DNAP

Intranasal Fentanyl for Myringotomy and Tympanostomy Tubes in Children:

A Case Report

 

Michael Storm CRNA, MNA
Missouri State University

 

Abstract

Pain management without an intravenous access is always a challenge. This case report shows the feasibility of an alternative route for delivery of intraoperative pain medication for the short bilateral myringotomy and tympanostomy with tube placement procedure. Intranasal fentanyl 2 mcg/kg, given in divided doses to each naris, was shown to be a suitable route of intraoperative opioid administration. The literature shows that time from the end of surgery to discharge is not extended. The intranasal route is both a convenient and safe practice to administer intraoperative opioids.

Keywords

Intranasal fentanyl, myringotomy and tympanostomy, BMT, acetaminophen, pain management, anesthesia.

Clinical Question

This case report examines whether intranasal fentanyl is an acceptable approach to pain management for children having myringotomy and tympanostomy tube placement.

Bilateral myringotomy and tympanostomy tube placement (BMT) is a common, very short pediatric procedure performed under general anesthesia.1 Due to the short nature of the procedure and with no manipulation of the airway involved most BMT surgeries are done without intravenous (IV) access.1 Although BMT surgery is not considered a very painful procedure, the tympanic membrane is a sensitive area,1 and children may show signs of behavioral agitation in the recovery phase after surgery.2 Differentiation between pain-related behavior and emergence agitation (EA) can be especially difficult in young, preschool children.2,3 This subset of children encompasses most BMT surgeries.

Without IV access, pain management becomes a challenge. Since liquids given by mouth within two hours of surgery may increase the risk for perioperative pulmonary aspiration,4 an alternative is necessary making the intranasal (IN) route attractive. Other routes for opioid medication include intramuscular injection (IM)3,5 or sublingual administration while other modalities include the use of acetaminophen rectal suppository1,2,5,6 or a regional block.7 Many centers utilize a multi-pronged approach to pain management with opioids and rectal or oral acetaminophen being the most popular combination, although, some use oral ketorolac as well.1,2,5,6,8 Oral acetaminophen only adds a very small volume to the gastric content (US concentration is 160 mg/5 mL),9 which is similar to chewing gum.10 At this institution, the current analgesic therapy is oral acetaminophen combined with IN fentanyl for some CRNAs or oral analgesics dispensed when patients arrive to PACU. This case report provides evidence for the use of oral acetaminophen combined with IN fentanyl and may result in improvements to the current analgesic approach.

Case History

The patient was a 29-month-old boy scheduled for bilateral  myringotomy and tympanostomy with tube placement (BMT) who was scheduled for his fourth BMT surgery due to chronic recurrent otitis media.

Demographics, as well as pertinent pre-operative vital signs and medical history include patient height 89 cm with a weight of 13.2 kg, which fell within normal range on the US growth chart for children.11 Both parents were present during admission. The staff were unable to obtain pre-operative non-invasive blood pressure (BP), heart rate (HR) 108, respiratory rate (RR) 22, temperature 98.0 degree Fahrenheit, and pulse oximetry (SpO2) 100% on room air. Previous medical history included gastroesophageal reflux disease (GERD) for which the child uses Prevacid daily and reactive airway disease for which child uses Singulair daily. Otherwise the child was healthy. Previous surgical history included BMT three times in the past, cleft lip and palate repair, and a fistula repair. The child recovered well from previous surgeries.

Anesthetic examination revealed normal airway, despite the history of cleft lip and palate repair. Normal heart rhythm and rate with no murmurs noted, and lungs were clear to all fields by auscultation. Parents were not aware of any known drug allergies (NKDA) nor anesthetic complications after the previous anesthetic exposures. The child was assigned an American Society of Anesthesiologists (ASA) physical status class 2 and had been nil per os (NPO) for more than eight hours prior to surgery. No laboratory, x-ray, or other pre-surgical test were indicated for the scheduled procedure.

