Anaesthesia, 1999, 54, pages 444–453


Postoperative sore throat: cause, prevention and treatment

F. E. McHardy1 and F. Chung2
1 Specialist Registrar, Northern Schools of Anaesthesia (Newcastle), Royal Victoria Infirmary,Victoria Road, Newcastle upon
Tyne NE1 4LP, UK
2 Professor, Department of Anaesthesia, Toronto Western Hospital, 399 Bathurst St, Toronto,Ontario, Canada M5T 2S8

Sore throat is a common postoperative complaint, occurring most often following tracheal
intubation. Factors such as tracheal-tube size and cuff design have been shown to be important
causative factors. Routine tracheal intubation for elective surgical procedures can result in
pathological changes, trauma and nerve damage which may also account for postoperative throat
symptoms. Sore throat following the use of a laryngeal mask appears to be related to the technique
of insertion but the contribution of intracuff pressure remains to be clarified. It would appear,
however, that high intracuff pressure is associated with nerve palsies due to neuropraxia and nerve
compression. Careful insertion techniques for both the tracheal tube and laryngeal mask are of
paramount importance in the prevention of airway trauma and postoperative sore throat.

Keywords Complications; sore throat. Intubation, tracheal; complications. Equipment; tube, tracheal,
laryngeal mask.
Correspondence to: Dr F. E. McHardy
Accepted: 24 October 1998

Sore throat is a common postoperative complaint. After
Sore throat following tracheal intubation
tracheal intubation, the incidence of sore throat varies
from 14.4% to 50% [1–8] and after laryngeal mask inser- The highest incidence of sore throat and other airway-
tion from 5.8% to 34% [5, 9–11]. The wide variation in related symptoms tends to occur in patients who have
these figures is presumably due to different skills and undergone tracheal intubation. In a series of 1325 patients,
techniques among anaesthetists and to differences between there was an incidence of sore throat of 14.4% [1]. In
individual anaesthetists and patients in the definition of sore this study, women were intubated with an 8-mm tracheal
throat. It is well recognised that the method of questioning tube and men with a 9-mm tracheal tube. All tubes were
is an important determinant of the incidence of sore throat. lubricated with lignocaine jelly. However, the incidence of
After indirect questioning of 129 patients, only two sore throat in women (17%) was significantly higher than
complained of sore throat, whereas after direct questioning that in men (9%) which was attributed to the tube being a
of 113 patients, 28 complained of sore throat [2]. This tighter fit in women. Other factors that were found to be
difference may be due to the fact that patients concentrate implicated were thyroid surgery (because of movement of
on symptoms directly related to the operative site and do the tube and cuff within the trachea) and the presence of a
not immediately associate sore throat with anaesthesia and nasogastric tube. Surprisingly, multiple attempts at intuba-
surgery. The purpose of this article is to review the factors tion did not increase the incidence of sore throat. Fifty
that may cause postoperative throat symptoms such as pain, per cent of patients were hoarse, 18.5% had a cough and
dysphagia and hoarseness after the use of tracheal intu- 70.5% complained of dryness of the throat [1]. The sex
bation, the laryngeal mask airway (LMA) or the oral difference in that study was not confirmed in a study of
(Guedel) airway, and possible methods of reducing these 242 patients who had an overall sore-throat incidence of
symptoms. Trauma that occurs in association with airway 35% when questioned directly [2]. In neither study was
manipulation will also be discussed. any attempt made to standardise anaesthetic technique, but

444 䊚 1999 Blackwell Science Ltd

... mixture [22].. simple measures such higher incidence of sore throat because of the greater area as inflating the cuff with gas drawn from the breathing of cuff–tracheal contact.. Loeser and co-workers [13–17] extensively investi... damage was more superficial than that caused by the high... details were recorded so that possible causative factors that of the trachea but should be constructed of material could be identified. blood flow did not cease until intracuff pressures sore throat in patients intubated with this new tube (15%) were in the range 80–120 mmHg. low-pressure cuffs will exert high pressure women).. the mucosa in contact with the cuff. It was therefore recommended when all the cuffed tubes were lubricated with lignocaine that the ideal cuff should have a diameter slightly less than ointments. high-volume cuff was and of higher volume [24]. prevent intracuff pressure from increasing above 25 mmHg This ischaemia was thought to contribute to the occurrence (33 cmH2O)..... the diffusion.. It was thought that this could be due to nonhumidified air tion permitted a 100% incidence of aspiration of dye being drawn across the airway mucosa during spontaneous instilled directly above the vocal cords when the cuff was respiration.....’s study [17] found that the pressure cuffs [18]. No ventilatory difficulties were experienced as similar changes in volume and pressure as a result of N2O a result of using a small tube........ 1999.. and small tubes were 7 mm (for men) and 6. This was thought to was significantly lower than that after intubation with a be due to a more even distribution of pressure over the standard Mallinckrodt tube (60%)........ The Brandt Anaesthesia Tube is designed to covering the tracheal cartilage. a comparison was made The tracheal-tube cuff has been implicated as a cause of between cuff inflation with either saline or air....... One hundred and one patients were assigned pressures would not compromise the tracheal mucosa.. that sore throat.. i..... low-pressure..... These high-volume cuffs still allowed some per. After the introduction of high-volume. became ischaemic [12]... to two groups and received either a small or a large tube............ or if no allowance is made for N2O diffusion..... tracheal tube reduces the incidence of sore throat.... 54.. allowance could be made for ably because of decreased pressure at the tube–mucosal variation in tracheal size when obtaining a seal and intracuff interface [6]. an increase in the cuff–tracheal contact area [25].......... as opposed to a water-soluble jelly or no 䊚 1999 Blackwell Science Ltd 445 . and ment and adjustment of cuff pressure should be routine showed that the high-volume cuffs were associated with a clinical practice [26]. Loeser et al. presum. A further problem with the high. pages 444–453 F......... the inflation line with a pilot balloon that is more compliant When a thin-walled.......... compared with 22% in the group intubated with the Both high.. use of uncuffed tubes resulted in a significantly higher volume cuffs was that if their diameter was greater than incidence of sore throat than the use of cuffed tubes..e........ by virtue of the cuff communicating through of conditions such as tracheal stenosis and tracheomalacia.............. similar high-volume..... In this way... These wrinkles caused deep mucosal grooves and in addi..5 mm (for High-volume....... in the air-inflation group was significantly higher than that rubber tube had a low-residual-volume. Therefore... the cuff should be narrow in order to Large tubes were 9 mm (for men) and 8... Even so..Anaesthesia.and low-volume cuffs were shown to undergo small tubes................ low-pressure It has been suggested that in order to avoid these cuffs... Surprisingly... even that of the trachea. 48%..... In an animal study.... low-pressure cuffs.. flow in rabbit tracheal mucosa demonstrated that when a The application of high pressure to the tracheal mucosa high-pressure.. problems..5 mm (for women)... but these changes did tubes has the distinct advantage of reducing the incidence not occur when cuffs were inflated with the anaesthetic gas of postoperative sore throat.... Both types of tube had mucosa... Mchardy and F....... high-pressure cuff in the saline-inflation group at 120 min and thereafter.. that would allow a 10% increase in diameter over the It has been clearly demonstrated that the use of a smaller range of inflating pressure of 20–30 cmH2O..... when the patients breathed warmed and humidified gases. The incidence of postoperative used. the redundant material would wrinkle..... Furthermore.... Although the high-volume cuffs circuit or with saline will avoid the problem of N2O caused a greater area of damage to the tracheal mucosa. the use of smaller diffusion when inflated with air [21].. Alternatively..... The pressure serious sequelae following long-term intubation.. the cautious recommendation was postoperative sore throat. A study of blood that in the saline-inflation group [23]... Chung • Postoperative sore throat .. minimise the cuff–tracheal contact area [20]..... The red.... wrinkling would be avoided...... low-volume cuff was inflated to > 30 mmHg may also contribute to the occurrence of postoperative (39 cmH2O).. on the tracheal mucosa if overinflated following tracheal dence in the group intubated with the large tubes was intubation... There was a higher incidence of sore throat inflated to 25 cmH2O [19].. and and the exertion of this high pressure on the tracheal by 6 h the pressure in the air-inflation group was six times mucosa was thought to be damaging. which suggests fusion of the mucosa covering the cartilages at pressures that cuff-pressure limitation may reduce the incidence of > 30 mmHg.... No lubricants were used.. E......... Overinflation may further pre- made that intracuff pressure should be maintained at dispose the patient to postoperative sore throat by causing < 20 mmHg (26 cmH2O). The sore-throat inci... the cuff seal point should be carefully determined gated the effect of using tracheal tubes with different cuff after tracheal intubation and that the intermittent measure- designs on the incidence of postoperative sore throat..........

