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\begin{document}

\title{Post-operative Pain: An audit of patient reported pain scores after
endoscopic and microscopic ear surgery}



\author[1]{Rhona McCallum}%
\author[2]{Mohd Afiq Mohd Slim}%
\author[1]{Arunachalam Iyer}%
\affil[1]{Monklands Hospital}%
\affil[2]{Queen Elizabeth University Hospital Campus}%


\vspace{-1em}



  
  \date{June 17, 2024}


\begingroup
\let\center\flushleft
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\selectlanguage{english}
\begin{abstract}
Objectives The aim of this study was to compare patient reported pain
scores and analgesia requirements between endoscopic and microscopic ear
surgery. Design Prospective cohort study Setting Secondary care setting
from June 2017 to December 2020. Participants Patients undergoing ear
surgery performed by a single surgeon. Main outcome measures The primary
outcome measure was patient reported pain as recorded by a visual
analogue scale (VAS) at days 1,2,3 and 7 post-operatively. Secondary
outcome measure was post-operative analgesia requirement. Results
Overall, forty-nine patients encompassing 65.3 \% (32/49) endoscopic and
34.7\% (17/49) microscopic procedures were audited. Endoscopic
procedures have statistically significant lower VAS pain threshold
outcomes when compared against the microscopic procedures on post-
operative day one (endoscopic group median VAS 1.5 {[}0.00;11.5{]} mm
versus microscopic group median VAS 27.0 {[}15.0;65.0{]} mm); to day
seven (endoscopic group median VAS 0.5 {[}0.00;2.75{]} mm versus
microscopic group median VAS 9.00 {[}2.00;52.0{]} mm).~ Requirement for
analgesia was greater in the microscopic group at day one compared to
the endoscopic group (64.5 \%, 20/31 endoscopic group vs. 100 \%, 17/17
microscopic; p= 0.004). Conclusion Endoscopic ear surgery is less
painful and requires less analgesia in the initial post-operative period
than microscopic surgery in this cohort. The overall results of this
study are useful for pre-operative patient counselling and pain
management in the clinical setting. Given the differing applications of
microscopic and endoscopic ear surgery, further research is required to
study the influence of bone removal, type of operation, and incision
type on pain after ear surgery.%
\end{abstract}%



\sloppy


\emph{Post-operative Pain: An audit of patient reported pain scores
after endoscopic and microscopic ear surgery}

\textbf{Objectives}

The aim of this study was to compare patient reported pain scores and
analgesia requirements between endoscopic and microscopic ear surgery.

\textbf{Design}

Prospective cohort study

\textbf{Setting}

Secondary care setting from June 2017 to December 2020.

\textbf{Participants}

Patients undergoing ear surgery performed by a single surgeon.

\textbf{Main outcome measures}

The primary outcome measure was patient reported pain as recorded by a
visual analogue scale (VAS) at days 1,2,3 and 7 post-operatively.
Secondary outcome measure was post-operative analgesia requirement.

\textbf{Results}

Overall, forty-nine patients encompassing 65.3 \% (32/49) endoscopic and
34.7\% (17/49) microscopic procedures were audited. Endoscopic
procedures have statistically significant lower VAS pain threshold
outcomes when compared against the microscopic procedures on post-
operative day one (endoscopic group median VAS 1.5 {[}0.00;11.5{]} mm
versus microscopic group median VAS 27.0 {[}15.0;65.0{]} mm); to day
seven (endoscopic group median VAS 0.5 {[}0.00;2.75{]} mm versus
microscopic group median VAS 9.00 {[}2.00;52.0{]} mm).~ Requirement for
analgesia was greater in the microscopic group at day one compared to
the endoscopic group (64.5 \%, 20/31 endoscopic group vs. 100 \%, 17/17
microscopic; p= 0.004).

\textbf{Conclusion}

Endoscopic ear surgery is less painful and requires less analgesia in
the initial post-operative period than microscopic surgery in this
cohort. The overall results of this study are useful for pre-operative
patient counselling and pain management in the clinical setting. Given
the differing applications of microscopic and endoscopic ear surgery,
further research is required to study the influence of bone removal,
type of operation, and incision type on pain after ear surgery.