The preoperative diagnosis for this child was chronic recurrent otitis media. The child was expected to tolerate surgery and anesthesia well, and no complications were anticipated. Due to the very short nature of this procedure intravenous access, as well as airway manipulation, was avoided as is usual for BMT surgery in children.

The child received oral acetaminophen 10 mg/kg 20 minutes prior to going to the operating room (OR). After placement of standard ASA monitors, anesthesia was induced using 6% sevoflurane along with 70% nitrous oxide and 30% oxygen. Anesthesia was maintained with 2.4% sevoflurane in 50% nitrous oxide and 50% oxygen. After an uneventful inhalational induction and prior to start of surgery, intranasal (IN) fentanyl at 2 mcg/kg was administered by squirting 1 mcg/kg up each naris using a 1 mL syringe. The surgery lasted 15 minutes from incision time till leaving the OR.

After the procedure the patient was transported to the post-anesthesia care unit (PACU) in a crib. Report to the PACU RN was given by the CRNA. Initial PACU assessment documented an Aldrette score of 5/10 (deductions made for limited breathing, unresponsive, and unable to move voluntarily). In the narrative notes this was documented as “sleeping with easy respiration”. Vital signs were BP 83/47, HR 113, RR 15, temperature 98.5 degree Fahrenheit, and SpO2 100%. No supplemental oxygen was needed. After five minutes the Aldrette score was 10/10. After being in PACU for seven minutes the child was noted to awaken quietly with no crying. Ten minutes after arrival to PACU the mother was brought to the bedside and the child, at this time awake without crying, was placed with the mother in a reclining chair.

The child remained in PACU for 20 minutes before being transported in the recliner chair on mothers lap to outpatient (OPS) area for subsequent discharge. The child was noted to be calm with easy respiration. Vital signs on discharge from PACU to OPS were BP 98/52, HR 100, RR 16, temperature 98.5 degree Fahrenheit, and SpO2 100%.

Literature Search

Google Scholar and Missouri State University Library’s Academic Search Complete databases were used to find relevant research articles. University of South Carolina Medical School Library was utilized to download PDF files of articles not accessible by the other two methods. Included search terms were: BMT AND intranasal fentanyl; intranasal fentanyl AND pediatrics; indications for tympanostomy; onset oral acetaminophen AND BMT. Furthermore, reference lists from selected articles were also reviewed for potential additions to the search. Seventeen relevant articles, six articles specific for BMT, were selected.

Mean surgical time was quoted to be less than 7 minutes for BMT.3 Concerns could be raised if use of opioids during such a short procedure would delay discharge from the hospital. Both Dewhirst et al.1 and Finkel et al.2 addressed the opioid issue and showed no delays in total recovery time or time to discharge for children receiving opioids during surgery. 

Several of the studies compared different drugs, drug combinations, or regional block. Fentanyl was consistently shown1–3,6,7 to be at least as effective as morphine,3 ketorolac,5 dexmedetomidine,1 or regional block of the auricular branch of the vagus nerve also known as Arnold’s nerve.7

In studies not related to BMT surgery, Murphy et al.12 and Hansen et al.13 found IN fentanyl to be as effective as IV fentanyl to control acute pain. Saunders et al.14 also showed that IN fentanyl provided rapid and sustained analgesia in a majority of patients.

The risk that fluid injected intranasally could flow into the larynx, hit the vocal cords and cause laryngospasm, does exist. However, the risk for laryngospasm has been shown to be no different with fentanyl than with intranasal placebo sprays.3 None of the studies uncovered during the literature search, reported of increased risk for laryngospasm with the use of IN fentanyl.

American Society of Anesthesiologists (ASA) committee of Standards and Practice Parameters released the latest fasting guidelines in 2011.4 Although, these practice guidelines are not intended to set standards of care or absolute requirements, their mere existence would most certainly rise to this level if a complaint went to court.15 These practice guidelines recommend that patients remain fasting at a minimum of two hours prior to surgery for clear liquids, four hours for breast milk, six hours for infant formula, nonhuman milk, and a light meal, and finally eight hours for fatty or greasy foods and meats.

