Preoperative Anxiety: Causes, Evidence-Based Management Strategies and Patient Guide

Preoperative anxiety is clinically significant in 60-80% of patients undergoing surgery; 20-25% experience severe levels. Rates are higher in paediatric patients, women, those with prior negative surgical or anaesthetic experience, chronic pain patients and those with pre-existing anxiety or depression.

Clinical impact is substantial. High preoperative anxiety is associated with higher induction hypnotic requirement, intraoperative blood pressure fluctuations, increased postoperative nausea-vomiting risk, intensified postoperative pain perception and higher analgesic consumption, delayed recovery, longer hospital stay, impaired wound healing, transient immune suppression and psychological consequences (postoperative depression, sleep disturbance).

Special situations in ENT and head-neck surgery: rhinoplasty, septoplasty, functional endoscopic sinus surgery, tonsillectomy, thyroidectomy and head-neck oncologic surgery carry additional psychological burden due to perceived effects on appearance, breathing, voice or swallowing. In combined aesthetic and functional procedures, expectation management and post-surgery appearance concerns deserve dedicated attention.

Anxiety assessment: APAIS (Amsterdam Preoperative Anxiety and Information Scale), STAI (State-Trait Anxiety Inventory) and VAS (Visual Analogue Scale for anxiety) are common scales. Patients with high anxiety receive more intensive psychoeducational and pharmacological support. Related service: our general ENT services.

Evidence shows structured preoperative information reduces anxiety by at least 30-50%. It addresses fear of the unknown, increases sense of control and builds realistic expectations.

Core elements of effective briefing: surgical rationale and benefit, surgical steps (simple and visual), anaesthesia type and process, expected pain level and pain management plan, operation duration, hospital stay, recovery process, possible complications (realistic frequencies, no exaggeration), postoperative schedule, return to work and social life, opportunity for personal questions.

The most effective modality is multi-channel information: in-person surgeon consultation (15-30 minutes, open and empathic), anaesthesiologist consultation (personalised risk assessment and plan), written brochure (re-read at home), animated video or 3D simulation (especially effective in visual procedures like rhinoplasty), companion participation.

Health literacy alignment: language must be plain and free of medical jargon. The teach-back technique (asking the patient to explain in their own words) is effective for confirming understanding.

Digital support tools: pre-consultation patient education modules, mobile-app checklists, video links and online FAQ pages reduce anxiety and unnecessary hospital visits.

Expectation management: in aesthetic and head-neck reconstructive surgery, expected outcomes are openly discussed — aim for "realistic" rather than "perfect." 3D simulation and previously consented case examples provide visual reference.

Behavioural techniques are a safe and effective drug-free way to reduce anxiety. Most can be learned in 5-15 minutes and practised at home.

Diaphragmatic breathing: main mechanism is parasympathetic activation. The 4-7-8 technique is popular — inhale through the nose for 4 seconds, hold 7, exhale through the mouth for 8. Practise 4-6 times daily and at any anxiety spike on operation day.

Progressive muscle relaxation (Jacobson technique): sequential tensing (5 seconds) and releasing (10 seconds) of muscle groups from feet to face. A 15-20 minute session significantly reduces somatic tension.

Guided imagery: detailed mental visualisation of a calming place (sea, forest, garden) engaging all senses — smell, sound, temperature. Mobile apps (Calm, Headspace) offer guided audio.

Mindfulness and meditation: non-judgemental focus on the present. Regular practice (10-20 minutes daily for 2-4 weeks preoperatively) has positive effects on anxiety, depression and pain perception in randomised trials.

Music therapy: patient-selected music, preferably slow-tempo (60-80 BPM). Listening with headphones in the preoperative holding area lowers stress hormones (cortisol) and improves heart rate variability.

Cognitive restructuring: catastrophising thoughts ("what if something happens...", "what if I do not wake up...") are identified and replaced with realistic probabilities and prior successful examples. In highly anxious patients, 2-4 sessions of brief preoperative cognitive behavioural therapy (CBT) are effective.