...... increase the incidence of sore throat from 50% to 90%.... as a result of either mucosal controlled. lignocaine spray before intubation appears to increase the lubricants and cuff pressure that may or may not be incidence of sore throat..... possibly sore throat after tracheal intubation.... when compared with KY jelly [7]. Lubricants containing local anaesthetic those in the control group had only one. anaesthesia and 2 min of mask ventilation. Fifty-eight patients who were undergoing gynae- although it might have become so with greater numbers cological laparotomy were given either pancuronium or of patients. and the severity of sore throat in these patients suxamethonium. vocal cords and trachea.......... be recommended for routine use... suxamethonium with precurarisation after induction of The effect of the application of laryngotracheal ligno....... either as a bolus or by infusion. Of the 248 patients in that study.. it was con. It has been suggested that before insertion.. The distal edge of the rim pharyngeal muscles. However...... Precurarisation did containing 1% cinchocaine led the investigators to suggest not have any effect on these symptoms despite significantly that the use of lubricants containing a local anaesthetic may reducing the incidence of muscle fasciculation..... a comparison between significantly higher incidence of sore throat..... the effect of administration of when the uncuffed tubes were lubricated with 4% ligno..6% in the control group. the laryngeal mask should be tightly suxamethonium........... 39% the patients did not undergo intubation....... The highest inci- who were intubated with a lubricated tube.... Patients who received caine jelly.. and consideration should be tracheal mucosa.... pages 444–453 . had a was significantly greater........ In the study group....... which was not statistically significant.. it should be noted that subjects given to using either the anaesthetic gas mixture or saline in the study group underwent two laryngoscopies whereas to inflate the cuff...... was made in 60 patients between lubrication of the tube it could not be confirmed statistically that the use of the with jelly containing cinchocaine and lubrication with the nasopharyngeal airways contributed to the higher inci- same jelly without cinchocaine [8].... the incidence suxamethonium and the incidence of sore throat in these decreased rapidly in both groups... The incidence of sore dence of sore throat in patients receiving suxamethonium........F......... The application of because of differences in insertion skills and techniques..... After the first postoperative day.. Because airway manage- prior to intubation. Chung • Postoperative sore throat Anaesthesia...... The incidence of sore throat was 29. group that received suxamethonium as compared with Mask ventilation was then continued for a further 2 min 17% in the group that did not...... In a study of 83 should be smooth and flat to facilitate insertion.. gators. All of these patients underwent orotracheal caine spray on postoperative sore throat has also been intubation and one in whom intubation was deemed to investigated [3]... A further comparison patients was higher than in the other groups.... after induction of have been traumatic was excluded from the final analysis..... However...... The standard technique of insertion of the LMA recom- The role of suxamethonium in the aetiology of post. throat was 38% in the noncinchocaine group vs 25% in the These findings have not been confirmed by other investi- cinchocaine group.. lubricant at all.... hoarseness intubation with dry tubes or a tube lubricated with jelly and myalgia 24–30 h postoperatively... The back women undergoing dilatation and curettage who did not of the mask should be lubricated just before insertion so 446 䊚 1999 Blackwell Science Ltd ......... oval disk with the rim skeletal muscle pain..... agents are not useful and may actually increase sore throat Lubrication with 1% hydrocortisone was also found to incidence (Table 1).... a significant dence of airway use occurred in those given a bolus of difference.. did not have who were intubated with a dry tube complained of sore oral airways inserted and were not suctioned..................... Although be beneficial [8].... the lignocaine The postoperative sore throat incidence was 14% in the spray was applied to the epiglottis... Subjects in the control group were ment was standardised in this study.. it was further suggested Careful control of intracuff pressure may be beneficial even that the lignocaine may be irritating or damaging to the for short-term intubation... 20 patients throat on the first postoperative day compared with 24% had a nasopharyngeal airway inserted.... Sore throat and the laryngeal mask airway There is no study therefore that categorically demon- strates that the use of lubricating jelly containing a local As with the tracheal tube. Conversely.. McHardy and F.. the use of smaller tracheal tubes with cuffs this difference was not statistically significant.... which is known to cause postoperative deflated so that it forms a flat. However... causing sore throat.. suxamethonium was examined [27]. with no application suxamethonium does not increase the incidence of post- of spray... the reported incidence of anaesthetic is beneficial in the reduction of postoperative sore throat after use of the LMA varies widely... anaesthesia [4]... irritation or repeated laryngoscopy... that have a small area of contact with the tracheal mucosa cluded that the application of lignocaine spray could not will reduce the incidence of postoperative sore throat.. it would appear that intubated after 4 min of ventilation...2% in the operative sore throat... mended by the manufacturer and the inventor [28] is that operative sore throat is unclear.. E...... the incidence was as high as 90% undergo tracheal intubation.. 1999..... study group and 19...... could also lead to pain in the striated facing away from the aperture..... 54.... Although In summary..