\textbf{5 key points:}

\begin{itemize}
\tightlist
\item
  Endoscopic ear surgery is often described as minimally invasive, an
  advantage of which may be reduced pain
\item
  We assessed patient reported pain scores between endoscopic and
  microscopic ear surgery within the first week post-operatively
\item
  Pain scores related to endoscopic ear surgery were lower than those
  related to microscopic ear surgery in our cohort
\item
  At day one, analgesia requirements were lower in the endoscopic ear
  surgery group than the microscopic ear surgery group
\item
  Due to the differing applications of endoscopic and microscopic ear
  surgery, further research is required to study the influence of
  operation type, bone removal and incision type on pain after ear
  surgery.
\end{itemize}

\textbf{Introduction}

\textbf{Background}

Endoscopic ear surgery (ESS) has been increasingly adopted into practice
over recent years.\textsuperscript{1} The endoscope affords the ability
to ``look around corners'' during middle ear surgery and provides a
detailed view of spaces within the middle ear such as the facial recess
and anterior epitympanum through the trans-meatal
approach.\textsuperscript{2} As such, EES is often described as
minimally invasive, with the potential advantages over microscopic
surgery of preventing additional bone removal or use of the
post-auricular approach in cholesteatoma surgery.\textsuperscript{3} In
addition, the endoscope is also being utilised for non-cholesteatoma
surgery, with proponents citing that this may reduce the need for ear
canal bony removal during myringoplasty, and reduce the potential for
chorda tympani injury in stapes surgery.\textsuperscript{2}

As with every surgical technique, there is a responsibility to measure
and report outcomes. Although it is a widely held belief that EES is
less painful that microscopic ear surgery,\textsuperscript{1} there is
little evidence to support this supposition.\textsuperscript{4,5} Where
pain after endoscopic surgery has been prospectively studied, published
literature from Japan and the Czech Republic is in favour of endoscopic
surgery as being less painful than microscopic
surgery,\textsuperscript{4,5} but recent evidence from the Netherlands
has suggested that no link between surgical approach and pain outcomes
exist.\textsuperscript{6}

\textbf{OBJECTIVES}

We aim to prospectively compare patient-reported pain scores and
analgesia requirements between endoscopic and microscopic ear surgery in
our population.

\textbf{STUDY DESIGN AND SETTING}

\textbf{Setting}

A prospective audit was undertaken of patient-reported post-operative
pain scores after ear surgery performed in the secondary care setting
from June 2017 to December 2020. STROBE reporting guidance has been
followed.

\textbf{Operative Details}

Surgery was either total EES, which we classified as our `endoscopic'
group, whereby the endoscope was used as the sole instrument for
visualisation, or 'microscopic', whereby the microscope was used for
operating with either an endaural or post aural incision. Where the
procedure was endoscopic, a 3 mm, 14 cm rigid telescope (Storz\selectlanguage{ngerman}®,
Tuttlingen, Germany), and a HD 3CCD chip camera (Stryker®, Kalamazoo,
USA). Where EES had to be converted to open surgery, this was classified
into the microscopic surgery group.

\textbf{PARTICIPANTS}

Inclusion criteria were patients who underwent ear surgery by a single
surgeon within the secondary-care setting. These patients were included
if they consented to participate and returned a completed post-operative
pain questionnaire. Exclusion criteria included patients six years-old
and under, due to concerns regarding ability to accurately report pain
via VAS.\textsuperscript{7}

\textbf{Ethical Considerations}

This study was registered and approved as an audit.

