What are the recommended first‑line analgesics and dosing for ear‑nose‑throat conditions and postoperative ENT pain, and when should opioids be added?

First-Line Analgesics for ENT Pain

For ear-nose-throat conditions and postoperative ENT pain, acetaminophen (paracetamol) combined with NSAIDs (ibuprofen or ketoprofen) should be administered at fixed intervals as first-line therapy, with opioids reserved strictly for moderate-to-severe pain and limited to 48-72 hours maximum. 1, 2, 3

Initial Analgesic Strategy

Non-Opioid Foundation (Start Immediately)

Acetaminophen (Paracetamol):

• Adults: 650-1000 mg every 6 hours (maximum 4 g/24 hours) 1, 4
• Pediatrics: 10-15 mg/kg every 6 hours (maximum 60 mg/kg/day) 5
• Administer at fixed intervals, not PRN, when frequent dosing is required 1

NSAIDs (choose one):

• Ibuprofen: 10 mg/kg every 8 hours (pediatrics) or 600 mg every 8 hours (adults) 5, 2, 4
• Ketoprofen: 1 mg/kg IV every 8 hours 5, 3
• Ketorolac: 0.5-1 mg/kg IV (maximum 30 mg single dose), then 0.15-0.2 mg/kg every 6 hours (maximum 48 hours) 5

Critical timing: Acetaminophen and ibuprofen should ideally be taken simultaneously every 6 hours when combined, not staggered 2

Evidence for Combination Therapy

The combination of acetaminophen plus NSAIDs provides superior analgesia compared to either agent alone. In tonsillectomy patients, adding paracetamol to ketoprofen reduced opioid rescue doses by 27-38% without reducing the proportion requiring rescue 3. Most ENT surgery patients (63-84%) achieve adequate pain control with acetaminophen alone or acetaminophen plus ibuprofen 4, 6

When to Add Opioids

Indications for Opioid Addition

Add opioids only when:

• Pain intensity is moderate-to-severe (VAS ≥5 or EVENDOL 7-10 in children) 2
• Pain remains inadequately controlled (residual VAS ≥3) despite optimal non-opioid therapy 2
• Procedure is tonsillectomy (significantly higher pain and opioid requirements than other ENT procedures) 6

Opioid Selection and Dosing

Immediate postoperative (PACU):

• Fentanyl: 1-2 mcg/kg IV in divided doses to treat breakthrough pain 5, 7

Ward/outpatient:

• Oxycodone: 5 mg immediate-release every 4-6 hours as needed 4, 8
• Hydromorphone: Immediate-release for breakthrough pain 8
• Tramadol: Oral or rectal (pediatrics) 5

Strict Opioid Limitations

Maximum duration: 48-72 hours 1, 9

• Prescribe 5 days standard, 7 days absolute maximum 9
• Never prescribe as refill/repeat prescriptions 9
• Most ENT patients require fewer than 15 doses total 6
• Tonsillectomy is the exception requiring longer duration 6

Procedure-Specific Algorithms

Tonsillectomy (Highest Pain)

1. Preoperative: Dexamethasone 8 mg IV (adults) or 0.15 mg/kg (pediatrics) to reduce swelling 5
2. Intraoperative: Fentanyl 1-2 mcg/kg + ketamine 0.5 mg/kg bolus 5
3. Postoperative:
   • Acetaminophen + NSAID at fixed intervals 5, 2
   • Oxycodone 5 mg for breakthrough pain (VAS >5) 4
   • Continue for 5-7 days given higher pain trajectory 6

Endoscopic Sinus Surgery (Lower Pain)

1. Postoperative:
   • Acetaminophen 650 mg as first-line 4
   • Ibuprofen 600 mg as second-line if VAS >3 4
   • Oxycodone 5 mg reserved for breakthrough only (26% of patients required any opioid) 4
2. Duration: Most patients need only acetaminophen or acetaminophen + ibuprofen 4

Ear Surgery (Variable Pain)

1. First-line: Acetaminophen or NSAIDs 1
2. Moderate-severe pain: Fixed-combination acetaminophen/oxycodone or ibuprofen/oxycodone 1
3. Duration: 48-72 hours maximum 1
4. Avoid: Benzocaine otic drops (not FDA-approved, masks disease progression) 1

Multimodal Adjuncts to Reduce Opioid Requirements

Intraoperative Additions

• Dexamethasone: 8 mg IV (adults) or 0.15-0.25 mg/kg (pediatrics) 5
• Ketamine: 0.5 mg/kg bolus after induction, then 0.125-0.25 mg/kg/h infusion (stop 30 minutes before end of surgery) 5
• IV Lidocaine: 1-2 mg/kg bolus, then 1-2 mg/kg/h infusion 5
• Alpha-2 agonists: Clonidine or dexmedetomidine 5, 7

These adjuncts decrease acute pain intensity for 24 hours and reduce morphine consumption by approximately 15 mg/24 hours 5

Critical Pitfalls to Avoid

NSAID Contraindications in ENT

Do NOT prescribe NSAIDs when:

• Severe or complicated pediatric ENT infections present 2
• Unusual clinical presentation develops (suspend NSAIDs immediately) 2
• Duration exceeds 72 hours in pediatric infections 2
• Curative-dose anticoagulation is prescribed 5

Opioid Prescribing Errors

Never:

• Add opioids to repeat prescription templates (leads to inadvertent chronic therapy) 9
• Prescribe beyond 7 days without specialist consultation 9
• Use extended-release formulations for acute ENT pain 9
• Prescribe opioids without concurrent non-opioid analgesics 1, 4

Diagnostic Errors

Always visualize the tympanic membrane before treating ear pain—failure to remove obstructing cerumen leads to misdiagnosis and inappropriate therapy 1. Treating ear pain without otoscopic examination risks missing acute otitis media (requiring different management than otitis externa) or serious complications like mastoiditis 1

Monitoring and Follow-Up

• Reassess at 48-72 hours: Patients should show clinical improvement; lack of improvement warrants reassessment for treatment failure or misdiagnosis 1
• Check PDMP if considering opioid refill 9
• Wean systematically: Follow reverse analgesic ladder—stop opioids first, then NSAIDs, finally acetaminophen 9
• Unused opioids: Patients must return excess to pharmacy, never dispose at home 9

Special Populations

Pediatric Considerations

• Use weight-based dosing for all analgesics 5, 2
• Combine acetaminophen and ibuprofen simultaneously every 6 hours for moderate pain (VAS 3-5 or EVENDOL 4-7) 2
• NSAIDs at analgesic doses (20-30 mg/kg/day ibuprofen), not anti-inflammatory doses 2
• Tramadol or nalbuphine as rescue opioid 5

Patients on Chronic Opioids

• Avoid mixed agonist-antagonist opioids (pentazocine, nalbuphine, butorphanol) as they precipitate acute withdrawal 1
• Start with higher opioid doses due to tolerance 5
• Consider ketamine 0.5 mg/kg/h as anti-hyperalgesic adjunct 5