Postoperative sore throat: a systematic review

Postoperative sore throat has a reported incidence of up to 62% following general anaesthesia. In adults undergoing tracheal intubation, female sex, younger age, pre‐existing lung disease, prolonged duration of anaesthesia and the presence of a blood‐stained tracheal tube on extubation are associated with the greatest risk. Tracheal intubation without neuromuscular blockade, use of double‐lumen tubes, as well as high tracheal tube cuff pressures may also increase the risk of postoperative sore throat. The expertise of the anaesthetist performing tracheal intubation appears to have no influence on the incidence in adults, although it may in children. In adults, the i‐gel^™ supraglottic airway device results in a lower incidence of postoperative sore throat. Cuffed supraglottic airway devices should be inflated sufficiently to obtain an adequate seal and intracuff pressure should be monitored. Children with respiratory tract disease are at increased risk. The use of supraglottic airway devices, oral, rather than nasal, tracheal intubation and cuffed, rather than uncuffed, tracheal tubes have benefit in reducing the incidence of postoperative sore throat in children. Limiting both tracheal tube and supraglottic airway device cuff pressure may also reduce the incidence.     

Cuffed oropharyngeal airway (COPA) as an adjunct to fibreoptic tracheal intubation

The cuffed oropharyngeal airway (COPA) was evaluated as an adjunct to oral and nasal fibreoptic tracheal intubation in 40 adult patients during general anaesthesia. Time from start to completion of intubation decreased rapidly with experience (median time 138 s). We conclude that the COPA may be a useful adjunct to fibreoptic tracheal intubation, allowing control and support of the airway during the procedure, using various anaesthetic techniques, in an acceptable amount of time. The ability to perform fibreoptic tracheal intubation while effectively supporting the airway using the COPA may be advantageous in managing the difficult airway and in trainee education.      

Beclomethasone prevents postoperative sore throat

The effects of a dose of beclomethasone inhaler (50 μg) or lidocaine 10% spray on postoperative sore throat were studied in 120 patients undergoing tracheal intubation for elective surgical procedures. Fifty-four patients (90%) in the beclomethasone group scored no postoperative sore throat compared with 27 (45%) in the lidocaine group (P<0.00l). Beclomethasone inhaler seems to be highly effective in the prevention of postoperative sore throat and is therefore to be recommended before tracheal intubation for general anaesthesia.     

Prophylactic laryngo-tracheal aerosolized lidocaine against postoperative sore throat

A randomized, double-blind study was carried out on 193 ASA I-II surgical patients to assess the effect of aerosolized lidocaine on sore throat, hoarseness and cough in connection with tracheal intubation. The study group received aerosolized lidocaine 100 mg 2 min before tracheal intubation, using a spray. The control group received no spray. The patients underwent a standardized general anaesthesia. The patients were interviewed when leaving the recovery room and the next day in the ward. Specific questions were asked regarding sore throat, cough and hoarseness. There were no significant differences between the two groups, which suggests that topical anaesthesia of the mucosa of the upper airway is ineffective as a means of ameliorating airway complaints in connection with tracheal intubation.     

Pharyngo-laryngeal discomfort after breast surgery: comparison between orotracheal intubation and laryngeal mask

Sore throat and dysphonia are a significant source of postoperative discomfort for patients scheduled for breast surgery who have been intubated for general anaesthesia. The aim of this study was to compare the incidence of postoperative pharyngo-laryngeal pain and dysphonia in the use of the laryngeal mask airway (LMA) or tracheal intubation in these patients. In a prospective, double-blind, randomised clinical trial we studied 53 women undergoing elective breast surgery to test the hypothesis that the use of the LMA could reduce the incidence of pharyngo-laryngeal morbidity compared with tracheal intubation. Postoperative sore throat and hoarseness were assessed at 6 and 24h by a standardised interview. The incidence of postoperative sore throat was significantly higher in the case of tracheal intubation at 6h (74% vs. 27%, p=0.0003) and at 24h (27% vs. 0%, p=0.004). The incidence of hoarseness was significantly higher in the tracheal intubation group than in the LMA group at 6h after surgery (40% vs. 15%, p=0.04), but not at 24h. Compared with tracheal intubation, the use of the LMA is associated with a lower incidence of postoperative sore throat and hoarseness and may contribute for improving patient comfort after breast surgery.     

