512
ANESTH ANALG 1990;70512-6
Postoperative Sore Throat: Effect of Oropharyngeal Airway in Orotracheally Intubated Patients Mark C. Monroe,
MD,
Nikolaus Gravenstein,
MONROE MC, GRAVENSTELN N, SAGA-RUMLEY S. Postoperative Sore throat: effect of OrOPhaVngeal airway in orotracheally intubated patients. Anesth Analg 1990;70:512-6.
The incidence of postoperative sore throat was evaluated prospectively in 203 orotracheally intubated patients undergoing general anesthesia for surgical procedures. Patients were randomly assigiied to have either a plastic orophay n geal airway or a 0.05). The incidence of postoperative sore throat was significantly higher when blood was noted on the airway
Sore throat is a common complaint after general anesthesia. The reported incidence vanes widely: 0%-22%in nonintubated patients (1-5) and 6%-100% in intubated patients (1,3,6-14). Although a minor complication, sore throat is a source of considerable discomfort and inconvenience to patients. Numerous studies have shown that the etiology of postoperative sore throat includes size and design of endotracheal tube and cuff, cuff lubricants, cuff pressures, and other factors (3,5,8-16). The use of the Guedel rubber oropharyngeal airway in nonintubated patients has no effect on the incidence of postoperative sore throat (17). The effect of the use of a hard, plastic, oropharyngeal airway has not been evaluated. We hypothesized that the intraoperative use of a plastic oropharyngeal airway would irritate the posterior pharynx during placement or maintenance and thus cause a greater inciReceived from the Departments of Anesthesiology and Neurosurgery, University of Florida College of Medicine, Gainesville, Florida. Accepted for publication December 29, 1989. Address correspondence to Dr. Gravenstein, Deuartment of Anesthesiology, Box 1-254, J . Hillis Miller Health Ceiter, Gainesville, FL 32610-0254. 01990 by the International Anesthesia Research Society
MD,
and Segundina Saga-Rumley, MD
instruments (64.5%) than when it was not (30.9%)
(P < 0.01). There was an association, although not statistically significant, between the incidence of postoperative sore throat and intubation by an anesthesia resident with < I yr experience (P = 0.064). The data from this study indicate that the intraoperative use of hard plastic orophayngeal airzuays, compared with the use of soft gauze bite-blocks, does not increase the incidence of postoperative sore throat. These data also suggest that pha ryngeal trauma may contribute significantly to the development of postoperative sore throat. W e suggest that aggressive oropharyngeal suctioning may contribute to this pharyngeal trauma.
Key Words: COMPLICATIONS, SORE THROAT-pharyngitis, pharyngeal trauma. INTUBATION, TxucmAL-complications.
dence of postoperative sore throat than would the use of a soft, interdental, gauze bite-block.
Methods Postoperative sore throat was evaluated prospectively in 203 patients (218 yr of age) requiring general endotracheal anesthesia for operative procedures estimated to last 1-3 h. The investigation was approved by the institutional review board and human experimentation committee, and informed consent was waived. Patients who needed a nasogastric tube; who underwent abdominal surgery, except for minilaparotomies and laparoscopies, or head and neck surgery, except for eye surgery; or who required nasotracheal intubation or postoperative intensive care were excluded from the study. Patients were assigned to have either a hard plastic oropharyngeal airway or an interdental, gauze, roll bite-block inserted during anesthesia according to the last digit of their medical record number: the airway was assigned to patients with odd numbers, and the bite-block to patients with even numbers. The biteblock was made by folding two 10 x 10-cm gauze
OROPHARYNGEAL AIRWAY AND POSTOPERATIVE SORE THROAT
pads in half, rolling them up, and securing them with Patients underwent orotracheal intubation with cuffed endotracheal tubes with highlow-pressure cuffs cuff vO1umes and pressures were not standardized and no lubricants or local anesthetic ointments were applied to the endotracheal tubes or cuffs. Patients were anesthetized by anesthesiology residents (supervised by faculty). NO attempt Was made to standardize the anesthetic technique, except that men were intubated with 8.0-mm endotracheal tubes and women with 7.0-mm endotracheal tubes, and hard, plastic suction devices were not used to suction the airway. If suctioning of the airway or stomach was deemed necessary, flexible suction catheters (Argyle) were used. All patients were supine during the operative procedure. For each patient, the anesthesiologist recorded patient's age, sex, and smoking history; months of experience of the resident administering anesthesia; difficulty, if any, during intubation; number of laryngoscopy attempts; use of muscle relaxants for intubation; duration of operation; whether coughing or bucking occurred during intubation; and whether there was blood on the laryngoscope blade, oropharyngeal airway, suction catheter, or bite-block. The day after surgery, each patient was given a questionnaire with the following five yes-or-no questions:
Do you have a backache now that you did not have before your operation? Have you had nausea or vomiting at any time since your operation? Is your voice hoarse or scratchy? Do you have a sore throat? Do you have a headache? Patients were not assisted in filling out the questionnaire or in interpreting the questions; questionnaires for outpatients were completed by telephone interview. The telephone interviewers were specifically instructed not to interpret the questions or to provide guidance in the answers. The two groups were compared statistically by ,$ test with Yates' correction; P < 0.05 was considered statistically sigruficant. The data were also analyzed by discriminant analysis to determine whether postoperative sore throat correlated SigNficantly with gender, blood on airway instruments, use of anticholinergic agents, level of resident experience, number of laryngoscopies, or occurrence of bucking during endotracheal intubation.
