1. Patient evaluation and education are of utmost importance in the preoperative clinic consultation.

   2. Consult the treating pain doctor for patients on chronic opioid therapy.

   3. Multimodal analgesia should begin in the preoperative setting and continued throughout all perioperative settings.

       ▪ Oral celecoxib (200 mg to 400 mg) 30 minutes to 1 hour before surgery.

       ▪ Gabapentin (600 mg or 1200 mg) OR Pregabalin (150 mg or 300 mg) 1 to 2 hours before surgery.

   1. Consider locoregional anesthesia by evaluating patient factors and provider's expertise and experience.

       ▪ Bilateral superficial cervical plexus block, wound infiltration with local anesthesia, infiltration of local anesthesia at incision site.

   2. Anti-emetics should be used judiciously as post-operative nausea and vomiting can increase risk for post-operative bleeding and hematoma formation.

       ▪ Intravenous dexamethasone may reduce post-operative nausea and vomiting and be protective for dissected parathyroid glands and recurrent laryngeal nerves.

   1. Acetaminophen and NSAIDs should be scheduled, unless patient contraindication exists.

   2. Short-acting opioids should be reserved for moderate to severe pain and given orally, if tolerated.

   3. Do not increase extended release or long acting formulations in chronic opioid users.

   4. Avoid other CNS depressants.

   5. Consider ice packs and neck stretching exercises.

   1. Round the clock, scheduled acetaminophen may be all that a patient requires.

   2. NSAIDs should be combined with acetaminophen on postoperative day 2 or 3.

   3. If prescribing opioids for outpatient use, limit prescription to 5-10 doses of oral opioid.

   4. Initiate bowel regimen ASAP if using opioids.

   5. Avoid other CNS depressants if using opioids.