Table 1 Means of reducing of the incidence of postoperative pharyngeal wall.. It was further suggested that cuff pressure throat symptoms..... but it has recommended volume of air [11].........5 cmH2O) or water and water-based gels.......... were monitored but not adjusted..1%.... because the group in which pressures were likely to be highest.... LMA cuff pressures reduced from 28.....Anaesthesia.. and back-to-front insertion with the cuff fully per cent of patients in the low-pressure group and 42% in deflated. result of N2O diffusion. was compared to 22 mmHg (29 cmH2O) in spontaneously breathing with insertion of the LMA already fully inflated with the patients without affecting tidal ventilation [32]. There was no was compared with three other methods: insertion significant difference in the incidence of sore throat.... This leak pressure blood on them after removal when they had been inserted has been recommended in spontaneously breathing already inflated........ After tracheal i... groups and was still present in 20% of patients in each lubricants and the effect of cuff-pressure limitation in group the day after surgery......... In addition.... This standard technique obtain these pressures were not specified.. In the control group.. followed by rotation of the LMA through 180⬚ as the high-pressure group had a throat-related complaint. it is unlikely that the terms of ease of insertion of the LMA....5% to 18%. insertion of the LMA by significantly lower pressures after insertion and reduced means of the standard technique. cuff being inflated to either 30 mmHg (39...... defined by the The effect of cuff pressure limitation on sore-throat presence of blood on the LMA after removal..... so a proportion of the pressure measured would trauma by preventing the tip of the LMA from folding have been due to elastic recoil. with a Guedel airway [29]. Fifty inflated. with the laryngeal mask that it does not dry out.. The volumes of air used to anaesthetic have also been used.........4% to 4.......e............... the occur- Experience of Smaller tracheal tube Correct size of LMA rence of pharyngeal trauma and hence the incidence of anaesthetist postoperative sore throat can be reduced either by the use Adequate anaesthesia/ Minimal cuff– ?Inflation of cuff of an insertion aid or by inflation of the LMA cuff before relaxation of patient tracheal contact before insertion/ area use of insertion aid insertion........ Both techniques had a minimum leak pressure (airway pressure at which leaks high success rate (> 94%)... However... was not a factor in the causation of sore throat............ with the cuff semi-inflated. 54.... the mask being fully sore-throat incidence from 8% to 0%... and the inci...... 0% compared with 15. been argued that this pressure may be too low to provide a cated with a water-based lubricant....3%.. reduced the incidence of trauma..... pharyngeal trauma high pressure was transmitted directly to the pharyngeal and postoperative throat symptoms. All masks were lubri... Therefore...... A study in which the effect anaesthetic/steroid intracuff pressure of high and low intracuff pressures on laryngopharyngeal lubricants discomfort was compared concluded that cuff pressure was not a factor in the causation of sore throat [30]... The standard technique was but this percentage decreased rapidly in both groups over found to be the most successful according to position the next 2 days......... This difference may have been due to the In a study of 120 patients who were anaesthetised with presentation of a softer leading edge to the posterior the use of a laryngeal mask. Dysphagia was the most common complaint in both Several studies have evaluated insertion techniques..... 1999....... Chung • Postoperative sore throat .. and they increased cantly different from that after anaesthesia with only a significantly during the first 60 min of anaesthesia as a facemask. Minimising cuff pressure led to In a study of 200 patients... the group that had the LMA inserted already fully General principles intubation After LMA insertion inflated. Careful technique Monitoring and Use of KY jelly/saline There is conflicting evidence as to whether limitation of adjustment of lubricant pressure exerted on the pharyngeal mucosa by the LMA intracuff pressure Soft suction catheters Avoidance of local Minimisation of cuff reduces throat symptoms..... insertion with the cuff fully hoarseness or dysphagia between the two groups..... an incidence not signifi... Significantly fewer LMAs had occur around the LMA) of 10 cmH2O.. The use of a special mucosa: the elastic of the cuff must have been stretched insertion aid which was designed to avoid pharyngeal excessively. There was also no difference in the quality obtained (as assessed with a fibreoptic bronchoscope) and of airway obtained or in the occurrence of air leak.. Suitable lubricants include saline.......... 21....... lubrication of the LMA with 䊚 1999 Blackwell Science Ltd 447 . Extremes of pressure were chosen and maintained by a micro- processor-controlled monitor... but gels containing a local 180 mmHg (237 cmH2O)...... back.. patients in order to protect the larynx from oropharyngeal dence of sore throat was also significantly reduced from secretions [33]...... pages 444–453 F..... function........ the incidence of sore throat was ventilation [31]. Mchardy and F. It has been demon- deflated before insertion and then inflated with enough air strated that it is possible to reduce the intracuff pressure to obtain an adequate seal after placement......... from 22% incidence was studied in patients receiving positive pressure to 4% [9]..... had the lower incidence...... E..