Correlation between extraction force during tracheal intubation stylet removal and postoperative sore throat

Study ObjectiveTo examine postoperative sore throat resulting from tracheal intubation stylet removal.DesignProspective cohort study.SettingOperating rooms and hospital ward.PatientsA total of 50 American Society of Anesthesiologists physical status 1 and 2 patients who underwent elective abdominal and/or orthopedic surgery under general anesthesia.InterventionsPatients were allocated to 2 groups: those who developed sore throat postoperatively (ST group) and those who did not (NST group). Comparative analysis of these 2 groups was performed to identify risk factors of the development of sore throat.MeasurementsThe extraction force during stylet removal was measured using a force measuring device. Postoperative sore throat was assessed by an anesthesiologist.Main ResultsNine patients (18%) complained of postoperative sore throat. Increased extraction force (P = .0054; odds ratio, 1.84; 95% confidence interval, 1.20-2.84) was the only significant risk factor for the development of postoperative sore throat. An extraction force of > 10.3 N was determined as a cutoff for developing postoperative sore throat.ConclusionPostoperative sore throat was significantly related to increased extraction force during stylet removal.     

Postoperative sore throat: influence of tracheal tube lubrication versus cuff design

The incidence and severity of postoperative sore throat was evaluated in six groups of 20 patients each after elective orthopedic surgery. Groups I to V had tracheal intubation with Portex disposable polyvinylchloride tracheal tubes and group VI had mask anaesthesia. All groups were exposed to heated humidified gases. Tracheal tubes in groups I—III were uncuffed and lubricated with four per cent lidocaine jelly (group I), four per cent lidocaine hydrochloride anaesthetic solution (group II) or normal saline (group III). Patients in group IV had unlubricated tubes with large residual volume cuffs, patients in group V unlubricated tubes with small residual volume cuffs and patients in group VI (mask anaesthesia) had the lowest incidence and severity of postoperative sore throat while those in group I had the highest incidence and most severe postoperative sore throats. Patients in group V had a lower incidence and severity of postoperative sore throat than patients in all other groups, except group VI. Postoperative sore throat was equally common and severe in patients in groups II, III, and IV. The data indicate that, with the use of heated humidified gases, tracheal intubation with either cuffed or uncuffed tubes produces a greater incidence and severity of postoperative sore throat than mask anaesthesia. In addition, our findings suggest that lubrication of tracheal tubes provides no advantage in terms of reducing postoperative sore throat and, depending on the lubricant, can increase the incidence and severity, Finally, our results demonstrate that the tracheal tube causing the least incidence and severity of postoperative sore throat is one with an unlubricated low residual volume cuff.     

Topical tenoxicam from pharyngeal pack reduces postoperative sore throat

BACKGROUND: One puff of beclomethasone inhaler has been shown to reduce the incidence of sore throat following endotracheal intubation. The aim of this study was to determine the effect of a pharyngeal pack on the incidence of sore throat and whether tenoxicam-impregnated gauze pack significantly influenced the frequency of sore throat. METHODS: Eighty patients undergoing general anaesthesia for elective surgery of the nasal septum were evaluated. The anaesthetist sprayed the upper airway towards the trachea with one puff of beclomethasone inhaler (50 microg) before orotracheal intubation. Patients were randomly assigned to have either a 0.2% tenoxicam- or a 0.9% saline-impregnated gauze pack in the oropharynx during operation. They were evaluated for occurrence and severity of postoperative sore throat by direct questions 12-24 h after surgery. RESULTS: Four patients who experienced any symptoms in the tenoxicam group scored mild sore throat compared to 16 patients in the control group scoring mild, gradually developing moderate or severe sore throat (P<0.01). No drug-related side effects were observed. CONCLUSION: The intraoperative use of a tenoxicam-impregnated gauze pack is effective in reducing moderate or severe postoperative sore throat following the use of throat pack.     

Fastrach — a new intubating laryngeal mask airway: successful use in patients with difficult airways

Purpose

The Laryngeal Mask Airway — Fastrach? (Fastrach) is a new modified laryngeal mask with the capability for guided tracheal intubation while maintaining ventilation. We report the use of this device in patients with proven difficult airways, following induction of general anaesthesia.

Clinical features

After induction of general anaesthesia, having failed tracheal intubation with conventional laryngoscopy, the first patient’s trachea was intubated via the Fastrach with fibreoptic guidance. In the second and third patients, who had documented histories of difficult tracheal intubation, tracheal intubation was performed electively with the Fastrach following induction of inhalational anaesthesia with spontaneous respiration.

Conclusion

The Fastrach is an option in the management of the airway following failed tracheal intubation or for elective tracheal intubation in patients with anatomically difficult airways.     

