Effects of different types of pharyngeal packing in patients undergoing nasal surgery: A comparative study.

CONTEXT: Postoperative throat complaints such as postoperative sore throat (POST), dysphagia, and hoarseness frequently arises after tracheal intubation and throat packing for patient undergoing general anesthesia. This condition is very disturbing to patient. Avoiding POST is a major priority for these patients because preventing postoperative complications contributes to patient satisfaction. AIMS: To describe and analyze the postoperative throat effects of nasopharyngeal packing and oropharyngeal packing in patients undergoing nasal surgery. SETTINGS AND
DESIGN: A randomized comparative study. SUBJECTS AND METHODS: After obtaining approval of Ethical Committee 40 patients were included in study. After this patient were randomly allocated into two groups of 20 each. Group A - in which the oropharynx was packed and Group B - inwhich the nasopharynx was packed. General anesthesia were given and throat packing was done and patients were interviewed postoperatively for any throat complications such as sore throat, difficulty in swallowing (dysphagia), hoarseness of voice, throat irritation, and any other symptom pertaining to the study were noted and data were analyzed. STATISTICAL ANALYSIS USED: T-test to compare the age, while Chi-square test and Fisher's exact test were used to compare sex distribution, sore throat, dysphagia, hoarseness, and throat irritation.
RESULTS: Results showed statistically significant difference in incidence and severity of POST in Group A patients when compared to Group B patients to be more. Patients in Group A had a higher incidence of dysphagia when compared to their Group B counterparts. With respect to the incidence of hoarseness and throat irritation, there was no statistical significance between the groups.
CONCLUSION: We concluded that the site of pharyngeal packing influences the incidence and severity of POST and as well as the incidence of dysphagia after general anesthesia. The use of nasopharyngeal packing in the patients undergoing nasal surgeries might lead to a reduction of the same.

RCT Entities:   Population Interventions Outcomes

INTRODUCTION

Postoperative throat complaints frequently arise after tracheal intubation for general anesthesia in the first 2 postoperative days, but they are of limited intensity and duration.[1] The main symptom reported after tracheal intubation is sore throat, but patients also report hoarseness, difficulty in swallowing (dysphagia) and as well as throat irritation.[23] Etiological factors playing a significant role in this minor anesthetic complication are: Size of the endotracheal tube, design and pressure of cuff, the use of nasogastric tubes, lubricants, muscle relaxants, duration of surgery, surgery in and around the oral cavity, trauma arising from laryngoscopy, and use of pharyngeal packs.[3456]

Pharyngeal packs are commonly used during oral and Ear Nose Throat surgeries to prevent aspiration, tracheal contamination and passage of blood into the stomach.[78] They are disputed to increase the incidence of postoperative sore throat (POST), but are necessary as surgery in and around the oral cavity necessitates them to soak blood and debris that result as consequence of surgery itself as well as to clear the surgical field.[9]

Numerous studies have been carried out to analyze the causes of POST. However, no systematic study has been done to examine the influence of the site of pharyngeal packing on postoperative throat complaints. Therefore, this study was designed to investigate the postoperative throat effects of nasopharyngeal packing and oropharyngeal packing in patients undergoing nasal surgery.

SUBJECTS AND METHODS

After approval from the Ethics Committee, this randomized comparative study was conducted in American Society of Anaesthesiologists (ASA) Grades I and II adult patients posted for nasal surgery having a Mallampatti Grades of I and II and presumed to undergo routine orotracheal intubation. Written informed consent was obtained prior to commencement.

Patients who underwent nasal surgeries like unilateral or bilateral functional endoscopic sinus surgery, sub mucous resection, septoplasty, and rhinoplasty satisfying the following criteria were eligible:

Age between 15 and 60 years

ASA Grades I and II

Modified Mallampatti Grades I and II

No previous significant preexisting laryngotracheal diseases

And presumed to undergo easy intubation.

After this patients were randomly allocated into two groups of 20 each

Group A - in which the oropharynx was packed

Group B - in which the nasopharynx was packed.

After wheeling to patient in operation theater a firm pad (7 cm in height) was placed under the patient's occiput and all noninvasive monitored were attached as per standard protocol. After this, the patient was preoxygenated through a facemask for a minimum of 3 min. Anesthesia was induced with an induction dose of propofol 2.0–3.0 mg/kg intravenous and fentanyl 2 mcg/kg was given for analgesia. Vecuronium 0.1 mg/kg was used to facilitate endotracheal intubation. Endotracheal tubes with a low-pressure high volume cuff were utilized. 8 mm and 7 mm inner diameter tubes were used to intubate male and female patients, respectively. The cuff was inflated just to the point of obtaining a seal in the presence of positive airway pressure. The ventilation was adjusted to maintain end-tidal carbon dioxide levels of 30–35 mmHg. Anesthesia was maintained with isoflurane 0.5–1.5% in combination with 67% nitrous oxide in oxygen. Oropharyngeal suction before extubation was performed under direct vision to avoid trauma to the pharyngeal mucosa, with standard recommended suction pressure. The neuromuscular blockade was reversed with neostigmine 5 mcg/kg and glycopyrrolate 10 mcg/kg after completion of the surgery. Prior to extubation patient was given lidocaine 1.5 mg/kg to produce smooth extubation.

