Intranasal 10% Lidocaine Spray Versus Intravenous Morphine During Partial Turbinectomy (SPG block)

Patients will receive standardized general anaesthesia: fentanyl 2 mcg/kg actual body weight (ABW) at induction, propofol 1.5 mg/kg, rocuronium 0.6 mg/kg, and sevoflurane 1 MAC for maintenance. After intubation and bilateral application of xylometazoline nasal decongestant drops, morphine 0.05 mg/kg ABW will be administered intravenously. All patients will additionally receive paracetamol 1g IV and ketorolac 30 mg IV in 100 mL normal saline intraoperatively. Intraoperative rescue analgesia: fentanyl 50 mcg IV will be administered in response to tachycardia (heart rate exceeding 20% above individual baseline) or hypertension (systolic blood pressure exceeding 20% above individual baseline). The rescue dose will be repeated after 10 minutes if the haemodynamic response criterion persists. Postoperatively pethidine 50 mg IV will be administered for VAS score greater than 4. Regular paracetamol 1g IV will be given every 8 hours for up to 24 hours postoperatively or until discharge.

Standardized general anaesthesia with fentanyl 2 mcg/kg ABW at induction, propofol 1.5 mg/kg, rocuronium 0.6 mg/kg, sevoflurane 1 MAC for maintenance, followed by morphine 0.05 mg/kg ABW after intubation and nasal decongestant application. Intraoperative rescue fentanyl 50 mcg IV for tachycardia or hypertension exceeding 20% above baseline, repeatable after 10 minutes. Postoperative paracetamol 1g IV every 8 hours and pethidine 50 mg IV for VAS greater than 4.

Patients receive the same standardized induction and maintenance of general anaesthesia as the active comparator arm (fentanyl 2 mcg/kg ABW, propofol 1.5 mg/kg, rocuronium 0.6 mg/kg, sevoflurane 1 MAC), but no intravenous morphine; intranasal lidocaine spray replaces the morphine given in the active comparator arm. After intubation and bilateral application of xylometazoline nasal decongestant drops, intranasal lidocaine 10% spray will be applied bilaterally 10 puffs per nostril by directing the spray applicator parallel to the nasal floor in a postero-superior direction until resistance is felt, targeting the region of the sphenopalatine fossa. Total lidocaine dose will be verified not to exceed 3 mg/kg ABW. All patients will additionally receive paracetamol 1g IV and ketorolac 30 mg IV in 100 mL normal saline intraoperatively. Intraoperative rescue analgesia and postoperative managment as group A.

Identical general anaesthesia induction and maintenance as the control arm, without intravenous morphine. After intubation and bilateral xylometazoline nasal decongestant: intranasal lidocaine 10% spray 10 puffs per nostril bilaterally, directed parallel to the nasal floor in a postero-superior direction until resistance is felt, targeting the sphenopalatine fossa. Total dose not to exceed 3 mg/kg ABW. Identical rescue and postoperative analgesia as control arm.

Total cumulative intraoperative fentanyl rescue dose (mcg) administered in response to tachycardia defined as heart rate exceeding 20% above individual baseline or hypertension defined as systolic blood pressure exceeding 20% above individual baseline, given in increments of 50 mcg intravenously and repeatable every 10 minutes if the triggering criterion persists.

Postoperative pain intensity will be assessed using the Visual Analogue Scale for Pain (VAS-Pain), a unidimensional 10-point numerical scale ranging from 0 to 10, where 0 indicates no pain and 10 indicates the worst imaginable pain; higher scores indicate worse pain outcome. VAS-Pain will be assessed at four prespecified timepoints: recovery room arrival, 2 hours, 6 hours, and 12 hours postoperatively, by a blinded outcomes assessor. Rescue analgesia with pethidine 50 mg intravenously will be administered for VAS-Pain score greater than 4.

Number of patients experiencing at least one episode of heart rate exceeding 20% above individual baseline intraoperative heart rate, recorded by continuous ECG monitoring with non-invasive readings documented every 5 minutes from T0 to end of surgery

Number of patients experiencing at least one episode of systolic blood pressure exceeding 20% above individual baseline systolic blood pressure, recorded by non-invasive blood pressure monitoring every 5 minutes from T0 to end of surgery

Cumulative dose of pethidine in milligrams administered intravenously in response to Visual Analogue Scale score greater than 4, recorded from recovery room arrival to 12 hours postoperatively by a blinded outcomes assessor

Time in minutes from end of surgery to successful tracheal extubation, assessed by the blinded outcomes assessor

Time in minutes from tracheal extubation to attainment of a modified Aldrete score of 9 or above, indicating readiness for discharge from the post-anaesthesia care unit, assessed by the blinded outcomes assessor