ANESTH ANALC 1990;70512-6
513
Results In the 203 patients studied, a plastic oropharyngeal airway was placed in 102 and a gauze bite-block in 101. The groups were comparable in age, gender, history, duration of operation, number race, of ~aryngoscop~es, frequency of buckng or coughing during tracheal intubation, average months of experience of the anesthesiology resident, use of anticholinergics, and incidence of blood on the airwav instrument (P > 0.10); groups were not comparable in the use of succinylcholine (Table 1).According to the questionnaire answers, the incidence of sore throat did not differ significantly between the groups (P = 0.28) (Table2). When data from only those patients in both groups receiving succinylcholine were analyzed, incidence of postoperative sore throat still did not differ sigruficantly between oral airway (28 of 73, 38%)and bite block (40of 85, 47%) (P = 0.27). The overall incidence of postoperative sore throat was not sigruficantly related to the number of laryngoscopy attempts, anesthesiology resident experience, bucking or coughing during tracheal intubation, use of anticholinergic agents, or gender of the patient (Table 3). The incidence of postoperative sore throat was greater in patients when blood had been noted on the airway instrument (64.5%)than when this did not occur (30.9%)(P = O.crOCro3). Of the 47 times blood was noted on an airway instrument, a laryngoscope was involved three times and an oral airway, a bite-block, or a suction catheter the other times. When patients in whom blood was noted on the airway instrument were excluded, the incidence of postoperative sore throat did not differ between oropharyngeal airway (23 of 79, 29%)and bite-block (25 of 76, 33%) (P > 0.05). v
-
Discussion Numerous authors have suggested that the oropharyngeal airway may cause sore throat (1,3,5,1115,18,19), and some excluded the use of oropharyngeal airways in their studies (5,10,15). In a study of the effect of the oropharyngeal airway on the incidence of postoperative sore throat during general anesthesia in unintubated patients (17), the incidence of sore throat did not differ statistically sigruficantly between patients who did or did not have a rubber Guedel airway in place during anesthesia. No previous studies of the effect of an oropharyngeal airway on the incidence of postoperative sore throat in intubated patients have been reported. In our study, we attempted to eliminate or control the factors
MONROE ET AL.
ANESTH ANALG 1990;70:512-6
514
Table 1 . Demographic Comparison of Orotracheally Intubated Patients Undergoing Gynecologic, General, or Orthopedic Surgical Procedures With Oropharyngeal Airway or Bite-Block in Place
Average age (yr) (mean f SD) Gender Women (%) Men (%) Race White (%) Black (a) Cigarette smokers (%) Duration of operation (h) (mean f SD) > 2 Laryngoscopy attempts (% of patients) Bucking or coughing during tracheal intubation' (5%) Resident experience (mo) (mean f SD) Succinylcholine"(%) Anticholinergics"(%) Blood on airway instrumentsa(%)
Oropharyngeal airway
Bite-block
P
40.4 f 15.07
38.9 f 14.5
-
59.8 40.1
51.5 48.5
0.23 0.23
82 17.6
0.59 0.73 0.48
1.95 2 0.95 13.7 (14/102) 40.4 (8194) 13.2 f 8.3
1 15.8 25.7 1.89 f 0.86 11.9 (12/104) 50 (44/88) 13.1 f 8.8
75 41.6 32.3
87.5 32.6 42.5
0.03 0.21 0.33
18
0.19 -
'Data not reported in all patients.