\textbf{Data `Sources and Measurement}

Patients were asked to record pain on a visual analogue scale (VAS) at
days 1, 2,3 and 7 post-operatively. Outcomes recorded were pain on a
visual analogue scale, from 0 mm to 100 mm, where 0mm is ``no pain'' and
100mm is ``worst pain imaginable''. A 100 mm VAS was selected as this
scale is accepted for determining pain outcomes in
otolaryngology.\textsuperscript{8} They were given this document to
complete after discharge, and then asked to return it at their first
follow up outpatient appointment or post it back to the department. In
addition, they were asked to fill out a post-operative analgesia diary,
with details regarding the date, dose and type of analgesia taken. For
purpose of data analysis, analgesia used by patients was categorised
into those requiring only simple analgesia or those needing additional
opioid analgesia. Simple analgesia encompassed use of non-steroidal
anti-inflammatory drugs (NSAIDs) and paracetamol.

Data was recorded prospectively using the Common Otology
Audit.\textsuperscript{9} Data used from the database was patient age at
time of operation, name of operation, whether procedure was endoscopic
or microscopic, International Otology Outcome Group (IOOG) mastoidectomy
category where cholesteatoma surgery had taken
place,\textsuperscript{10} IOOG middle ear access category where
applicable,\textsuperscript{10} and incision type.

\textbf{MAIN OUTCOME MEASURES}

Primary outcome measure was VAS at days 1, 2, 3 and 7. Secondary outcome
measure was post-operative analgesia requirement.

\textbf{Subgroup Analysis}

In order to reduce potential sources of bias, for subgroup analysis,
patients were divided into those who had reconstructive procedures,
which were stapes surgery, myringoplasty and ossiculoplasty; and those
who had what we classified as non-reconstructive procedures which
included surgery for cholesteatoma and bony meatoplasty. This was
similar to the categories used by Salzman \emph{et al}
.\textsuperscript{5} In addition, presence or absence of bone removal
was recorded.

\textbf{Statistical Analysis}

The R language was used to analyse the
data.\textsuperscript{11,12}Numerical data was analysed with the
Shapiro-Wilk test for normality distribution. The unpaired Two Sample
T-test (w), reported as mean ± standard deviation, or Mann-Whitney
U-test (u), reported as median {[}Interquartile Range (IQR){]}, was used
depending on distribution. Categorical data were analysed with
Chi-squared test (x\textsuperscript{2}) or Fisher's Exact Test (f). Odds
ratio (OR) was calculated to determine the degree of association between
the type of procedure and analgesia requirement. Sub-analysis based on
the aim of the procedure were also performed and analysed with the
Kruskal Wallis test. Significance value was set at p \selectlanguage{english}[?] 0.05.

\textbf{Results}

\emph{Patient Demographics}

Overall, forty-nine patients encompassing 65.3 \% (32/49) endoscopic and
34.7\% (17/49) microscopic procedures from a single surgeon experience
were audited (Table 1). Of these, 61.2\% (30/49) were categorised into
the reconstructive group and 38.8 \% (19/49) into the non-reconstructive
group (Table 1). Most endoscopic procedures were performed for
reconstructive purposes (84.4\%; 27/32, p\textless{}0.001), and the
majority of procedures in the microscopic group were performed for
non-reconstructive purposes (82.4 \%; 14/17, p\textless{}0.001; Table
1). Of the microscopic group, the post-auricular incision was most used
(70.6\%,12/17) followed by the endaural (23.5, 4/17) incision for
access. (Table 1). Of the endoscopic group, all patients had their
procedure conducted via the trans-canal route.

\emph{VAS}

Overall, endoscopic procedures have statistically significant lower VAS
pain threshold outcomes when compared against the microscopic procedures
on post- operative day one, two, three and seven (Table 2). On subgroup
analysis, pain scores were lower for the endoscopic group at day one
where procedures were carried out for reconstructive reasons (median VAS
1 {[}0;9{]} mm, n=27) compared to the microscopic group (median VAS 80
{[}45;86.5{]} mm, n=3). This was also the case at day two (endoscopic
median VAS 1 {[} 0;6.5{]} mm, n=27, vs. microscopic median VAS 48
{[}34;55.5{]} mm, n=3) (Figure 1, Supplementary Table 1). This
difference did not reach significance at days three and seven (Figure 1,
Supplementary Table 1). For the non-reconstructive procedures at all
time points, this difference did not reach significance, although there
was a trend towards higher pain scores for the microscopic procedures
(Figure 1, Supplementary Table 1).