Discussion

Based on personal experiences with bilateral myringotomy and tympanostomy with tube placement (BMT) surgeries this case report hypothesizes that the use of intranasal (IN) fentanyl is an effective and safe analgesic choice for children having BMT surgery and that IN fentanyl does not prolong the time to discharge.

Children suffering from chronic bilateral otitis media with serous effusions and hearing loss are well documented for need of tympanostomy tubes.16,17 Tube placement for recurrent acute otitis media infection is only recommended if middle ear effusion is present.17 Preoperative acetaminophen will provide pain relief after discharge. The onset of rectal acetaminophen is highly variable and range from 45-60 minutes.5 The onset of oral acetaminophen is much more predictable and ranges from 15-30 minutes.18 None of the included studies for this case report used oral acetaminophen. This institution currently attempts to administer 10 mg/kg of oral acetaminophen 30-60 minutes prior to surgery. Support is found in the literature that increasing the oral dose to 15 mg/kg could potentially improve the postoperative and post-discharge pain management.8

The majority (5/6) of the studies1–3,6,7 specific to BMT surgery found unequivocal benefit of IN fentanyl. These studies found that IN fentanyl was as effective or better than comparable drugs studied. Use of IN fentanyl is indicated for the acute pain during surgery and in the immediate recovery phase. The combination of rectal acetaminophen and an opioid was utilized for all patients in 4/6 of the studies.1,2,5,6 Rampersad et al.5 found that IN fentanyl was not effective in reducing emergence agitation, although, a significantly smaller dose of IN fentanyl (1 mcg/kg versus 2 mcg/kg) was dispensed in this study compared to the other studies.

The combination of preoperative acetaminophen and intraoperative fentanyl provides adequate pain relief for BMT surgical patients. Furthermore, there is substantial support in the literature, that IN fentanyl is a viable alternative route for the administration of intraoperative opioid. The use of IN fentanyl solves the issue of not having intravenous access for pain management. The utilization of IN fentanyl has not been shown to increase the time from end of surgery to discharge of the patient and can safely be utilized for pain management for the BMT patient.

Conclusions and Recommendations

In summary, intraoperative intranasal (IN) fentanyl 2 mcg/kg in combination with preoperative oral acetaminophen 15 mg/kg is likely the best combination of drugs to control pain after bilateral myringotomy and tympanostomy with tube placements (BMT). Oral acetaminophen is a more predictable choice than rectally administered acetaminophen. Although, the referenced studies all used rectal acetaminophen, this change in protocol will add a needed predictability to the pain management of these patients.

Increased length of stay after surgery is a concern for the parents and a financial constraint for the hospital. Therefore, prolongation of time to discharge, due to the use of opioids for these short procedures, is not acceptable. This case study confirms the feasibility of using the intranasal route for administering intraoperative opioids for the child undergoing bilateral myringotomy and tympanostomy with tube placements without prolonging the time to discharge.

References

1.        Dewhirst E, Fedel G, Raman V, et al. Pain management following myringotomy and tube placement: Intranasal dexmedetomidine versus intranasal fentanyl. Int J Pediatr Otorhinolaryngol. 2014;78(7):1090-1094. doi:10.1016/j.ijporl.2014.04.014.

2.        Finkel JC, Cohen IT, Hannallah RS, et al. The effect of intranasal fentanyl on the emergence characteristics after sevoflurane anesthesia in children undergoing surgery for bilateral myringotomy tube placement. Anesth Analg. 2001;92(5):1164-1168. doi:10.1097/00132586-200204000-00024.

3.        Hippard HK, Govindan K, Friedman EM, et al. Postoperative analgesic and behavioral effects of intranasal fentanyl, intravenous morphine, and intramuscular morphine in pediatric patients undergoing bilateral myringotomy and placement of ventilating tubes. Anesth Analg. 2012;115(2):356-363. doi:10.1213/ANE.0b013e31825afef3.