Table 2. Incidence and Types of Postoperative Complaints Reported on Questionnaire by Patients 24 h After Endotracheal General Anesthesia With an Airway or Bite-Block in Place' Postoperative complaint Backache (%) Headache (%) Hoarseness (%) Nausea, vomiting (%) Sore throat (%)
"P
=
Responses to questionnaire Oropharyngeal airway
Bite-block
8 11.8 46 32.3 35.2
9.9 11.8 49.5 34.6 42.5"
0.28 compared with the same complaint with oropharyngeal
airway.
previous investigations indicated were associated with postoperative sore throat (1,3-6,8,11-15,17-25). The only other report besides ours that has related postoperative sore throat to pharyngeal trauma in orotracheally intubated patients was a study of 100 intubated patients in whom extubation was done under direct vision (20). In that study, the pharynx, epiglottis, and glottis were examined for evidence of trauma; in 47 patients in whom trauma was noted, postoperative sore throats developed in 41 (87%). In patients without evidence of trauma, sore throat developed in only 29 of 53 (54%; P < 0.01 by ,$! analysis with Yates' correction). Thus the data in that study (20) support our data in this study showing that pharyngeal trauma is a significant factor in postoperative sore throat. In our study, the incidence of blood on the laryngoscope blade was low, which suggests the cause of pharyngeal trauma was not related to the intubation itself. We believe that pha-
Table 3. Incidence of Factors Associated With Postoperative Sore Throat in Patients 24 h After Endotracheal General Anesthesia With an Oropharyngeal Airway or a Bite-Block in Place" Factor
Sore throat (%)
P
47.3 34
0.064
64.5 30.9
0.00003
38.8 40.0
0.905
36.4 39.7
0.661
38.1 40.6
0.64
44.7 32.5
0.079
Resident experience 1 yr (n = 129) Blood on airway instruments Yes (n = 48) No (n = 155) Number of laryngoscopies 1 (n = 176) 2 2 (n = 26) Bucking during intubation Yes (n = 85) No (n = 83) Anticholinergics Yes (n = 63) N o (n = 123) Gender Women (n = 114) Men (n = 89)
-
-
-
-
-
"Data analyzed by discriminant analysis.
ryngeal trauma and, it is likely, a significant portion of postoperative sore throats are associated with suctioning at the end of the procedure, because the suction catheters we used had a stiff, pointed tip that was not vented and thus allowed a high negative pressure to be exerted on airway mucosa. Also, some patients' airways may be more susceptible to trauma than others, which may lead to the development of postoperative sore throat.
OROPHARYNGEAL AIRWAY AND POSTOPERATIVE SORE THROAT
ANESTH ANALG 1990:70512-6
In this study, sore throat and resident experience of 0.2). Because anesthetic technique was not standardized in our study, succinylcholine was used sigruficantly more often (P = 0.030) in patients with bite-blocks than in patients with oropharyngeal airways. In a study in unintubated patients of the effect that succinylcholine administered as an intravenous bolus has in sore throats occurring 2 4 3 0 h after the procedure (15), the incidence of postoperative sore throat was significantly higher in patients who received succinylcholine (68% vs 10%) (P < 0.001). However, the number of patients in each group was small (n = 2 0 4 , and the method of questioning patients about postoperative sore throat was not standardized; therefore, these data are not conclusive. To ensure that succinylcholine did not affect the results of our study, we also analyzed our data separately for patients given succinylcholine, and there was, again, no significant effect. We conclude that the intraoperative use of a hard, plastic oropharyngeal airway compared with a soft gauze bite-block does not increase the incidence of postoperative sore throat. However, pharyngeal trauma is a significant factor in postoperative sore throat and is probably caused by aggressive oropharyngeal suctioning measures. We recommend suc-
515
tioning maneuvers be done carefully. The use of suction catheters with less risk of trauma might decrease the incidence of postoperative sore throat; this deserves further investigation.