9%.F... removed from 45% to 34% with LMA use.. Reduction of intracuff significant factor in postoperative sore throat.. E.. including dry throat..... it spontaneous tidal ventilation. LMA....5%... using warmed... The suction the larynx from contamination with oropharyngeal catheters that were used had a stiff.. early and late [37]... It was con....... significantly more patients in the tracheal tube group immediate.... and there was therefore the potential for high negative pressures to be exerted on the airway mucosa... Because the pressure is certainly possible without adversely affecting incidence of blood on the laryngoscope blade was low.. a com- insertion............... symptoms: sore throat (continuous throat pain). Careful suctioning was recommended.. whereas significantly more complications is beyond the scope of this review.... This is A small number of studies have been published in which possibly due to the fact that the airway does not come into direct comparisons were made between the LMA and the contact with the posterior pharyngeal wall. nonvented suction catheters............ the investigators also noted whether may have similar benefits. 2% lignocaine gel was compared with lubrication with Sore throat and the Guedel airway saline [10].... the use of an oropharyngeal airway does of the LMA and the tracheal tube not appear to increase the incidence of sore throat... Once again... dysphonia The use of soft suction catheters may be beneficial.. However. there is increasing evidence that it may be significant difference between the two groups.. was 20%... However... (voice changes).. 17]. but it may be necessary was concluded that pharyngeal trauma was associated with to maintain the pressure above a certain level to protect suctioning at the end of the procedure.......... However. intubation for routine surgical procedures can also cause cluded that the LMA may not be superior with regard to pathological changes that may provide an organic basis for minor laryngopharyngeal morbidity.. but the incidence of postoperative The incidence of postoperative sore throat after anaesthesia complications (hoarseness........ the use of saline or incidence of sore throat in patients in whom blood was KY jelly is preferred. nausea with a facemask and oral plastic airway.5% compared limitation of intracuff pressure is beneficial in reducing with 30... advantageous to adopt an alternative technique of LMA In 203 patients undergoing tracheal intubation.. In a lignocaine was thought to be an unsuitable lubricant.......... The incidence of sore throat was not reduced by the lignocaine.. was 15–22% [16. 75%...... the gels containing a local anaesthetic before insertion did not laryngoscope and the suction catheter. Lubrication of the LMA with blood was present on the airway instruments. A and a gauze bite block [36].. It was suggested that limitation of cuff was 4. The study of 88 patients.8%) who were anaesthetised with or without a Guedel airway and was attributed to the limitation of LMA cuff pressure was compared [35]....... but it is possible that partial inflation groups.g.. The overall incidence of sore throat to 60 cmH2O... 2% humidified anaesthetic gases. as opposed to the from patients who were intubated as part of a resuscitation tracheal tube... pages 444–453 ... The overall incidence of all throat complaints. were stained with methylene blue to determine surgical patients [5]... was demonstrated in a study of ambulatory attempt.. McHardy and F.... One such study divided still occur after emergence from anaesthesia as a result of the blanket term ‘sore throat’ into several...... to parison was made between the use of the Guedel airway reduce pharyngeal trauma and postoperative sore throat...... pointed tip that was secretions [33]....... Chung • Postoperative sore throat Anaesthesia...... the extent of epithelial damage occurring as a result of 448 䊚 1999 Blackwell Science Ltd ..... A recognised that prolonged intubation can have serious similar number of patients in each group complained of consequences.... more precise suctioning by means of stiff. reduction in the incidence of postoperative sore throat Post-mortem specimens of larynx and trachea. which suggests that pharyngeal trauma is a sore throat remains unresolved. tongue paraesthesiae. the incidence of high success rate was obtained when the LMA was inserted sore throat was not significantly different between the two already fully inflated... It should tracheal tube with reference to intra-operative use and be noted that damage to the pharyngeal mucosa may postoperative throat complaints... and there was no significant difference between pressure may also reduce the incidence of problems the groups.... but it is less well recognised that uneventful pharyngeal dryness (tube. e.... The reduce the incidence of sore throat [27]... the incidence of sore throat in those overall incidence of sore throat was extremely low (5.. the issue of whether present on the airway instruments was 64... On the evening of surgery and on the first postoperative Complications of tracheal intubation can be classified as day.. therefore. There was no significant difference in the overall incidence Injuries resulting from tracheal intubation of throat complaints........ It is well patients in the LMA group complained of dysphagia. inflation of the LMA cuff before insertion.... not vented... a significant patients’ postoperative throat symptoms (Table 2).. but the pattern of complaints differed. Direct comparison of symptoms following use In summary.. and vomiting) may have been increased........ 1999....... dysphagia and pharyngeal dryness [34]. 54.. at any time.......... during emergence from anaesthesia................ 61%)...... but again there was no In summary.. A full discussion of these complained of dysphonia.........