Fibreoptic-guided tracheal intubation through i-gel® and LMA® ProtectorTM supraglottic airway devices - a randomised comparison

Fibreoptic-guided tracheal intubation using a supraglottic airway device as a conduit is a technique that can be used in anticipated and unanticipated difficult airway management. Although the i-gel^® supraglottic airway device has been examined for this purpose, the LMA^® Protector^TM, a recently introduced second-generation supraglottic airway device, has not been evaluated for this use in clinical trials. This prospective, randomised clinical trial compared fibreoptic-guided tracheal intubation via i-gel and LMA Protector supraglottic airway devices in two UK hospitals. Patients who were ASA physical status 1 or 2 and undergoing elective surgery requiring tracheal intubation were recruited to the study. A block randomisation list was generated for each study site. The primary outcome measure was time to successful tracheal intubation and secondary outcomes were tracheal intubation success rate, glottic view through flexible fibrescope, ease of tracheal intubation using operator visual analogue score, supraglottic airway device insertion time and insertion success rate. Ninety patients were randomly allocated to each device, and final data analysis was carried out for 92 patients in the i-gel group and 86 patients in the LMA Protector group. Mean (SD) tracheal intubation time in the i-gel and LMA Protector groups were 54.3 (13.8) s and 52.0 (13.0) s, respectively (p = 0.240). There were no significant differences in tracheal intubation success rate, glottic view and ease of tracheal intubation between the two groups. This study demonstrates that the LMA Protector supraglottic airway device is comparable to the i-gel supraglottic airway device as a conduit for fibreoptic-guided tracheal intubation.     

Complaints of sore throat after tracheal intubation: a prospective evaluation

BACKGROUND AND OBJECTIVE: Sore throat and hoarseness rank, besides pain and nausea, among the most frequent subjective complaints after tracheal intubation for general anaesthesia. Our intention was to determine the incidence of postoperative sore throat from a large sample of patients and thus to identify the most important associated factors. METHODS: We prospectively followed up 809 adult patients who underwent elective surgical interventions and examined their history, the applied anaesthetic techniques, perioperative course and the occurrence, intensity and duration of postoperative throat complaints. The assignment and professional experience of the involved intubators were also assessed. The influence of a multitude of variables on postoperative throat complaints was statistically analysed. RESULTS: Postoperative sore throat was present in 40% overall being significantly higher in female than in male (44% vs. 33%; P = 0.001). The mean pain intensity in the affected patients (n = 323) was 28+/-12 mm on a visual analogue scale where 0 = no pain and 100 = extreme pain. The average duration was 16+/-11 h. Main factors associated with throat complaints were female sex; history of smoking or lung disease, duration of anaesthesia, postoperative nausea, bloodstain on the endotracheal tube and natural teeth. We could find no influence on the occurrence or intensity of throat complaints by the professional assignment or the length of professional experience of the personnel involved. CONCLUSIONS: Postoperative throat complaints frequently arise after tracheal intubation for general anaesthesia in the first 2 postoperative days, but they are of limited intensity and duration.     

The use of the GlideScope® for tracheal intubation in patients with halo vest

ObjectiveGlideScope^® provides better laryngoscopic view and is advantageous in tracheal intubation in ankylosing spondylitis patients with difficult airway.MethodsThis study was performed to investigate the use of the GlideScope^® for tracheal intubation in 15 patients wearing halo vests scheduled for elective surgery under general anesthesia. Preoperative airway assessments were evaluated to predict the difficulty of tracheal intubation. Before intubation, all patients were given a modified Cormack and Lehane (MCLS) grade and percentage of glottic opening (POGO) score by the intubating anesthesiologist having resorted to direct laryngoscopy (DL) with a Macintosh Size 3 blade depiction. Then intubation with the GlideScope^® was performed, during which the larynx was inspected and given another MCLS grade and POGO score.ResultsFourteen of the 15 patients had MCLS Grade III or IV by direct Macintosh laryngoscopy and were considered to have a difficult laryngoscopy. Nasal tracheal intubation by the GlideScope^® was successful on all occasions. The GlideScope^® improved the MCLS grade and POGO score in all patients who had put on a halo vest as compared with those on DL (p < 0.01). The GlideScope^® also provided a better laryngoscopic view than that by a DL. All of the patients who wore halo vests and presented with suspected difficult airways could be intubated successfully with the GlideScope^®.ConclusionThe use of the GlideScope^® for tracheal intubation could be an alternative option in patients with a difficult airway, whose surgery was circumscribed under general anesthesia with tracheal intubation.     