References 1. Conway CM,Miller JS, Sugden FL. Sore throat after anaesthesia. Br J Anaesth 1960;32219-23. 2. Edmonds-Seal J, Eve NH. Minor sequelae of anaesthesia: a pilot study. Br J Anaesth 1%2;34:4&7. 3. Stock MC, Downs JB. Lubrication of tracheal tubes to prevent sore throat from intubation. Anesthesiology 1982;57418-20. 4. Harding CJ, McVey FK. Interview method affects incidence of postoperative sore throat. Anaesthesia 1987;42:110&7. 5. Jensen PJ, Hommelgaard P, Sondergaard P, Erikson S. Sore throat after operations: influence of tracheal intubation, intracuff pressure and type of cuff. Br J Anaesth 1982;54:45M. 6. Hartsell CJ, Stephen CR. Incidence of sore throat following endotracheal intubation. Can Anaesth Soc J 1964;11:307-12. 7. Baron SH,Kohlmoos HW.Laryngeal sequelae of endotracheal anesthesia. Ann Otol Rhino1 Laryngol 1%1;60:767-91. 8. Stout DM, Bishop MJ, Dwersteg JF, Cullen BF. Correlation of endotracheal tube size with sore throat and hoarseness following general anesthesia. Anesthesiology 1987;67419-21. 9. Stenqvist 0, Nilsson K. Postoperative sore throat related to tracheal tube cuff design. Can Anaesth SOCJ 1982;29:384-6. 10. Sprague NB,Archer PL. Magdl versus Mallinckrodt tracheal tubes. A comparative study of postoperative sore throat. Anaesthesia 1987;42:30&11. 11. Loeser EA, Machin R, Colley J, Orr D, Bennett GM, Stanley TH. Post-operative sore throat-importance of endotracheal tube conformity versus cuff design. Anesthesiology 1978;49: 430-2. 12. Loeser EA, Bennett GM, Orr DL, Stanley TH. Reduction of postoperative sore throat with new endotracheal tube cuffs. Anesthesiology 1980;52257-9. 13. Loeser EA, Stanley TH, Jordan W, Machin R. Postoperative sore throat: influence of tracheal tube lubricant versus cuff design. Can Anaesth SOCJ 1980;27156-8. 14. Loeser EA, Kaminsky A, Diaz A, Stanley TH, Pace N. The influence of endotracheal tube cuff design and cuff lubrication on postoperative sore throat. Anesthesiology 1983;58:376-9. 15. Capan LM, Bruce DL, Pate1 KP, Turndorf H. Succinylcholineinduced postoperative sore throat. Anesthesiology 1983;59: 202-6. 16. Lund LO, Daos FG. Effects on postoperative sore throats of two analgesic agents and lubricants used with endotracheal tubes. Anesthesiology 1%5;26681-3. 17. Browne B, Adams CN.Postoperative sore throat related to the use of Guedel airway. Anaesthesia 1988;43590-1. 18. Loeser EA, Orr DL, Bennett GM, Stanley TH. Endotracheal tube cuff design and postoperative sore throat. Anesthesiology 1976;45684-7. 19. Coppolino CA. Postanesthetic sore throat a statistical analysis. J Int Coll Surg 1963;39177431. 20. Wylie WD. Hazards of intubation. Anaesthesia 1950;5:1434. 21. Winkel E, Knudsen J. Effect on the inadence of postoperative sore throat of 1 percent cinchocaine jelly for endotracheal intubation. Anesth Analg 1971;50:92-4. 22. Wolfson B. Minor laryngeal sequelae of endotracheal intubation. Br J Anaesth 1958;30:32&32.
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ANESTH ANALG 1990;70512-6
23. Cozanitis DA. Postoperative sore throat. Can Anaesth SOCJ 1982;29:285-6. 24. Hamelberg W, Welch CM, Siddall J, Jacoby J. Complications of endotracheal intubation. JAMA 1958;1681959-62. 25. Gard MA, Cruickshank LFG. Factors influencing the incidence of sore throat following endotracheal intubation. Can Med ASSOCJ 1961;84:662-5. 26. Fahy A, Watson BG, Marshall M. Postanaesthetic follow-up by questionnaire: a research tool. Br J Anaesth 1969;41:43941.
MONROE ET AL.
27. Cronin M, Redfern PA, Utting JE. Psychometry and postoperative complaints in surgical patients. Br J Anaesth 1973;45:87986. 28. Muir JJ, Warner MA, Offord KP, Buck CF, Harper JV, Kunkel SE. Role of nitrous oxide and other factors in postoperative nausea and vomiting: a randomized and blinded prospective study. Anesthesiology 1987;66513-8.