\emph{Analgesia Scores}

One patient did not complete their analgesia diary and was therefore
excluded. Of the remaining 48 patients, requirement for analgesia was
greater in the microscopic group at day one compared to the endoscopic
group (100 \%, 17/17 microscopic group vs. 64.5 \%, 20/31 endoscopic
group p= 0.004) (Table 3). Difference in analgesia requirements did not
reach significance at each of the other post-operative days studied
(Table 3)\emph{.} In addition, requirement for opioid analgesia was
higher in the microscopic group at day one (p=0.001) and day two (OR:
6.71; p= 0.030) although significance diminishes thereafter (Table 4).
Post-hoc power calculation based on the findings of a recent study
confirmed our study size to have sufficient power (92.7\% with alpha
0.05).\textsuperscript{5} The minimum sample size requirement is 9 for
each arm to reach alpha of 0.05 and power of 80\% to assess the
analgesia requirement on post-operative day-1.

\textbf{Discussion}

\emph{Summary of results/Comparison with Literature}

Overall, EES was associated with lower post-operative pain scores than
microscopic ear surgery in our population. Our overall results agree
with the findings of a group from Japan, who found that pain reported
for total EES was significantly lower than for microscopic ear surgery
from days 1 to 7 post-operatively.\textsuperscript{4} A study from the
Czech Republic of the first four post-operative days, found less pain on
VAS at the first post-operative day in their endoscopic group compared
to their microscopic group.\textsuperscript{5}

Our findings are contradictory to the results of Baazil \emph{et al.} ,
who found no difference in pain thresholds between endoscopic and
microscopic groups, where pain was measured using the Brief Pain
Inventory-Short Form (BPI-SF) on a scale of 0-10.\textsuperscript{6}They
compared pain after 20 operations carried out by endoscopic transmeatal,
microscopic endaural, and retro-auricular approaches, respectively, and
found no difference between groups. As pain scores were generally low,
they concluded that any difference between pain scores were so small as
to be of limited clinical relevance. In our study, VAS was reported at a
median of 1.5 {[}0;11.5{]} mm at post-op day one for the endoscopic
group and a median of 27 {[}15;65{]} mm for the microscopic group.
Difference in median results exceeds what is defined as the minimally
clinically important difference (MCID) which has been measured for
post-operative VAS scores as being 10mm.\textsuperscript{13} We
therefore believe differences between our groups to be of significance.
Of note, operations studied by Baazil et al., within the endoscopic
group included tympanoplasty and atticotomy; and those within the
microscopic groups included stapedotomy, tympanoplasty, atticotomy, and
canal wall up mastoidectomies.\textsuperscript{6} Our study included
stapes procedures only within the endoscopic group, and canal wall down
mastoidectomy within the microscopic group (Table 1), perhaps explaining
our relatively higher pain scores in the microscopic group.

\emph{Subgroup analysis}

Salzman \emph{et al} ., set to address the differing uses of endoscopic
and microscopic surgery by dividing operations into reconstructive and
cholesteatoma procedures.\textsuperscript{5} All mastoid surgery was
excluded. On subgroup analysis, endoscopic cholesteatoma patients
suffered from less pain on post-operative day 1 than the microscopic
group. Where the procedure was reconstructive, there was no significant
difference between groups, but a trend towards less pain within the
endoscopic group than the microscopic group. Unlike this study, we did
not detect a statistically significant difference in pain scores between
our microscopic and endoscopic groups for non-reconstructive procedures,
which included both meatoplasty and cholesteatoma surgery; but found a
statistically significant reduction in VAS after EES compared to
microscopic ear surgery in our reconstructive group at post-operative
days 1 and 2. Numbers within our subgroup analysis were small
(Supplementary Table 1), therefore these results should be approached
with caution. With regards to reconstructive procedures, case series and
metanalysis provide some evidence to support that these may be less
painful than microscopic surgery whilst being conducted
endoscopically.\textsuperscript{14,15,16}

