“Reimagining Pain Management: SZM Nerve Block in Pediatric
Adenotonsillectomy”
Dear Editor! With approximately 289,000 procedures performed in 2010
alone, adenotonsillectomy is one of the most common surgeries among the
pediatric patient population (1). Despite its reputation for favorable
perioperative outcomes, a substantial body of research indicates that
adenotonsillectomy is also one of the most painful pediatric surgeries
(2). The current insufficient and potentially unsafe treatment options
for managing postoperative pain after adenotonsillectomy compel patients
to resort to high doses of opioids, posing long-term adverse effects. In
this critical context, suprazygomatic maxillary (SZM) nerve block, an
intricate anesthetic technique, emerges as a promising solution.
An SZM nerve block is a regional anesthesia technique predominantly
employed to provide analgesia for surgeries involving the midface, such
as procedures on the maxillary sinus, upper lip, and upper teeth. This
anesthetic nerve block targets the maxillary nerve (V2), which is the
second branch of the trigeminal nerve (cranial nerve V).
A recently published randomized clinical trial in JAMA
Otolaryngology-Head & Neck Surgery evaluated the SZM nerve block for
patients undergoing adenotonsillectomy. This first-of-its kind,
groundbreaking trial demonstrated that SZM block was effective in
minimizing postoperative pain and significantly reducing postoperative
opioid consumption (3). Furthermore, the SZM nerve block also had a
higher opioid-free postanesthesia care unit (PACU) stay compared with
placebo, reflecting its efficacious impact on postoperative opioid
utilization (3). These findings are corroborated by a case report by
Smith et al., which showed clinically meaningful analgesic benefit from
SZM nerve block for adenoidectomy and tonsillectomy, as the patient did
not require any postoperative opioid drugs (4).
Opioids remain a major part of postoperative pain management for
pediatric patients after adenotonsillectomy. However, the black box
warning and contraindication statements from the US Food and Drug
Administration stress that opioids are known to result in serious
postoperative consequences, including respiratory depression and even
death (5). The SZM nerve block offers a highly effective and safe
alternative for managing postoperative pain in these patients. To fully
establish if the SZM nerve block is the silver bullet for opioid-free
postoperative pain management, more clinical trials with larger patient
populations are required. Adopting this technique could address the
urgent need for safer pain management methods in pediatric surgery, as
well as improve recovery outcomes and patient safety.
Keywords: adenotonsillectomy, suprazygomatic maxillary nerve
block, opioids, analgesia
Disclaimer: None to declare
Conflict of Interest: None to declare
Funding Disclosure: None to declare
REFERENCES
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- Lin C, Abboud S, Zoghbi V, Kasimova K, Thein J, Meister KD, Sidell DR,
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(SZM) nerve blocks for perioperative pain control in pediatric
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doi: 10.1016/j.jclinane.2021.110240. Epub 2021 Mar 20. PMID: 33756446.
- FDA updates safety review of codeine use in children; new Boxed
Warning and Contraindication on use after tonsillectomy and/or
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