Flexible, tapered-tip tube facilitates conventional orotracheal intubation by novice intubators

Orotracheal intubation is the standard technique for airway management, but several untoward airway complications are possible with this method. To avoid airway trauma caused by the tube tip during intubation, the Parker Flex-Tip tube (PFT), which has a flexible, tapered tip, was developed. It has been reported that the PFT facilitates fiberoptic orotracheal intubation and introducer-guided tracheal intubation. In this study, we compared the PFT to a standard endotracheal tube (SET), regarding the time of intubation during conventional orotracheal intubation and the incidence of postoperative sore throat and hoarseness. One hundred and thirty-four patients scheduled for elective anesthesia using orotracheal intubation were randomized to either the PFT or SET and 132 completed the study. The intubators were classified into three groups: staff anesthesiologists, inexperienced anesthesiologists, and anesthesia trainees. The tube was selected by another anesthesiologist and the time required for intubation was measured. PFT did not shorten the time required for intubation and did not reduce the incidence of sore throat and hoarseness. However, a detailed analysis revealed that the PFT decreased the time required for intubation in the anesthesia trainee group. The PFT may help novice intubators to conduct a smooth intubation.     

Lightwand intubation: II — Clinical trial of a new lightwand for tracheal intubation in patients with difficult airways

Lightwands have been used to assist in the tracheal intubation of patients with difficult airways for many years. A new lightwand (Trachlight?) with a brighter light source and a flexible stylet permits both oral and nasal intubation under ambient light. This study reports the effectiveness of the Trachlight? in tracheal intubation in patients with difficult airways. Two groups of patients were studied: Group 1 — patients with a documented history of difficult intubation or anticipated difficult airways; Group 2 — anaesthetized patients with an unanticipated failed laryngoscopic intubation. In Group I, the tracheas were intubated using the Trachlight? with patients either awake or under general anaesthesia. In Group 2, tracheas were intubated under general anaesthesia using the Trachlight?. The time-to-intubation, number of attempts, failures, and complications during intubation for all patients were recorded. Two hundred and sixty-five patients were studied with 206 patients in Group 1, and 59 in Group 2. In most patients, the tracheas were intubated orally (183 versus 23 nasal) during general anaesthesia (202 versus 4 awake) in Group 1. Intubation was successful in all but two of the patients with a mean (± SD) time-to-intubation of 25.7 ± 20.1 sec (range 4 to 120 sec). The tracheas of these two patients were intubated successfully using a fibreoptic bronchoscope. Orotracheal intubation was successful in all patients in Group 2 using the Trachlight? with a mean (± SD) time-to-intubation of 19.7 ± 13.5 sec. Apart from minor mucosal bleeding (mostly from nasal intubation), no serious complications were observed in any of the study patients. With proper preparation, this study has demonstrated that Trachlight? is an effective and safe device to intubate the tracheas of elective surgical patients with a history of difficult airway in experienced hands.     

Controlled comparison between betamethasone gel and lidocaine jelly applied over tracheal tube to reduce postoperative sore throat, cough, and hoarseness of voice

BACKGROUND: Postoperative sore throat, cough, and hoarseness of voice though minor sequelae after general tracheal anaesthesia can be distressing to the patient. METHODS: This prospective, randomized, double blind, controlled study compares the incidence of postoperative sore throat, cough, and hoarseness of voice after general tracheal anaesthesia when applying betamethasone gel (betamethasone group) or lidocaine jelly (lidocaine group) on the tracheal tube. One hundred and fifty ASA class I and II patients undergoing elective surgeries under general orotracheal anaesthesia were randomized into three groups: betamethasone gel, lidocaine jelly, and control groups. In the post-anaesthesia care unit, a blinded anaesthesiologist interviewed all patients on postoperative sore throat, cough, and hoarseness of voice at 1, 6, 12, and 24 h after operation. RESULTS: In the first 24 h after surgery, the incidence of postoperative sore throat was 40, 100, and 100%; cough was 6, 40, and 28%; and hoarseness of voice was 4.1, 32.9, and 50%, for the betamethasone, lidocaine and control groups, respectively. The incidence of postoperative sore throat, cough, and hoarseness of voice was significantly lower in the betamethasone group compared with the other two groups (P<0.05). CONCLUSIONS: A wide spread application of betamethasone gel on the tracheal tube decreases the incidence and severity of postoperative sore throat, cough, and hoarseness of voice.     