\emph{Bone removal}

There are indications which exist for microscopic surgery which preclude
total EES; for example, if cholesteatoma is present within the mastoid
cavity proper, then microscopic ear surgery is recommended for removal
of disease.\textsuperscript{2} All mastoid procedures were carried out
within our microscopic group (Table 1). This raises the question of
whether differing degrees of bone removal account for the difference in
pain scores between endoscopic and microscopic groups. Similarly,
Kakehata \emph{et al.} , also reported mastoid surgery only within the
microscopic group.\textsuperscript{4} To overcome this, they conducted
subgroup analysis between procedures with no bony removal and those with
varying degrees of removal. Between these subgroups, no significant
difference was detected in pain scores, and it was concluded that bony
removal has no influence over pain scores. We also carried out a
subgroup analysis based on bone removal and no statistically significant
result was found between pain scores between groups. As this subgroup
analysis was underpowered (n=1) in the microscopic non-bone removal
group), this was not included within our main results (Supplementary
Table 2, Supplementary Figure 1). It is therefore difficult to make any
statement about the influence of bone removal on our results.

\emph{Incision Type}

Another difference between endoscopic and microscopic approaches is the
incision type. All but one patient within our microscopic group had
endaural or post-aural incision, and this may account for the difference
between pain scores. In a previous study, patients undergoing EES
reported significantly less scar discomfort, compared to the microscopic
ear surgery group, although this group found no difference in overall
post-operative pain scores.\textsuperscript{17} Patients were asked to
score pain retrospectively at follow-up 2 weeks
post-operatively.\textsuperscript{17} The influence of incision type on
pain is an area which requires further study.

\emph{Analgesia requirements}

We found increased requirement for analgesia in the microscopic group at
day 1 post-operatively, and an increased requirement for opioid
analgesia at day 1 and day 2 post-operatively in the microscopic group
(Table 3; Table 4). Kakehata \emph{et al.} kept patients as inpatients
for the course of their stay, and only offered hospital prescribed
NSAIDs.\textsuperscript{4} They detected significantly lower analgesia
use post-operatively in their endoscopic compared to microscopic group
from day 1 to day 7. Although Salman \emph{et al.} also found a trend
towards lower painkiller use in patients who were operated
endoscopically, these results did not reach
significance.\textsuperscript{5} Baazil \emph{et al.} reported that the
endaural microscopic group required half as much medication as their
retro-auricular microscopic and endaural transmeatal groups, a result
which is unexplained.\textsuperscript{6} However, their endoscopic group
had a lower requirement for opioids for pain control post-operatively
compared to the other groups, consistent with our findings. We therefore
believe that the current evidence points towards lesser analgesia
requirements after EES.

\emph{Limitations}

As stated, a limitation of this study is sample size, which diminishes
on subgroup analysis and would be better served by greater patient
numbers. As discussed, types of operations in each group differed due to
both patient and surgeon factors. Although subgroup analysis has helped
to eliminate some of this bias, a randomised control trial would be the
best way to measure pain outcomes between groups. Secondly, the number
of patients audited was dependent upon patients remembering to fill in
and return their forms, which may have opened our audit to bias.

Additionally, a previous study has reported that the threshold below
which patients consider themselves recovered postoperatively from
surgery to be 33mm on VAS.\textsuperscript{13} Overall median VAS scores
are lower that this value across our study, with the exception of a
median post-operative VAS at day 2 of 36 {[}20;63{]} mm for the
microscopic group (Table 1). However, as discussed above, the difference
between endoscopic and microscopic VAS scores has clinical relevance.
Ear surgery has been found to be 4 to 10 ten times less painful in
general compared to pain in other subsites of the head and neck, such as
oral cavity and pharynx, and therefore our lower VAS scores were not
unexpected.\textsuperscript{8} We believe that the generally low VAS
scores across our study should not preclude future groups from studying
differences in pain between otologic interventions in their population.