In Group A, the oropharynx was packed with saline soaked gauze once the patient was under anesthesia. In Group B, the nasopharynx was packed in a similar manner as for Group A. In both groups, the otolaryngologist under vision carried out packing of the pharynx.

Nearing the completion of the planned surgical procedure prior to extubation, the pharyngeal pack was removed by the otolaryngologist. This was followed by an examination of the oropharynx, epiglottis, laryngeal inlet, and vocal cords under direct laryngoscopy by the otolaryngologist to note any lesions of the same.

Patients were interviewed postoperatively for any throat complications. Complaints of the patients such as sore throat, difficulty in swallowing (dysphagia), hoarseness of voice, throat irritation, and any other symptom pertaining to the study were noted during the interview. The observations were made at the following intervals: Half hour after extubation, 2 h after extubation, 6 h after extubation and 24 h after extubation.

Sore throat was graded as following:

0 = Nil

1 = Mild

2 = Moderate

3 = Severe as possible.

Dysphagia, hoarseness and throat irritation were graded as:

1 = Absent

2 = Present.

Statistical analysis was performed using t-test to compare the age, whereas Chi-square test and Fisher's exact test were used to compare sex distribution, sore throat, dysphagia, hoarseness and throat irritation. P < 0.05 was considered as significant.

RESULTS

Forty patients were included in this study and were equally allocated to Group A, the oropharynx group and Group B, the nasopharynx group and there were no significant differences in age and sex between the two groups [Table 1].

Table 1

Demographic profile

Of those patients who were included in Group A, 5% had no sore throat, 5% had mild sore throat, 80% had moderate sore throat and 10% had severe sore throat, ½ h after extubation. Similarly in Group B, 35% of patients had no sore throat, 40% had mild sore throat, 20% had moderate sore throat and 5% had severe sore throat ½ h after extubation. 2 h after extubation, 5% patients in Group A had no sore throat, while 10% had a mild sore throat, 80% had moderate sore throat and 15% had severe sore throat. In Group B, 40% had no sore throat, 50% had a mild sore throat, 10% had moderate sore throat and none had severe throat 2 h after extubation. 6 h after extubation, 10% patients in Group A had no sore throat, while 40% had a mild sore throat, 30% had moderate sore throat and 20% had severe sore throat. In Group B, 45% of patients had no sore throat, 50% had a mild sore throat, 5% had moderate sore throat and none had severe throat 6 h after extubation and 24 h after extubation, 15% of patients in Group A had no sore throat, while 60% had a mild sore throat, 15% had moderate sore throat and 10% had severe sore throat. In Group B, 55% had no sore throat, 45% had a mild sore throat, and none had moderate or severe sore throat 24 h after extubation. Results were statistically significant [Table 2].

Table 2

Data of sore throat

Incidence of sore throat ½ h after extubation shows that majority of Group B patients had no or only mild sore throat, while a large number of patients in Group A had moderate sore throat ½ h after extubation [Figure 1].

Figure 1

Sore throat ½ h after extubation

Whereas incidence of sore throat 2 h after extubation shows that majority of patients in Group B had no or only mild sore throat, while in comparison majority of patients in Group A had moderate sore throat [Figure 2] and also it is shown that majority of patients in Group A had developed a mild to moderate sore throat while, majority of patients in Group B had no or only mild sore throat 6 h after extubation [Figure 3].

Figure 2

Sore throat 2 h after extubation

Figure 3

Sore throat 6 h after extubation

Data for 24 h after extubation illustrates that majority of patients in Group A had developed moderate to severe sore throat, in comparison to Group B patients who only had mild sore throat [Figure 4].

Figure 4

Sore throat 24 h after extubation

In Group A, it was noted that 95% of patients had dysphagia ½ h after extubation. After 2 h the incidence of dysphagia remained the same, and after 6 h the incidence fell to 65%. 24 h after extubation 40% of patients in Group A continued to complain of dysphagia. In Group B, only 25% of patients had dysphagia ½ h after extubation. 2 h later the incidence was 30%, and 6 h after extubation it was only 20%. 24 h after extubation only 20% of patients still complained about dysphagia [Table 3] and the results obtained ½ h after extubation, 2 h after extubation and 6 h after extubation were statistically significant.