4.        ASA Committee on Standards and Practice Parameters. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures. Anesthesiology. 2011;114(3):495-511. doi:10.1097/ALN.0b013e3181fcbfd9.

5.        Rampersad S, Jimenez N, Bradford H, Seidel K, Lynn A. Two-agent analgesia versus acetaminophen in children having bilateral myringotomies and tubes surgery. Paediatr Anaesth. 2010;20(11):1028-1035. doi:10.1111/j.1460-9592.2010.03427.x.

6.        Galinkin JL, Fazi LM, Cuy RM, et al. Use of intranasal fentanyl in children undergoing myringotomy and tube placement during halothane and sevoflurane anesthesia. Anesthesiology. 2000;93(6):1378-1383. doi:10.1097/00132586-200108000-00004.

7.        Voronov P, Tobin MJ, Billings K, Coté CJ, Iyer A, Suresh S. Postoperative pain relief in infants undergoing myringotomy and tube placement: Comparison of a novel regional anesthetic block to intranasal fentanyl - A pilot analysis. Paediatr Anaesth. 2008;18(12):1196-1201. doi:10.1111/j.1460-9592.2008.02789.x.

8.        Bean-Lijewski JD, Stinson JC. Acetaminophen or ketorolac for post myringotomy pain in children? A prospective, double-blinded comparison. Paediatr Anaesth. 1997;7(2):131-137.

9.        McNeil Consumer Healthcare, Tylenol.com. Children’s TYLENOL Oral Suspension. 2012. http://www.tylenolprofessional.com/patient-education-handouts.html#. Accessed July 4, 2015.

10.      Goudra BG, Singh PM, Carlin A, et al. Effect of Gum Chewing on the Volume and pH of Gastric Contents: A Prospective Randomized Study. Dig Dis Sci. 2015;60(4):979-983. doi:10.1007/s10620-014-3404-z.

11.      National Center for Health Statistics. Birth to 36 months: Growth Chart. Heal Promot. 2000. http://www.cdc.gov/growthcharts/data/set1clinical/cj41l017.pdf. Accessed July 2, 2015.

12.      Murphy A, O’Sullivan R, Wakai A, et al. Intranasal fentanyl for the management of acute pain in children. Cochrane Database Syst Rev. 2012;Volume|(7). doi:10.1002/14651858.CD009942.

13.      Hansen MS, Mathiesen O, Trautner S, Dahl JB. Intranasal fentanyl in the treatment of acute paina systematic review. Acta Anaesthesiol Scand. 2012;56(4):407-419. doi:10.1111/j.1399-6576.2011.02613.x.

14.      Saunders M, Adelgais K, Nelson D. Use of intranasal fentanyl for the relief of pediatric orthopedic trauma pain. Acad Emerg Med. 2010;17(11):1155-1161. doi:10.1111/j.1553-2712.2010.00905.x.

15.      Miller RD (ed). Miller’s Anesthesia. Vol 7th ed. (Miller RD, Eriksson LI, Fleisher LA, Wiener-Kronish HP, Young WL, eds.). Philadelphia, PA: Churchill Livingstone, Elsevier; 2010.

16.      Rosenfeld RM, Schwartz SR, Pynnonen M, et al. Clinical Practice Guideline: Tympanostomy Tubes in Children. Otolaryngol -- Head Neck Surg. 2013;149(1 Suppl):S1-S35. doi:10.1177/0194599813487302.

17.      Whittemore KR. Tympanostomy tubes: Patient selection and special considerations. Pediatr Heal Med Ther. 2015;6:41-44.

18.      Prescott LF. Kinetics and metabolism of paracetamol and phenacetin. Br J Clin Pharmacol. 1980;10 Suppl 2:291S - 298S. doi:10.1111/j.1365-2125.1980.tb01812.x.