\textbf{Conclusions}

We have found that EES overall is less painful and requires less
analgesia in the initial post-operative period than microscopic surgery.
Where differing applications of endoscopic and microscopic procedures
are accounted for within subgroup analysis, the difference only holds
true for reconstructive procedures. It must be acknowledged that the
strength of conclusion which can be drawn from subgroup analysis is weak
due to small patient numbers. However, the overall results of this study
are useful for pre-operative patient counselling and pain management in
the clinical setting. Further research is required to study the
influence of bone removal, type of operation, and incision type on pain
after ear surgery.

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T\textbf{able 1:}\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
& All & Endoscopic & Microscopic & p-value\tabularnewline
\midrule
\endhead
& n=49 & n=32 & n=17 &\tabularnewline
\textbf{Age (years-old)} & 40.3 (16.1) & 42.5 (15.6) & 36.1 (16.7) &
0.200\tabularnewline
\textbf{Age Category}: & & & & 1.000\tabularnewline
Adult & 44 (89.8\%) & 29 (90.6\%) & 15 (88.2\%) &\tabularnewline
Child & 5 (10.2\%) & 3 (9.38\%) & 2 (11.8\%) &\tabularnewline
\textbf{Gender:} & & & & 0.917\tabularnewline
Female & 24 (49.0\%) & 15 (46.9\%) & 9 (52.9\%) &\tabularnewline
Male & 25 (51.0\%) & 17 (53.1\%) & 8 (47.1\%) &\tabularnewline
\textbf{Bone Removal:} & & & & \textless{}0.001\tabularnewline
No & 27 (55.1\%) & 26 (81.2\%) & 1 (5.9\%) &\tabularnewline
Yes & 22 (44.9\%) & 6 (18.8\%) & 16 (94.1\%) &\tabularnewline
\textbf{Procedure aim:} & & & & \textless{}0.001\tabularnewline
Non-Reconstructive Procedure & 19 (38.8\%) & 5 (15.6\%) & 14 (82.4\%)
&\tabularnewline
Reconstructive Procedure & 30 (61.2\%) & 27 (84.4\%) & 3 (17.6\%)
&\tabularnewline
\textbf{Name of Operation}: & & & &\tabularnewline
Attico-antrostomy & 2 (4.1\%) & 1 (3.12\%) & 1 (5.9\%) &\tabularnewline
Atticotomy & 5 (10.2\%) & 4 (12.5\%) & 1 (5.9\%) &\tabularnewline
Bony Meatoplasty & 4 (8.2\%) & 0 (0 \%) & 4 (23.5\%) &\tabularnewline
Mastoidectomy with canal wall preserved & 1 (2.0\%) & 0 (0 \%) & 1
(5.9\%) &\tabularnewline
Mastoidectomy with canal wall preserved plus atticotomy & 1 (2.0\%) & 0
(0\%) & 1 (5.9\%) &\tabularnewline
Mastoidectomy with canal wall preserved plus posterior tymp & 3 (6.1\%)
& 0 (0\%) & 3 (17.6\%) &\tabularnewline
Modified radical mastoidectomy & 3 (6.1\%) & 0 (0\%) & 3 (17.6\%)
&\tabularnewline
Myringoplasty & 9 (18.4\%) & 8 (25.0\%) & 1 (5.9\%) &\tabularnewline
Ossiculoplasty & 6 (12.2\%) & 4 (12.5\%) & 2 (11.8\%) &\tabularnewline
Stapedectomy & 15 (30.6\%) & 15 (46.9\%) & 0 (0\%) &\tabularnewline
\textbf{Incision Type:} & & & & .\tabularnewline
Endaural & 4 (8.16\%) & 0 (0\%) & 4 (23.5\%) &\tabularnewline
Post-aural & 12 (24.5\%) & 0 (0\%) & 12 (70.6\%) &\tabularnewline
No incision & 3 (6.1\%) & 32 (100 \%) & 1 (5.9\%) &\tabularnewline
\bottomrule
\end{longtable}