Tracheal intubation and sore throat: a mechanical explanation

Although tracheal intubation remains a valuable tool, it may result in pressure trauma and sore throat. The evidence for an association between these sequelae is not conclusive and sore throat may be caused at the time of intubation. This hypothesis was tested in a mechanical model and the results from tracheal intubation compared with those from insertion of a laryngeal mask airway, which is associated with a lower incidence of sore throat. Use of the model suggests that the tracheal tube and laryngeal mask airway impinge on the pharyngeal wall in different manners and involve different mechanisms for their conformation to the upper airway, but that in a static situation, the forces exerted on the pharyngeal wall are low with both devices. It also suggests that the incidence of sore throat should be lower for softer and smaller tracheal tubes and that the standard 'Magill' curve (radius of curvature 140 +/- 20 mm) is about optimum for the average airway.     

Use of cuffed oropharyngealvs laryngeal mask airway in elderly patients

PURPOSE: This study was designed to compare the new cuffed oropharyngeal airway (COPA) to the laryngeal mask airway (LMA) in elderly patients. METHODS: In a randomized, controlled study, 80 patients, age > or = 65, ASA I-III, undergoing urology procedures, were managed with either COPA or LMA. Propofol requirements for insertion of the devices, ease of insertion and removal, airway manipulations, mean arterial pressure, heart rate, P(ET)CO2, SpO2, peak inspiratory pressure, selection of the appropriate size of the device and leaks, fibreoptic visualization of larynx and complications were studied. RESULTS: There were more airway manipulations in the COPA group than in the LMA group (40% and 5% respectively) whereas P(ET)CO2 was higher in the LMA group (P < 0.05). In 60% of COPA patients the vocal cords could not be visualized but ventilation was adequate in all but two cases. Postoperative sore throat occurred in 20% of patients with LMA vs 10% with COPA). Bloody secretions on the device were present in two patients managed with LMA. CONCLUSION: In elderly patients COPA required more airway manipulations than the LMA. Laryngeal mask airway caused more sore throats, but was better for fibreoptic visualisation of the larynx. Both are excellent options when intubation is not indicated/desired.     

Sore throat incidence with the laryngeal mask: A comparison with orotracheal intubation

The incidence of sore throat was evaluated among 80 healthy (ASA 1 and 2) nonpremedicated adult patients undergoing general anesthesia for general, plastic, urologic, gynecologic, and orthopedic surgery. The patients were randomly allocated in two groups: group one (n=39) consisted of patients in whom the airway was maintained by a laryngeal mask, and in group 2 (n=40), orotracheal intubation was performed. Both groups were similar in age, gender, site of surgery, and time of airway cannulation. Intraperitoneal surgery of the upper abdomen, and insertion of a nasogastric tube were exclusion criteria. The severity of sore throat was graded by the patients themselves using a visual analogue 100 mm scale, varying from 0 (no sore throat) to 10 (extremely sore). The sore throat incidence, severity and duration were significantly lower in the laryngeal mask group in comparison with the endotracheal intubation group.     

Tips and tricks to increase the success rate of blind tracheal intubation through the Air-Q™ versus the intubating laryngeal mask airway Fastrach™

BackgroundThe Air-Q intubating laryngeal airway is a new supraglottic airway device which overcomes some of the limitations inherent to the intubating laryngeal mask airway (ILMA Fastrach^™) for tracheal intubation. Previous studies showed lower success rate of the Air-Q^™ versus ILMA Fastrach^™. This study was conducted to illustrate new maneuvers for increasing the success rate of Air-Q^™ versus ILMA Fastrach^™ and compare between both devices.MethodsOne-hundred and seventy adult patients, ASA I or II, aged >16 years old undergoing elective surgery under general anesthesia were divided randomly into 2 equal groups (85 each). Group A: using Air-Q ILA size 3.5 or size 4.5 Group B: using ILMA size 4 or size 5 according to the manufacturer’s recommendations for body weight in both groups. The time and the total success rate of blind intubation through them in 2 attempts only were recorded. In Group A, extension of the head with cricoid pressure was applied. The hemodynamic response to devices insertion and the complications related to both devices were compared.ResultsIn Group A, the total success rate in 2 attempts was 94.12%, while in Group B, it was 96.47%. However, this difference was not statistically significant. The first attempt success rate was 81.18% in Group A, while it was 82.35% in Group B. The total time to intubate the hemodynamic response to device insertion and the incidence of complications (sore throat, trauma and hoarseness of voice) showed no statistically significant difference between both groups.ConclusionThis study showed that extension of the head with cricoid pressure greatly increases the success rate of blind intubation through the Air-Q to 94.12% versus the ILMA Fastrach 96.47% with no statistically significant difference between both devices.