.. it was thought that they would demonstrated focal or complete loss of mucosal epithelium constitute a very efficient barrier against mucus flow.... Contact ulcer granuloma Decreased elasticity of the trachea and surrounding tissues in older people may also increase the likelihood of damage occurring during laryngoscopy and intubation.. Table 2 Pathological changes secondary to intubation..... patients underwent indirect laryngoscopy 5 days posteriorly over the cricoid plate and also over the vocal postoperatively [43]. respectively. were found to have vocal-cord granu- had been intubated for elective surgery demonstrated that lomata [44]............ Chung • Postoperative sore throat . however... Microscopically.......... and sore throat. In a study of 200 patients in which intubation with a both the intubation itself and the presence of the tracheal standard polyvinylchloride (PVC) tube was compared with tube [38].... complication of tracheal intubation and should be suspected laryngeal and included vocal cord and glottic congestion....... this trauma sumably due to the elastic recoil of the PVC tube.. there was no significant repair of complained of laryngeal irritation... Mchardy and F. 54 (32%) complained of hoarse- tears.......... a if the patient complains of prolonged hoarseness... Sixty of the patients had evidence of Contact-ulcer granuloma is the most common late airway trauma...... and may have during intubation or to poor or careless technique... Possible causes include Glottic haematoma Glottic oedema neuropraxia due to high intracuff pressure and nerve Submucosal tears demyelination due to gas sterilisation of the tubes...... Damage was greatest in those patients who group. as in the post-mortem studies.... Laryngeal trauma most commonly occurred airway. In a series ‘crushed’ epiglottis and a small number of submucosal of 167 intubated patients.. Trauma was extensive in all ten specimens that with a tube shaped to conform to the anatomy of the examined... The injuries resolved within 4 weeks and were open end of the tube.... with damage to the submucosa membrane comprising less than one-third of the circum- in some cases.......... due of the larynx or hypopharynx [41].... as a result of forces exerted by group had pathological changes (32% in the standard PVC the rigid tubes.. None were considered to be serious and no perma.. It was noted.. In be reduced by prevention of trauma at intubation.. and hooking of the arytenoid by the intubation. one by resting the voice should contact ulceration occur.. that many lesions One hundred patients..... It was sug- patients in the injured group complained of sore throat and gested that the incidence of contact-ulcer granuloma could hoarseness.. bilateral vocal-cord paralysis after short- term intubation [42] may cause complete airway obstruc- Epithelial loss tion..... but lesions were seen had been intubated the longest........ Most of the injuries sustained were intra... E......... Although these coinciding with the area of cuff contact..... rigid stylet [46]... 1999. Another possible contributory factor thought to be due to inadequate relaxation of patients was that the tubes used were re-usable.. 23% in the study group). among other things. Similar numbers of patients in each processes of the arytenoids.... but in most cases the symptoms lasted less than 5 days.........Anaesthesia. and this series............. laryngoscopy........ Two patients in whom hoarseness persisted for 54 and 99 Indirect laryngoscopic examination of 475 patients who days... although the difference was not significant......... their incessant movement [45].. all of whom had undergone may have improved or healed in the 5-day period before intubation.. were glottic haematomas. ness.. even if the patient had been intubated for as short a time significantly more patients in the standard PVC group as 1 h... only hoarseness... Most of these injuries to..... More become roughened during repeated cleaning.. tending when the standard PVC tube was used....... nent damage resulted... were examined by indirect laryngoscopy post... Furthermore. This injury was prevent granuloma formation..... Although in both cases it was not known Although unilateral vocal-cord paralysis usually causes whether the tip of the stylet protruded beyond the lumen 䊚 1999 Blackwell Science Ltd 449 .. possibly because of the fact that the tube during intubation and when the depth of anaes- the tube was turned to the left by the anaesthetist during thesia was lightened...... operatively [40]... two cases of vocal-cord paralysis occurred... which presumably resulted from the insertion or removal of the exerted more pressure against the posterior wall of the tube. thought to have resulted from high intracuff pressures Both pharyngeal and oesophageal perforation have been causing neuropraxia of the recurrent laryngeal nerve reported following repeated attempts at intubation using a where it lies between the cricoid and arytenoid cartilages........ pages 444–453 F... There was evidence of more frequently in the interarytenoid and subglottic area trauma over the cartilaginous rings of the trachea..... A separate series of 99 autopsy specimens ference of the airway. difficulties in coughing epithelium or stroma as long as the tube was in place [39].... to of which lasted for at least 2 months. The site of the granuloma was usually at the a small proportion of patients (6. Also....3%) had traumatic lesions tip of the vocal processes of the arytenoid cartilages.... This was pre- to occur only along the anterior tracheal wall.. lesions were only superficial ulcerations of the mucous epithelial loss was seen.......... Some of the specimens had an area of annular trauma larynx. 54..... necessitating tracheostomy.. with the left cord being affected Further risk factors included clamping of the cords onto more often than the right.

