Missing Pharyngeal Pack Endoscopically Retrieved: An Avoidable Complication.

Throat packing/pharyngeal packing routinely was done during almost all otorhinolaryngology and head and neck surgery, dental, and oral and maxillofacial surgeries. We present an unusual case of a pharyngeal throat pack inadvertently left behind postextubation. The pack was subsequently identified and retrieved successfully from the gastrointestinal tract.

INTRODUCTION

Pharyngeal packing was routinely done during almost all otorhinolaryngeal and oral and maxillofacial surgeries (OMFSs). We encountered a missing throat pack postextubation in a patient who underwent closed reduction of the right temporomandibular joint (TMJ) fracture. This case report highlights the sequence of events that happened to remove pack successfully and also emphasizes the need of extra care in securing proper counts from the anesthesiologist, nursing staff, and the surgeon.

CASE REPORT

A 23-year-old male involved in a road traffic accident was brought to the emergency room of our hospital. He was diagnosed of having TMJ fracture. The plan was closed reduction and arch bar placement under general anesthesia (GA). The patient was nasally intubated. The pack was placed by the anesthesiologist. In the operating room, on the white board in bold letters “Throat Pack In” was written along with its time of placement. Occlusion was achieved and intermaxillary fixation (IMF) was released; the patient was extubated and shifted to the recovery with stable vitals.

Nurse informed of an unaccounted pack while erasing the whiteboard. The patient was shifted back to the operation theater. Direct laryngoscopy revealed no signs of pack. A fine suction catheter was passed through the nostrils hoping that the pack was lodged in the nasopharynx. There was free movement of the suction catheter indicating its absence in the nasopharynx.

The pack used was a plain roll gauze, and the use of C-arm to localize was ruled out. With the help of gastroenterologist, endoscopy was performed under sedation. Pack had partly crossed the pyloric sphincter of the gastrointestinal tract. The foreign body was removed endoscopically without complications [Figure 1]. Postoperatively, the family was explained about the missing throat pack. Recovery was uneventful. IMF was done after the patient was alert. The patient was discharged.

Figure 1

Retrieval of throat pack/foreign body

DISCUSSION

Throat packs are commonly employed to prevent saliva or blood from tracking down into the pharynx and the respiratory tract during otorhinolaryngeal and OMFS procedures.[1] It also helps to seal the area and prevent leakage of gases around the tracheal tube during the provision of GA and the surgical procedure and to stabilize the artificial airway device in order to prevent displacement.[2] A retained surgical pack in the immediate postoperative extubation phase is potentially catastrophic in obstructing the airway.[3]

Several cases of missing throat packs have been reported earlier in literature. To et al. report a similar case where the pack was identified in the stomach. While the patient was being prepared for endoscopic retrieval of the ingested pack, the patient vomited and the pack was regurgitated in the vomitus.[4]

Hariharan et al. report a case where while preparing for reversal, direct laryngoscopy was performed and found that the throat pack was missing. Extubation was deferred, and fiber-optic bronchoscopy was done through the endotracheal tube and no airway foreign body was found. A rigid esophagoscopy until the lower end of the esophagus was also done. The pack could not be found. They hypothesized that the throat pack could have migrated down the digestive tract. They extubated the patient. Within minutes of extubation, the patient had a bout of vomiting and he vomited out the entire throat pack.[5]

Various techniques have been proposed to prevent retention of pack, which are like placing a label on the forehead of the patient or at the end of the tracheal tube or fixing the pack onto the tube at a predetermined site.[67] OMFS prefers the throat pack to be inserted completely as it is away from the surgical site and does not interfere with the occlusion.

Our patient was extubated and shifted to the recovery. Due to the alertness of the nursing, we retrieved the pack. The “forgotten” pack was probably swallowed at the time of extubation, while the patient was still in postanesthetic stupor. Quick steps were taken for pack removal. Our pack had no radiopaque marker, and the use of a radio-opaque strip (Raytec gauze) in the pack is beneficial in detecting its position on C-arm.[4]

CONCLUSION

Missing pack is a life-threatening complication and has medicolegal implications on the operating team. A standardized documentary protocol should be used. One who places the pack is responsible for its removal. The surgeon should verbally remind the anesthesiologist regarding pending pack. In our case, the surgeon visually saw it but did not remind the anesthesiologist.

The circulating nurse should record the time of insertion and removal of the pack on the whiteboard and also document surgical count record. Any alteration of the throat pack or additional pack insertion by the anesthesiologist/surgeon should be clearly communicated to and documented on the whiteboard. At the end of the surgical procedure, the surgeon/anesthesiologist should verbally communicate the removal of the pack to the surgical team. The anesthetist shall communicate the removal of the throat pack to the recovery room staff.[2]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.