T\textbf{able 2:}\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
& \textbf{All} & \textbf{Endoscopic} & \textbf{Microscopic} &
\textbf{p-overall}\tabularnewline
\midrule
\endhead
& n=49 & n=32 & n=17 &\tabularnewline
VAS Post-op Day-1 (mm) & 8 {[}0.00;22.0{]} & 1.50 {[}0.00;11.5{]} & 27.0
{[}15.0;65.0{]} & \textless{}0.001\tabularnewline
VAS Post-op Day-2 (mm) & 5.00 {[}0.00;35.0{]} & 1.50 {[}0.00;9.25{]} &
36.0 {[}20.0;63.0{]} & \textless{}0.001\tabularnewline
VAS Post-op Day-3 (mm) & 2.00 {[}0.00;22.0{]} & 0.00 {[}0.00;9.50{]} &
24.0 {[}12.0;71.0{]} & \textless{}0.001\tabularnewline
VAS Post-op Day-7 (mm) & 2.00 {[}0.00;9.50{]} & 0.50 {[}0.00;2.75{]} &
9.00 {[}2.00;52.0{]} & 0.003\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 3}\selectlanguage{english}
\begin{longtable}[]{@{}lllllll@{}}
\toprule
& \textbf{All} & \textbf{Endoscopic} & \textbf{Microscopic} &
\textbf{OR} & \textbf{p ratio} & \textbf{p overall}\tabularnewline
\midrule
\endhead
& \textbf{n=48} & \textbf{n=31} & \textbf{n=17} & & &\tabularnewline
\textbf{Day 1 analgesia requirement:} & & & & & &
\textbf{0.004}\tabularnewline
\textbf{None} & \textbf{11 (22.9\%)} & \textbf{11 (35.5\%)} & \textbf{0
(0.00\%)} & & &\tabularnewline
\textbf{Yes} & \textbf{37 (77.1\%)} & \textbf{20 (64.5\%)} & \textbf{17
(100\%)} & & &\tabularnewline
\textbf{Day 2 analgesia requirement:} & & & & & &
\textbf{0.073}\tabularnewline
\textbf{None} & \textbf{18 (37.5\%)} & \textbf{15 (48.4\%)} & \textbf{3
(17.6\%)} & & &\tabularnewline
\textbf{Yes} & \textbf{30 (62.5\%)} & \textbf{16 (51.6\%)} & \textbf{14
(82.4\%)} & \textbf{4.12 {[}1.06;21.7{]}} & \textbf{0.040}
&\tabularnewline
\textbf{Day 3 analgesia requirement:} & & & & & &
\textbf{0.227}\tabularnewline
\textbf{None} & \textbf{24 (50.0\%)} & \textbf{18 (58.1\%)} & \textbf{6
(35.3\%)} & & &\tabularnewline
\textbf{Yes} & \textbf{24 (50.0\%)} & \textbf{13 (41.9\%)} & \textbf{11
(64.7\%)} & \textbf{2.47 {[}0.73;9.04{]}} & \textbf{0.148}
&\tabularnewline
\textbf{Day 7 analgesia requirement:} & & & & & &
\textbf{0.080}\tabularnewline
\textbf{None} & \textbf{41 (85.4\%)} & \textbf{29 (93.5\%)} & \textbf{12
(70.6\%)} & & &\tabularnewline
\textbf{Yes} & \textbf{7 (14.6\%)} & \textbf{2 (6.45\%)} & \textbf{5
(29.4\%)} & \textbf{5.58 {[}1.00;48.2{]}} & \textbf{0.050}
&\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 4:}\selectlanguage{english}
\begin{longtable}[]{@{}lllllll@{}}
\toprule
& \textbf{All} & \textbf{Endoscopic} & \textbf{Microscopic} &
\textbf{OR} & \textbf{p ratio} & \textbf{p overall}\tabularnewline
\midrule
\endhead
& \textbf{n=48} & \textbf{n=31} & \textbf{n=17} & & &\tabularnewline
\textbf{Day 1:} & & & & & & \textbf{0.001}\tabularnewline
\textbf{None} & \textbf{11 (22.9\%)} & \textbf{11 (35.5\%)} & \textbf{0
(0.00\%)} & & &\tabularnewline
\textbf{Simple Analgesia} & \textbf{23 (47.9\%)} & \textbf{16 (51.6\%)}