55].F.... even among experienced personnel.. Laceration pharyngeal erythema... resulted in of the right cord to compensate...... the and epiglottitis have been described in association with the patient suffered from severe rheumatoid arthritis and there LMA [49–56]................ of the tube.. which.7 before surgery. Nasopharyngeal the cricoid cartilage itself has been reported following rapid laryngoscopy revealed a left vocal-cord palsy with inability sequence induction.......... Two patients who complained arrest [48]..... it is unlikely that even high pressure 6 months [50].... Haematoma Transient bilateral vocal-cord palsy has also been described. Examination revealed a unilateral 12th cranial Injuries resulting from LMA insertion nerve paralysis that resolved 8 days postoperatively.... the LMA was should be avoided............ group. which resolved Table 3 Airway complications following LMA insertion.... The consensus of opinion is that recurrent could fracture a normal cricoid cartilage... hypoxia and cardiorespiratory returned within 3 weeks... symptoms lasted for up to are difficult to measure. the patient complained underwent indirect stroboscopic laryngoscopy 18–24 h of difficulty swallowing and on examination her tongue postoperatively.. Pressure on the cricoid cartilage is known to make Several cases of vocal-cord palsy have been reported intubation more difficult in some cases by moving the following apparently uneventful anaesthesia with the larynx away from the midline and also.... 54. Chung • Postoperative sore throat Anaesthesia.... After In a very small study comparing the effects of the LMA induction of anaesthesia........ Seven of 11 patients in whom a LMA was found to deviate to the right... indirect laryngoscopy.. this may have been due to lignocaine diffusion.. Compression of the nerve between the LMA cuff and the hyoid bone was thought to be the cause Pharyngeal erythema Nerve palsies of this injury............ A significantly greater number of of the left mainstem bronchus is believed to have been patients in the tracheal tube group believed that throat caused when a stylet was used with an old Mallinckrodt and voice parameters had deteriorated than in the LMA Broncho-Cath [47]. LMA.. normal vocal function marked inspiratory stridor. patients lateral position.. but 4 h postoperatively the patient complained of difficulty swallowing and slurred speech [52]....... In another case.. however...... resulting in bruising and consequent neuro- device.. These were most 450 䊚 1999 Blackwell Science Ltd .. Fracture of present ever since his anaesthetic [49]... inserted without difficulty.. if applied incorrectly.......... Various types of nerve injury..... she was rotated into the right and the tracheal tube on vocal function [57]....... of the left vocal cord is the most common injury seen on with full recovery 40 min postoperatively [51]. even with apparently uneventful use of this hypopharynx. E. and it was awareness of the serious injury that can occur to airway postulated that the LMA had traumatised an area of the structures. A diagnosis was made of paralysis of the right 12th cranial nerve... there is less Normalised Ratio (INR) of 1........... on extubation..... One young patient returned to hospital 2 days by causing obstruction of the trachea.... palsies with associated laryngeal incompetence........ within 1 week..... These injuries are summarised in Table 3....... Prolonged lingual nerve paralysis Hypoglossal resulting in loss of taste sensation has also been associated Lingual Arytenoid dislocation with uneventful LMA use and again was thought to be Epiglottitis secondary to neuropraxia [54]...... and in aspiration in one case... McHardy and F....... Although pressures applied to the cricoid carti... arytenoid dislocation praxia of the 12th nerve.... pages 444–453 ... extensive damage to the laryngeal and pressure on the nerve at the point at which it lies tracheal epithelia occurs as a result of tracheal intubation... complaining of hoarseness that had been with intubation predisposes to airway trauma.. Increased difficulty postoperatively. is easy to patient had received warfarin and had an International learn and has a high first-time success rate. dysphagia and hoarseness postoperatively the larynx that may have predisposed to cricoid cartilage were found to have unilateral recurrent laryngeal nerve fracture.... The most intubation aid will predispose to trauma if it does protrude common change in the remaining four patients was and if it is used blindly and with excessive force.. it is logical to assume that the use of this had been used had no pathological changes....... In one case. The patient had a previous history of trauma to of sore throat. was some difficulty with LMA insertion [53].. The following day...... resulting lage vary widely. even with an intubation period as short as 1 h. because ditions and careful technique are necessary to minimise the LMA had been lubricated with 2% lignocaine jelly. Optimisation of intubating con. This Because LMA insertion is a blind technique..... laryngeal nerve palsy is due to neuropraxia from cuff In summary. airway trauma. unprotected at the lower level of the piriform fossa. 1999................ the compression being exacerbated by the Recurrent laryngeal position of the patient......... However.. Uvular bruising Two cases of arytenoid dislocation resulting from LMA insertion have been reported [50.... Overinflation of the tracheal tube cuff has Paralysis of the hypoglossal nerve has also occurred been associated with recurrent laryngeal nerve palsy and following use of the LMA...