Table 3

Data of dysphagia

Nearly all patients in Group A had dysphagia ½ h and 2 h after extubation, in comparison to patients in Group B patients [Figures 5 and 6]. Data obtained 6 h after extubation shows majority of patients in Group A had dysphagia, while majority of patients in Group B did not [Figure 7]. Similarly, it is observed that the incidence of dysphagia in Group A had decreased, but is more than that of Group B, 24 h after extubation [Figure 8]. The results between the groups were found to be statistically insignificant.

Figure 5

Dysphagia ½ h after extubation

Figure 6

Dysphagia 2 h after extubation

Figure 7

Dysphagia 6 h after extubation

Figure 8

Dysphagia 24 h after extubation

In Group A, hoarseness was present in 50% of patients at ½ h after extubation and the incidence at 2, 6 and 24 h after extubation was 40%, 40% and 30% respectively. Similarly in Group B, 25%, 40%, 10% and 5% of patients had hoarseness at intervals of ½, 2, 6 and 24 h after extubation respectively and result were statistically insignificant [Table 4].

Table 4

Data of hoarseness

In Group A, throat irritation was present in 55% of patients at ½ h after extubation and the incidence at 2, 6, and 24 h after extubation was 70%, 55% and 35% respectively. Similarly in Group B, 35%, 55%, 40% and 40% of patients had throat irritation at intervals of ½, 2, 6 and 24 h after extubation respectively [Table 5] and the results between the Groups A and B were found to be statistically insignificant.

Table 5

Data of throat irritation

DISCUSSION

Pharyngo-laryngeal complications of endotracheal intubation are either major or minor.[3] Major sequelae are uncommon and take the form of granulomas and contact ulcers. Minor complications, however, are common. These include sore throats, hoarseness, pain and difficulty in swallowing, pharyngeal ulceration and even aphonia.

Sore throat is a common complaint after anesthesia and surgery, and the incidence can be as high as 80%.[10] Some of the common causes include:

Trauma during tracheal intubation.[11] The laryngoscope blade can cause injury to the pharynx and tonsillar fauces

Trauma to the larynx.[12] This is more likely if a red rubber tracheal tube is used rather than a plastic disposable tube, or if the tube has been forced through the vocal cords. A poorly stabilized tube causes more frictional damage to the larynx than one that is securely stabilized

Trauma to the pharynx. This may occur during the passage of a nasogastric tube or insertion of an oropharyngeal or laryngeal mask airway and is particularly common when a throat pack has been used. Occasionally the pharynx or upper esophagus may get perforated during difficult tracheal intubation and severe pain in the throat is often the first symptom. Sore throat is likely if a nasogastric tube remains in situ during the postoperative period. In the absence of a nasogastric tube POST is usually of short duration, most patients are symptom-free within 48 h

Other factors. The mucous membranes of the mouth, pharynx, and upper airway are sensitive to the effects of nonhumidified gases; the drying effect of anesthetic gases may cause POST. The antisialagogue effect of anti-cholinergic drugs may also contribute to this symptom. Movement of the head, use of cuffed or un-cuffed tubes, site of surgery, bucking and coughing with the endotracheal tube in place are some of the factors, which play a role in the development of POST.[12]

Hoarseness is another major complaint following endotracheal intubation. It is almost always associated with tracheal intubation and is caused predominantly by the prolonged abduction of and pressure on the vocal cords. However, traumatic tracheal intubation can cause direct trauma to the vocal cords resulting in prolonged hoarseness.[1213]

In this randomized comparative study two groups of 20 adults were analyzed, each one them had an oropharyngeal pack or nasopharyngeal pack depending on the group they were allocated to and their postoperative throat complaints were studied for incidence of sore throat, dysphagia, hoarseness and throat irritation at definite intervals of time. The study was designed primarily to elucidate whether the location of a throat pack (nasopharynx vs. oropharynx) makes any difference as to the occurrence of pharyngeal and laryngeal morbidity in the postoperative period.

The scoring scale used for assessing POST was the same as described by Elhakim et al.[14] Dysphagia, hoarseness and throat irritation were scored as present or absent, as there is no scale described for them in the literature.

