Year: 2026 | Month: April-June | Volume: 11 | Issue: 2 | Pages: 128-143
DOI: https://doi.org/10.52403/gijhsr.20260216
Comparison of Opioid-Free versus Opioid-Based Anesthesia on Postoperative Pain and Nausea/Vomiting in Adult Upper Airway, Sinonasal, and Cervical Surgery: A Systematic Review of Randomized Controlled Trials
Hilda Citrajaya
Department of Anesthesiology, BIMC Kuta Hospital, Badung, Bali, Indonesia.
Corresponding Author: Hilda Citrajaya
ABSTRACT
Background: Opioid-free anesthesia (OFA) may reduce opioid-related adverse effects, particularly postoperative nausea and vomiting (PONV). Evidence in adult upper airway, sinonasal, and cervical surgery—where PONV-driven Valsalva maneuver can precipitate hemorrhage—has not been synthesized at the randomized-trial level. We compared OFA with opioid-based anesthesia (OBA) for postoperative pain and PONV in this population.
Methods: Following PRISMA 2020, five databases were searched from January 2016 to March 2026 for randomized controlled trials (RCTs) comparing OFA with OBA in adults undergoing elective sinonasal, nasal, or cervical (thyroid/parathyroid) surgery. Co-primary outcomes were postoperative pain and PONV. Two reviewers independently performed screening, extraction, and Cochrane RoB 2 assessment. A narrative synthesis was conducted a priori.
Results: Five RCTs (1,369 patients) were included; dexmedetomidine anchored every OFA regimen. All showed reduced PONV with OFA: the largest trial (endoscopic sinus surgery, n=773) reported 7.0% versus 15.1% (p=0.0021) and a thyroid/parathyroid trial (n=394) 5% versus 24% (p<0.001), with absolute risk reductions of approximately 8–19 percentage points. Pain was non-inferior, with small early advantages generally below the minimum clinically important difference. OFA also reduced rescue analgesia, blood loss, and sore throat. Two trials were low risk of bias, three had some concerns. Because dexmedetomidine has independent antiemetic activity, the PONV benefit cannot be attributed solely to opioid removal; bradycardia and prolonged emergence were more frequent with OFA.
Conclusions: Dexmedetomidine-based OFA is associated with consistently reduced PONV and non-inferior pain control versus OBA, tempered by bradycardia and slower emergence. Adequately powered RCTs with active opioid-sparing comparators and explicit safety endpoints are needed.
Keywords: opioid-free anesthesia; opioid-based anesthesia; postoperative nausea and vomiting; postoperative pain; dexmedetomidine; endoscopic sinus surgery; thyroidectomy; sinonasal surgery; systematic review.