Social support: a companion on the day significantly reduces anxiety. Talking with family, friends or support groups improves the preoperative night sleep.

Hypnosis and virtual reality: tried in some centres as complementary modalities. VR headsets in the preoperative holding area or during local anaesthesia reduce anxiety through distraction. More detail: our FAQ page.

In selected patients with persistent high anxiety despite behavioural and educational approaches, pharmacological premedication is planned. The decision is individualised — surgeon, anaesthesiologist and psychiatric consultation as needed.

Benzodiazepines are the most commonly used class. They provide anxiolysis, mild sedation and anterograde amnesia. Midazolam — oral 7.5-15 mg 30-60 minutes preoperatively or IV 1-2 mg 15 minutes prior — is favoured for short action. Lorazepam — 1-2 mg oral the night before — improves sleep quality.

Adverse effects and cautions: respiratory depression, sedation, imbalance, paradoxical agitation in the elderly. Use cautiously in respiratory failure, severe COPD or sleep apnoea; consider alternatives. May affect timing of postoperative arousal and extubation.

Melatonin: an alternative to benzodiazepines for moderate anxiety, especially in elderly and mild cases. 3-5 mg oral the night before and 3-5 mg on the morning of surgery. Safer side-effect profile and minimal impact on postoperative cognition.

Gabapentinoids (gabapentin, pregabalin): besides anxiolysis, perioperative use provides postoperative analgesia and opioid sparing. Dose: gabapentin 600-900 mg oral 1-2 hours preoperatively.

Beta blockers (propranolol, atenolol): suppress autonomic symptoms (tachycardia, tremor); used in high cardiovascular risk surgery under anaesthesiologist supervision.

Patients on antidepressants: SSRIs or SNRIs should not be stopped; the anaesthesiologist should be informed preoperatively. Some drugs (lithium, MAOIs) have anaesthesia interaction risk — multidisciplinary planning is essential.

Paediatric patients: oral midazolam (0.5 mg/kg) 20-30 minutes preoperatively is common. Parental presence at induction, toys, music and storytelling add behavioural support.

Dependence cautions: short-term (1-2 doses) preoperative benzodiazepines carry no dependence risk. In patients with prior benzodiazepine, alcohol or opioid dependence, multidisciplinary management is needed.

Preparation starting a week before significantly reduces anxiety and minimises operation-day stress.

7-10 days before surgery: write down all questions for the surgeon and anaesthesiologist; list of all medications (especially blood thinners, herbal supplements, vitamins); reduce or stop smoking and alcohol; regular nutrition and adequate fluid intake; learn and start practising breathing exercises and relaxation techniques.

3 days before surgery: clarify final details (arrival time, fasting duration, return-home plan, companion); home recovery plan (medications, cold compress, nutrition); arrange bedroom and bathroom access (raised pillows, reclined back support — especially after rhinoplasty or sinus surgery); keep important phone numbers accessible.

One day before surgery: light easily digestible dinner; fast from midnight or the time specified by the surgical team; light activity and early sleep; breathing exercises and relaxation; complete avoidance of alcohol and smoking; take prescribed night premedication if any (e.g. lorazepam or melatonin).

Morning of surgery: comfortable clothing (front-opening shirt/blouse preferred, not overhead garments), no jewellery or makeup, contact lenses removed, glasses available, ID and current medication list, companion phone on. The trip can be calmed by music or breathing practice.

In the holding area: companion stays nearby (as patient consents); personal music, book or tablet for distraction; brief team meeting — last questions answered, consent signed; anaesthesiologist final check.

Patient rights: the patient has the right to ask questions, withdraw or delay at any stage. Voicing anxiety to the team (no shame) — additional premedication or a technical pause may be offered.

Postoperative: clarity returns within 15-30 minutes after waking; the companion is brought to bedside; pain is assessed by VAS and analgesia added if needed. The first 24-48 hours at home should include calm surroundings, adequate fluids, light diet, cold compress (for oedema) and ample sleep. We share patient experiences on our Istanbul ENT services.