29. Gold MI. Post anaesthetic vomiting in the recovery room. Br J Anaesth 1969;41:143-9.
ANESTH ANALG 1990;70512-6
Postoperative Sore Throat: Effect of Oropharyngeal Airway in Orotracheally Intubated Patients Mark C. Monroe,
MD,
Nikolaus Gravenstein,
MONROE MC, GRAVENSTELN N, SAGA-RUMLEY S. Postoperative Sore throat: effect of OrOPhaVngeal airway in orotracheally intubated patients. Anesth Analg 1990;70:512-6.
The incidence of postoperative sore throat was evaluated prospectively in 203 orotracheally intubated patients undergoing general anesthesia for surgical procedures. Patients were randomly assigiied to have either a plastic orophay n geal airway or a 0.05). The incidence of postoperative sore throat was significantly higher when blood was noted on the airway
Sore throat is a common complaint after general anesthesia. The reported incidence vanes widely: 0%-22%in nonintubated patients (1-5) and 6%-100% in intubated patients (1,3,6-14). Although a minor complication, sore throat is a source of considerable discomfort and inconvenience to patients. Numerous studies have shown that the etiology of postoperative sore throat includes size and design of endotracheal tube and cuff, cuff lubricants, cuff pressures, and other factors (3,5,8-16). The use of the Guedel rubber oropharyngeal airway in nonintubated patients has no effect on the incidence of postoperative sore throat (17). The effect of the use of a hard, plastic, oropharyngeal airway has not been evaluated. We hypothesized that the intraoperative use of a plastic oropharyngeal airway would irritate the posterior pharynx during placement or maintenance and thus cause a greater inciReceived from the Departments of Anesthesiology and Neurosurgery, University of Florida College of Medicine, Gainesville, Florida. Accepted for publication December 29, 1989. Address correspondence to Dr. Gravenstein, Deuartment of Anesthesiology, Box 1-254, J . Hillis Miller Health Ceiter, Gainesville, FL 32610-0254. 01990 by the International Anesthesia Research Society
MD,
and Segundina Saga-Rumley, MD
instruments (64.5%) than when it was not (30.9%)
(P < 0.01). There was an association, although not statistically significant, between the incidence of postoperative sore throat and intubation by an anesthesia resident with < I yr experience (P = 0.064). The data from this study indicate that the intraoperative use of hard plastic orophayngeal airzuays, compared with the use of soft gauze bite-blocks, does not increase the incidence of postoperative sore throat. These data also suggest that pha ryngeal trauma may contribute significantly to the development of postoperative sore throat. W e suggest that aggressive oropharyngeal suctioning may contribute to this pharyngeal trauma.
Key Words: COMPLICATIONS, SORE THROAT-pharyngitis, pharyngeal trauma. INTUBATION, TxucmAL-complications.
dence of postoperative sore throat than would the use of a soft, interdental, gauze bite-block.
Methods Postoperative sore throat was evaluated prospectively in 203 patients (218 yr of age) requiring general endotracheal anesthesia for operative procedures estimated to last 1-3 h. The investigation was approved by the institutional review board and human experimentation committee, and informed consent was waived. Patients who needed a nasogastric tube; who underwent abdominal surgery, except for minilaparotomies and laparoscopies, or head and neck surgery, except for eye surgery; or who required nasotracheal intubation or postoperative intensive care were excluded from the study. Patients were assigned to have either a hard plastic oropharyngeal airway or an interdental, gauze, roll bite-block inserted during anesthesia according to the last digit of their medical record number: the airway was assigned to patients with odd numbers, and the bite-block to patients with even numbers. The biteblock was made by folding two 10 x 10-cm gauze
OROPHARYNGEAL AIRWAY AND POSTOPERATIVE SORE THROAT
pads in half, rolling them up, and securing them with Patients underwent orotracheal intubation with cuffed endotracheal tubes with highlow-pressure cuffs cuff vO1umes and pressures were not standardized and no lubricants or local anesthetic ointments were applied to the endotracheal tubes or cuffs. Patients were anesthetized by anesthesiology residents (supervised by faculty). NO attempt Was made to standardize the anesthetic technique, except that men were intubated with 8.0-mm endotracheal tubes and women with 7.0-mm endotracheal tubes, and hard, plastic suction devices were not used to suction the airway. If suctioning of the airway or stomach was deemed necessary, flexible suction catheters (Argyle) were used. All patients were supine during the operative procedure. For each patient, the anesthesiologist recorded patient's age, sex, and smoking history; months of experience of the resident administering anesthesia; difficulty, if any, during intubation; number of laryngoscopy attempts; use of muscle relaxants for intubation; duration of operation; whether coughing or bucking occurred during intubation; and whether there was blood on the laryngoscope blade, oropharyngeal airway, suction catheter, or bite-block. The day after surgery, each patient was given a questionnaire with the following five yes-or-no questions:
Do you have a backache now that you did not have before your operation? Have you had nausea or vomiting at any time since your operation? Is your voice hoarse or scratchy? Do you have a sore throat? Do you have a headache? Patients were not assisted in filling out the questionnaire or in interpreting the questions; questionnaires for outpatients were completed by telephone interview. The telephone interviewers were specifically instructed not to interpret the questions or to provide guidance in the answers. The two groups were compared statistically by ,$ test with Yates' correction; P < 0.05 was considered statistically sigruficant. The data were also analyzed by discriminant analysis to determine whether postoperative sore throat correlated SigNficantly with gender, blood on airway instruments, use of anticholinergic agents, level of resident experience, number of laryngoscopies, or occurrence of bucking during endotracheal intubation.
ANESTH ANALC 1990;70512-6
513
Results In the 203 patients studied, a plastic oropharyngeal airway was placed in 102 and a gauze bite-block in 101. The groups were comparable in age, gender, history, duration of operation, number race, of ~aryngoscop~es, frequency of buckng or coughing during tracheal intubation, average months of experience of the anesthesiology resident, use of anticholinergics, and incidence of blood on the airwav instrument (P > 0.10); groups were not comparable in the use of succinylcholine (Table 1).According to the questionnaire answers, the incidence of sore throat did not differ significantly between the groups (P = 0.28) (Table2). When data from only those patients in both groups receiving succinylcholine were analyzed, incidence of postoperative sore throat still did not differ sigruficantly between oral airway (28 of 73, 38%)and bite block (40of 85, 47%) (P = 0.27). The overall incidence of postoperative sore throat was not sigruficantly related to the number of laryngoscopy attempts, anesthesiology resident experience, bucking or coughing during tracheal intubation, use of anticholinergic agents, or gender of the patient (Table 3). The incidence of postoperative sore throat was greater in patients when blood had been noted on the airway instrument (64.5%)than when this did not occur (30.9%)(P = O.crOCro3). Of the 47 times blood was noted on an airway instrument, a laryngoscope was involved three times and an oral airway, a bite-block, or a suction catheter the other times. When patients in whom blood was noted on the airway instrument were excluded, the incidence of postoperative sore throat did not differ between oropharyngeal airway (23 of 79, 29%)and bite-block (25 of 76, 33%) (P > 0.05). v
-
Discussion Numerous authors have suggested that the oropharyngeal airway may cause sore throat (1,3,5,1115,18,19), and some excluded the use of oropharyngeal airways in their studies (5,10,15). In a study of the effect of the oropharyngeal airway on the incidence of postoperative sore throat during general anesthesia in unintubated patients (17), the incidence of sore throat did not differ statistically sigruficantly between patients who did or did not have a rubber Guedel airway in place during anesthesia. No previous studies of the effect of an oropharyngeal airway on the incidence of postoperative sore throat in intubated patients have been reported. In our study, we attempted to eliminate or control the factors
MONROE ET AL.
ANESTH ANALG 1990;70:512-6
514
Table 1 . Demographic Comparison of Orotracheally Intubated Patients Undergoing Gynecologic, General, or Orthopedic Surgical Procedures With Oropharyngeal Airway or Bite-Block in Place
Average age (yr) (mean f SD) Gender Women (%) Men (%) Race White (%) Black (a) Cigarette smokers (%) Duration of operation (h) (mean f SD) > 2 Laryngoscopy attempts (% of patients) Bucking or coughing during tracheal intubation' (5%) Resident experience (mo) (mean f SD) Succinylcholine"(%) Anticholinergics"(%) Blood on airway instrumentsa(%)
Oropharyngeal airway
Bite-block
P
40.4 f 15.07
38.9 f 14.5
-
59.8 40.1
51.5 48.5
0.23 0.23
82 17.6
0.59 0.73 0.48
1.95 2 0.95 13.7 (14/102) 40.4 (8194) 13.2 f 8.3
1 15.8 25.7 1.89 f 0.86 11.9 (12/104) 50 (44/88) 13.1 f 8.8
75 41.6 32.3
87.5 32.6 42.5
0.03 0.21 0.33
18
0.19 -
'Data not reported in all patients.
