The Throat Pack Debate: A Review of Current Practice in UK and Ireland Cleft Centers

Introduction: The use of throat packs during oropharyngeal surgery has long been a topic of debate among cleft surgeons. The advantage of inserting an absorbent tulle within the pharynx must be weighed against the risk of unintended retention postoperatively. Despite safety check mechanisms in place, retention may occur with potentially life-threatening consequences. We present a comprehensive review of throat pack use in all cleft units within the United Kingdom and Ireland. Methods: All 20 cleft surgery units in the United Kingdom and Ireland were surveyed on their use of throat packs in children aged 6 months to 2 years undergoing elective cleft palate surgery. Results: The response rate to the survey was 100%. Seventy-five percent of units currently use throat packs; in 40%, they are used in addition to cuffed endotracheal tubes (ETTs). Inclusion of the throat pack in the surgical swab count was perceived as the safest mechanism employed to avoid retention. 26.1% of respondents were aware of at least 1 incident of pack retention in their unit. Discussion/Conclusion: The reported UK and Irish experience demonstrates that three-quarters of units routinely use packs. Notably, a quarter of respondents to the survey have experience of an incident of throat pack retention. Nevertheless, the majority of respondents considered the perceived risk of retaining a pack to be low. The growing use of microcuffed ETTs in UK cleft units paired with a low incidence of perioperative complications when a throat pack is not introduced might prompt cleft surgeons to review routine pharyngeal packing.

Evaluation of Medicated Pharyngeal Pack for Prevention of Postoperative Sore Throat following Nasal Septal Surgery

Objective: To compare the difference in frequency of postoperative sore throat, dysphagia, hoarseness and cough after nasal septal surgery between pharyngeal packings soaked in normal saline, soluble aspirin or ketorolac. Study Design: A comparative study. Place and Duration of Study: The study was carried at ENT Department of Combined Military Hospital, Risalpur from July 2017 to June 2018. Materials and Methods: The study was performed on 180 patients of both genders, aged between 20-50 years. Cases were randomly allocated into three groups of 60 each. In group A (control), postoperative pharyngeal packing was done with ribbon gauze impregnated with 50 ml normal saline, in group B (soluble aspirin group) packing was done with gauze impregnated in 50 ml of normal saline in which 300 mg of soluble aspirin was dissolved, whereas in group C (ketorolac group) packing was done with gauze impregnated in 50 ml of normal saline in which 30 mg of ketorolac was dissolved. Results: In group A, 10 patients (16.7%) complained of sore throat, 8 (13.3%) dysphagia, 11 (18.3%) hoarseness and 12 (20%) cough. In group B, 4 (6.7%) patients complained of sore throat, 3 (5%) dysphagia, 3 (5%) hoarseness and 4 (6.7%) cough whereas in group C, 3 (5%) patients complained sore throat, 1 (1.7%) dysphagia, 2 (3.3%) hoarseness and 4 (6.7%) cough. All parameters were significantly raised (p<0.001) in group A as compared to group B and C whereas there was no significant difference found in the parameters between group B and C except dysphagia which was significantly lower (p<0.001) in group C as compared to group B. Conclusion: Use of soluble aspirin or ketorolac impregnated pharyngeal packing significantly reduced frequency of post-operative sore throat, dysphagia, hoarseness and cough as compared to simple normal saline impregnated packing among patients undergoing nasal surgery. How to cite this: Maka TA, Rehman A, Ali S. Evaluation of Medicated Pharyngeal Pack for Prevention of Postoperative Sore Throat following Nasal Septal Surgery. Life and Science. 2020; 1(1): 33-36. doi: https://doi.org/10.37185/L&S.1.1.16

A randomized, double-blind study of the ultrasound assessment of the effect of pharyngeal packing on perioperative gastric volume in nasal surgery

Background: Pharyngeal packing (PP) is commonly performed to reduce the incidence of perioperative blood ingestion (PBI) in nasal surgery (NS), and thus the incidence and severity of postoperative nausea and vomiting (PONV). This study examined the effects of PP on the perioperative gastric volume (GV) and PONV in patients undergoing NS, by ultrasound assessment. Methods: Patients undergoing elective NS [septoplasty, septo-rhinoplasty (SRP) and functional endoscopic sinus surgery (FESS)] were randomised to receive or not receive PP. In the PP group, pharyngeal packs were placed after the orotracheal intubation. Ultrasound assessments were performed for all patients preoperatively (before the anaesthesia induction) and postoperatively (before the extubation). The antero-posterior (AP) and cranio-caudal (CC) antral diameters, antral cross-sectional area (ACSA), and total GV were calculated. PONV incidence and severity were rated. These variables were compared between timepoints and groups, and in the subgroup analyses according to the surgery type. Pearson correlation analysis was performed to assess correlations between the variables. Results: AP and CC diameters and ACSAs were greater postoperatively than preoperatively in the PP and non-PP groups (n = 44 each; all p < 0.05). Postoperative AP and CC diameters and the ACSA were greater in the non-PP than in the PP group (all p < 0.05). Postoperative AP diameters were greater than preoperatively in patients undergoing SRP and FESS, and the postoperative CC diameter and ACSA were greater than preoperatively in patients undergoing SRP (all p < 0.05). Surgery duration was correlated positively with postoperative AP diameter (r = 0.380, p < 0.05), CC diameter (r = 0.291, p < 0.05), and ACSA (r = 0.369, p < 0.05). Patients who underwent septoplasty surgery, PP was decreased PONV incidence and severity at the first four hours, postoperatively (p < 0.05). Conclusions: The study findings indicate that PP reduces the increase in the perioperative GV due to PBI in an elective NS. It is therefore a useful and safe means of reducing the risk of perioperative pulmonary aspiration in such surgeries.