A major problem was the assessment of the throat soreness.[15] Hartsell et al. found only 5.7% of their patients who were intubated actually complained of sore throat. This corresponds well with Griffiths et al. who found that 5% of their patients volunteered information concerning sore throat, but on direct questioning the figure was 44%.[16] This difference may be due to the fact that patients concentrate on symptoms directly related to the operative site and do not immediately associate sore throat with anesthesia and surgery.[15]

In the study conducted, it was observed that patients in Group A were more likely to have POST than patients included in Group B (the at all-time intervals after extubation. The overall mean incidence of POST in Group A and Group B were 30% and 18.75%, respectively. The mean incidence for POST ½ h after extubation was 31.66% in Group A and 21.66% in Group B. 2 h after extubation it was 31.66% in Group A and 20% in Group B. 6 h after extubation the incidence was 30% and 18.3% in Groups A and B respectively. The incidence of POST fell to 28.3% and 15% in Groups A and B respectively 24 h after extubation. These findings imply that site of pharyngeal packing does influence incidence of POST.

Approximately, 70–80% of patients in Group A had moderate POST, ½ h and 2 h after extubation. On the other hand, only 10–20% of patients in Group B had moderate POST ½ and 2 h after extubation. At 6 and 24 h after extubation, Group A patients had an incidence of 15–30% of moderate POST, while only 5% of patients in Group B had moderate POST at the same time interval. The study by Griffiths et al. utilized three types of sterile throat packs (gauze soaked in sterile saline, gauze soaked in Vaseline, and tampons soaked in sterile saline), which were placed in the oropharynx of the patient.[16] Subsequently patients were observed for POST. The overall incidence of sore throat in the Griffiths et al. study was 70%. Moreover, 24% of patients in the study had a sore throat lasting longer than 48 h. The study pointed out that there was no statistical difference in the incidence of sore throat produced by any of the three different throat packs. This corresponds to the incidence of POST in Group A patients in our study. This again suggests that the site and type of pharyngeal packing influences the incidence of POST.

During the course of our study it was noted that 13.7% patients had severe POST in Group A where as in Group B the incidence of severe POST was only 1.25%. This suggests that the site of pharyngeal packing does influence the severity of POST.

In our study, it was also noted that patients included in Group A had a higher incidence of dysphagia up to 6 h after extubation when compared to patients who were included in Group B. The mean incidence of dysphagia in Group A patients up to 6 h after extubation was 75%, whereas in Group B patients, it was 25%. These results were found to be statistically significant. After 24 h the incidence of dysphagia in Group A was 40% and Group B it was 20%. However, this was not statistically significant.

In this study, the incidence of hoarseness and throat irritation was slightly higher in the oropharyngeal pack group, in comparison with the nasopharyngeal pack group. The results failed to show any significant difference with regard to the site of throat packing in the incidence of hoarseness and throat irritation. The mean incidence of hoarseness was 40% in Group A, and 20% in Group B. The mean incidence of throat irritation in Group A and Group B were 53.75%, and 42%, respectively.

Conway et al., studied 1480 patients and found that the insertion of gauze pharyngeal pack moistened with water was associated with a high incidence of sore throat.[4] About 42% of patients had mild sore throat, and 19% had severe sore throat. This is comparable to the overall incidence of sore throat as per our study. Conway et al. did not study whether the location of a pharyngeal pack influences incidence and severity of sore throat.

Marais and Prescott studied subjective pain assessments at 6 and 24 h postoperatively, in patients who had oropharyngeal throat packs that consisted of either gauze or tampon.[17] The study showed that 38% of patients had moderate or severe throat pain in the gauze group, while the tampon and control groups it amounted to only 15% and 1% respectively. The study also noted that a significantly higher proportion of patients in the former group had moderate or severe sore throat at 24 h. Intubation alone resulted in sore throat postoperatively in 50% of patients, but 85% of those who had sore throat, the severity was graded as mild. Marais and Prescott concluded endotracheal intubation often causes POST and this is aggravated by pharyngeal packs.[16]

Tay et al. conducted a study on POST after routine oral surgery and the influence of a pharyngeal pack on the incidence of POST.[3] Two groups were studied, patients with pharyngeal pack and patients without any pack. The study showed that overall incidence of sore throat immediately after recovery was 76% and after 24 h was 53%. There was no significant difference between the groups either immediately after the surgery or 24 h later. They concluded that the incidence and severity of POST is not influenced by the insertion of a pharyngeal pack. This finding is however conflicting with conclusions of Conway et al. and Marais and Prescott.

There were several drawbacks in our study. The sample size was only forty patients. A larger sample size would have made it easier to apply the results to the general population. The observations were made only up to a period of 24 h after extubation whereas patients continue to complain of throat discomfort up to 48 h after extubation. Extension of the study up to 48 h after extubation might have led to a clearer picture on the entity of postoperative throat discomfort. The study contained no control group, but only Group A and Group B where throat packs were inserted into the oropharynx and nasopharynx respectively. A control group, in which there were no throat packs used, would have been helpful to ascertain whether throat packs do increase the severity and incidence of postoperative throat discomfort although eliminating a throat pack in nasal surgeries would increase the likelihood of trachea-bronchial contamination from blood and debris.