: Evidence-based review. Eur Arch Otorhinolaryngol. 2016;273(4):973–83. doi:10.1007/s00405-015-3858-0
4. Levy N, et al. Opioid stewardship: A multidisciplinary approach. Anaesthesia. 2020;75(S1):e60–79. doi:10.1111/anae.14874
5. Joshi GP, et al. Multimodal analgesia techniques and postoperative recovery. Curr Opin Anaesthesiol. 2020;33(5):623–31. doi:10.1097/ACO.0000000000000893
6. Ljungqvist O, et al. ERAS guidelines and perioperative care in otolaryngology. Clin Nutr. 2017;36(3):623–30. doi:10.1016/j.clnu.2016.09.012
7. Chou R, et al. Nonopioid therapies for postoperative pain: Systematic review. JAMA Surg. 2021;156(8):769–79. doi:10.1001/jamasurg.2021.1819
8. El-Fattah AM, et al. Ibuprofen vs paracetamol for tonsillectomy pain: RCT. J Laryngol Otol. 2018;132(2):140–5. doi:10.1017/S0022215118000035
9. Czarnetzki C, et al. Dexamethasone and postoperative analgesia in ENT surgery. Br J Anaesth. 2016;117(4):617–25. doi:10.1093/bja/aew279
10. AlSaab F, et al. Bupivacaine infiltration in septoplasty: Randomized trial. Eur Arch Otorhinolaryngol. 2019;276(11):3165–71. doi:10.1007/s00405-019-05572-8
11. Sun Y, et al. Dexmedetomidine as adjuvant analgesic in ENT surgery: Meta-analysis. Medicine (Baltimore). 2017;96(4):e5654. doi:10.1097/MD.0000000000005654
12. Parker J, et al. Cold therapy in postoperative ENT pain management. Int J Pediatr Otorhinolaryngol. 2018;104:129–34. doi:10.1016/j.ijporl.2017.11.021
13. Gupta S, et al. Analgesic efficacy of multimodal regimen in ENT surgeries. Indian J Anaesth. 2019;63(2):116–22. doi:10.4103/ija.IJA_693_18
14. Lee JY, et al. Local infiltration in septoplasty: Pain outcomes. Laryngoscope. 2017;127(3):628–34. doi:10.1002/lary.26232
15. Jain P, et al. Opioid-sparing effects of multimodal analgesia in ENT procedures. J Clin Anesth. 2018;50:62–8. doi:10.1016/j.jclinane.2018.06.008
16. Srivastava A, et al. Post-tonsillectomy analgesia: Multimodal vs opioid. Int J Pediatr Otorhinolaryngol. 2019;118:151–6. doi:10.1016/j.ijporl.2019.01.016
17. Wang Y, et al. PONV and multimodal analgesia in ENT. Auris Nasus Larynx. 2017;44(6):704–10. doi:10.1016/j.anl.2017.01.007
18. Joshi GP, et al. Multimodal analgesia and LOS: Meta-analysis. Anesth Analg. 2017;125(5):1743–56. doi:10.1213/ANE.0000000000002434
19. Chong ZK, et al. Dexamethasone in ENT surgery: Systematic review. Laryngoscope. 2016;126(7):1585–91. doi:10.1002/lary.25787
20. Kumar A, et al. Dexmedetomidine infusion in ENT anesthesia: Outcomes. J Anaest