A randomized, double-blind study of the ultrasound assessment of the effect of pharyngeal packing on perioperative gastric volume in nasal surgery

Background: Pharyngeal packing (PP) is commonly performed to reduce the incidence of perioperative blood ingestion (PBI) in nasal surgery (NS), and thus the incidence and severity of postoperative nausea and vomiting (PONV). This study examined the effects of PP on the perioperative gastric volume (GV) and PONV in patients undergoing NS, by ultrasound assessment. Methods: Patients undergoing elective NS [septoplasty, septo-rhinoplasty (SRP) and functional endoscopic sinus surgery (FESS)] were randomised to receive or not receive PP. In the PP group, pharyngeal packs were placed after the orotracheal intubation. Ultrasound assessments were performed for all patients preoperatively (before the anaesthesia induction) and postoperatively (before the extubation). The antero-posterior (AP) and cranio-caudal (CC) antral diameters, antral cross-sectional area (ACSA), and total GV were calculated. PONV incidence and severity were rated. These variables were compared between timepoints and groups, and in the subgroup analyses according to the surgery type. Pearson correlation analysis was performed to assess correlations between the variables. Results: AP and CC diameters and ACSAs were greater postoperatively than preoperatively in the PP and non-PP groups (n = 44 each; all p < 0.05). Postoperative AP and CC diameters and the ACSA were greater in the non-PP than in the PP group (all p < 0.05). Postoperative AP diameters were greater than preoperatively in patients undergoing SRP and FESS, and the postoperative CC diameter and ACSA were greater than preoperatively in patients undergoing SRP (all p < 0.05). Surgery duration was correlated positively with postoperative AP diameter (r = 0.380, p < 0.05), CC diameter (r = 0.291, p < 0.05), and ACSA (r = 0.369, p < 0.05). Patients who underwent septoplasty surgery, PP was decreased PONV incidence and severity at the first four hours, postoperatively (p < 0.05). Conclusions: The study findings indicate that PP reduces the increase in the perioperative GV due to PBI in an elective NS. It is therefore a useful and safe means of reducing the risk of perioperative pulmonary aspiration in such surgeries.

Ultrasound assessment of the effect of pharyngeal packing on perioperative gastric volume in nasal surgery

Background Pharyngeal packing (PP) is commonly performed to reduce the incidence of perioperative blood ingestion (PBI) in nasal surgery (NS), and thus the incidence and severity of postoperative nausea and vomiting (PONV). This study examined the effects of PP on the perioperative gastric volume (GV) and PONV in patients undergoing NS by ultrasound assessment. Methods Patients undergoing elective NS [septoplasty, septo-rhinoplasty (SRP) and functional endoscopic sinus surgery (FESS)] were randomised to receive or not receive PP. In the PP group, pharyngeal packs were placed after orotracheal intubation. Ultrasound assessments were performed for all patients preoperatively (before anaesthesia induction) and postoperatively (before extubation). The antero-posterior (AP) and cranio-caudal (CC) antral diameters, antral cross-sectional area (ACSA), and total GV were calculated. PONV incidence and severity were rated. These variables were compared between timepoints and groups, and in subgroup analyses according to surgery type. Pearson correlation analysis was performed to assess correlations between variables. Results AP and CC diameters and ACSAs were greater postoperatively than preoperatively in the PP and non-PP groups (n = 44 each; all p < 0.05). Postoperative AP and CC diameters and the ACSA were greater in the non-PP than in the PP group (all p < 0.05). Postoperative AP diameters were greater than preoperatively in patients undergoing SRP and FESS, and the postoperative CC diameter and ACSA were greater than preoperatively in patients undergoing SRP (all p < 0.05). Surgery duration was correlated positively with the postoperative AP diameter (r = 0.380, p < 0.05), CC diameter (r = 0.291, p < 0.05), and ACSA (r = 0.369, p < 0.05). Conclusions The study findings indicate that PP reduces the increase in the perioperative GV due to PBI in elective NS. It is thus a useful and safe means of reducing the risk of perioperative pulmonary aspiration in such surgeries.

Damage to endotracheal cuff inflation tube by harmonic scalpel in tonsillectomy leading to compromised airway

Use of harmonic scalpel has increased in the recent past for different surgical procedures. We report a case of damage to an endotracheal tube inflation line in a 47 year old female patient who underwent elective tonsillectomy due to harmonic scalpel. Pre-anaesthetic evaluation of the patient revealed no abnormalities. The patient’s trachea was intubated via nasal route with a cuffed north facing Ring, Adair and Elwyn tube of 7.0 mm internal diameter. The cuff was inflated after confirmation of tracheal placement of tube and pharyngeal packing was done. After 30 minutes of surgery, the bellows of the ventilator were collapsing. Suspecting a leak an attempt was made to inflate the cuff, which revealed high resistance in inflation tube. Surgeon was immediately asked to stop the surgery. Check laryngoscopy revealed damage to cuff inflation tube which was sealed by harmonic scalpel in semi-inflated condition. Anticipating that the tracheal extubation in that inflated position would result in vocal cord trauma, a 23 gauge spinal needle attached to 5ml syringe was introduced under direct laryngoscopic guidance. The cuff was punctured and air aspirated so as to deflate the cuff. The tube was taken out and was replaced. The surgery continued for next one hour, was uneventful and trachea extubated at completion.