& \textbf{7 (41.2\%)} & & &\tabularnewline
\textbf{Opioid Analgesia} & \textbf{14 (29.2\%)} & \textbf{4 (12.9\%)} &
\textbf{10 (58.8\%)} & & &\tabularnewline
\textbf{Day 2:} & & & & & & \textbf{0.060}\tabularnewline
\textbf{None} & \textbf{18 (37.5\%)} & \textbf{15 (48.4\%)} & \textbf{3
(17.6\%)} & & &\tabularnewline
\textbf{Simple Analgesia} & \textbf{20 (41.7\%)} & \textbf{12 (38.7\%)}
& \textbf{8 (47.1\%)} & \textbf{3.15 {[}0.71;18.0{]}} & \textbf{0.134}
&\tabularnewline
\textbf{Opioid Analgesia} & \textbf{10 (20.8\%)} & \textbf{4 (12.9\%)} &
\textbf{6 (35.3\%)} & \textbf{6.71 {[}1.19;48.4{]}} & \textbf{0.030}
&\tabularnewline
\textbf{Day 3:} & & & & & & \textbf{0.151}\tabularnewline
\textbf{None} & \textbf{24 (50.0\%)} & \textbf{18 (58.1\%)} & \textbf{6
(35.3\%)} & & &\tabularnewline
\textbf{Simple Analgesia} & \textbf{16 (33.3\%)} & \textbf{10 (32.3\%)}
& \textbf{6 (35.3\%)} & \textbf{1.77 {[}0.43;7.38{]}} & \textbf{0.425}
&\tabularnewline
\textbf{Opioid Analgesia} & \textbf{8 (16.7\%)} & \textbf{3 (9.68\%)} &
\textbf{5 (29.4\%)} & \textbf{4.64 {[}0.84;30.7{]}} & \textbf{0.078}
&\tabularnewline
\textbf{Day 7:} & & & & & & \textbf{0.074}\tabularnewline
\textbf{None} & \textbf{41 (85.4\%)} & \textbf{29 (93.5\%)} & \textbf{12
(70.6\%)} & & &\tabularnewline
\textbf{Simple Analgesia} & \textbf{4 (8.33\%)} & \textbf{1 (3.23\%)} &
\textbf{3 (17.6\%)} & \textbf{6.40 {[}0.67;197{]}} & \textbf{0.110}
&\tabularnewline
\textbf{Opioid Analgesia} & \textbf{3 (6.25\%)} & \textbf{1 (3.23\%)} &
\textbf{2 (11.8\%)} & \textbf{4.39 {[}0.33;147{]}} & \textbf{0.261}
&\tabularnewline
\bottomrule
\end{longtable}

\textbf{Figure and Table Legends:}

\textbf{Table 1:} Baseline demographics and procedural details for
endoscopic and microscopic ear surgery groups

\textbf{Table 2:} Median Visual Analogue Scale (VAS) results at
post-operative days 1,2,3 and 7, where 0 mm represents ``no pain'' and
100 mm represents ``worst pain imaginable'' . Interquartile range is
represented in brackets.

\textbf{Figure 1:} Subgroup analysis. Postoperative pain score with
visual analogue scores at post-operative day 1, 2, 3 and 7. Procedures
are split into those with reconstructive aim (stapes surgery,
ossiculoplasty, myringoplasty) versus those in non-reconstructive group
(cholesteatoma surgery and meatoplasty); for both endoscopic and open
ear surgery groups

\textbf{Table 3:} Analgesia requirement at day 1,2,3 and 7
post-operatively for endoscopic and microscopic groups. OR= odds ratio

\textbf{Table 4:} Analgesia requirement at day 1,2,3 and 7
post-operatively for endoscopic and microscopic groups. Simple analgesia
encompasses non-steroidal anti-inflammatory drugs (NSAIDs) and
paracetamol. OR= odds ratio\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/figure1/figure1}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