Table 2. Incidence and Types of Postoperative Complaints Reported on Questionnaire by Patients 24 h After Endotracheal General Anesthesia With an Airway or Bite-Block in Place' Postoperative complaint Backache (%) Headache (%) Hoarseness (%) Nausea, vomiting (%) Sore throat (%)
"P
=
Responses to questionnaire Oropharyngeal airway
Bite-block
8 11.8 46 32.3 35.2
9.9 11.8 49.5 34.6 42.5"
0.28 compared with the same complaint with oropharyngeal
airway.
previous investigations indicated were associated with postoperative sore throat (1,3-6,8,11-15,17-25). The only other report besides ours that has related postoperative sore throat to pharyngeal trauma in orotracheally intubated patients was a study of 100 intubated patients in whom extubation was done under direct vision (20). In that study, the pharynx, epiglottis, and glottis were examined for evidence of trauma; in 47 patients in whom trauma was noted, postoperative sore throats developed in 41 (87%). In patients without evidence of trauma, sore throat developed in only 29 of 53 (54%; P < 0.01 by ,$! analysis with Yates' correction). Thus the data in that study (20) support our data in this study showing that pharyngeal trauma is a significant factor in postoperative sore throat. In our study, the incidence of blood on the laryngoscope blade was low, which suggests the cause of pharyngeal trauma was not related to the intubation itself. We believe that pha-
Table 3. Incidence of Factors Associated With Postoperative Sore Throat in Patients 24 h After Endotracheal General Anesthesia With an Oropharyngeal Airway or a Bite-Block in Place" Factor
Sore throat (%)
P
47.3 34
0.064
64.5 30.9
0.00003
38.8 40.0
0.905
36.4 39.7
0.661
38.1 40.6
0.64
44.7 32.5
0.079
Resident experience 1 yr (n = 129) Blood on airway instruments Yes (n = 48) No (n = 155) Number of laryngoscopies 1 (n = 176) 2 2 (n = 26) Bucking during intubation Yes (n = 85) No (n = 83) Anticholinergics Yes (n = 63) N o (n = 123) Gender Women (n = 114) Men (n = 89)
-
-
-
-
-
"Data analyzed by discriminant analysis.
ryngeal trauma and, it is likely, a significant portion of postoperative sore throats are associated with suctioning at the end of the procedure, because the suction catheters we used had a stiff, pointed tip that was not vented and thus allowed a high negative pressure to be exerted on airway mucosa. Also, some patients' airways may be more susceptible to trauma than others, which may lead to the development of postoperative sore throat.
OROPHARYNGEAL AIRWAY AND POSTOPERATIVE SORE THROAT
ANESTH ANALG 1990:70512-6
In this study, sore throat and resident experience of 0.2). Because anesthetic technique was not standardized in our study, succinylcholine was used sigruficantly more often (P = 0.030) in patients with bite-blocks than in patients with oropharyngeal airways. In a study in unintubated patients of the effect that succinylcholine administered as an intravenous bolus has in sore throats occurring 2 4 3 0 h after the procedure (15), the incidence of postoperative sore throat was significantly higher in patients who received succinylcholine (68% vs 10%) (P < 0.001). However, the number of patients in each group was small (n = 2 0 4 , and the method of questioning patients about postoperative sore throat was not standardized; therefore, these data are not conclusive. To ensure that succinylcholine did not affect the results of our study, we also analyzed our data separately for patients given succinylcholine, and there was, again, no significant effect. We conclude that the intraoperative use of a hard, plastic oropharyngeal airway compared with a soft gauze bite-block does not increase the incidence of postoperative sore throat. However, pharyngeal trauma is a significant factor in postoperative sore throat and is probably caused by aggressive oropharyngeal suctioning measures. We recommend suc-
515
tioning maneuvers be done carefully. The use of suction catheters with less risk of trauma might decrease the incidence of postoperative sore throat; this deserves further investigation.
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