Anaesthesia 1990. tial.. Trauma to the uvula after LMA use......... both to reduce the incidence of definitely excluded. Interview method affects airway. 73: 786–7.. A comparative remove the torn mucosa [60].. Dwersteg JF..... In moderate to anaesthesia. and limitation of tracheal tube and LMA cuff pressures Although other causes for the epiglottitis could not be should be considered... pages 444–453 F. The most 8 Winkel E.... It has an alkaline pH.... but it associated with trauma to the larynx and the pharynx. Laryngeal mask lubrication – a comparative study of saline versus 2% airway or the patient’s own teeth may require treatment lignocaine gel with cuff pressure control... Mchardy and F. No increased incidence of postoperative sore throat after In most cases..... British Journal of Anaesthesia 1994..... Butler PJ.... postoperative sore throat of 1 percent cinchocaine jelly for there is no specific treatment for this but it tends to resolve endotracheal intubation...Anaesthesia.. Willemoes-Larsen H... mask airway. Weber M.......... nerve palsy.. with topical antibiotics [61]. Use of the laryngeal chloride.... has also been reported [58]......... postoperative throat complaints resolve administration of suxamethonium in endotracheal spontaneously without specific treatment.... throat. 31: severe cases it may be beneficial to treat pain and dysphagia 768–70..... Anesthesia and Analgesia 1997.. 52: 586–602. Jakobsen KB. having other underwent mechanical reduction supplemented by been implicated as a cause of bilateral recurrent laryngeal botulinum toxin injection... Postoperative sore throat: topical after the use of airway instruments. although the injury does not study of the incidence of sore throat with the laryngeal usually cause an anatomical or functional disorder... which is approved for the symptomatic treatment mask airway as an alternative to the tracheal tube during of acute sore throat pain [59].... Lubricants containing local anaesthetics do not was treated conservatively with speech therapy and the appear to be beneficial and may actually be harmful.... Symptoms of postoperative throat discomfort such as sore 12 Nordin U.. Cullen BF.. Pene...... 67: 419–21. 5 Joshi GP. has local anaesthetic activity... hoarseness and dysphagia are common.... anticoagulants. Baxter PJC... 85: is a topical nonsteroidal anti-inflammatory agent that also 573–7....... means that it becomes concentrated in inflamed tissue and Correlation of endotracheal tube size with sore throat and hoarseness following general anaesthesia. the LMA to avoid undue trauma to structures of the 2 Harding CJ. Effects on the incidence of common injury is haematoma of the left vocal cord. Acta Anaesthesiologica Scandinavica 1992. Blood flow in the throat... Inagaki Y... The laryngeal mask Conclusion airway: a comparison between two insertion techniques..... most macroscopic hydrocortisone..... Anesthesia and Analgesia 1997. Brimacombe JR..... 36: 505–7.... Postoperative throat complaints after tracheal In summary. the likelihood of neuropraxia may be another reason to 3 Herlevsen P. 45: 968–71.... Lindholm CE.... Bredahl C...... 49: 251–4.. care should be taken during insertion of intubation... Appropriate sizes of tracheal tube and LMA should be Symptoms were sore throat and hoarseness.. This abnormality may have made it more susceptible to damage because of its more prominent position..... Hindsholm K..... Whitehead MJ.. Anesthesia and Analgesia 1971.. Special care is required in patients who are receiving incidence of postoperative sore throat.. References with consequent severe bruising and postoperative sore 1 Christensen AM...... Laceration of the mucosa of the vocal 92–4. and monitoring epiglottitis which developed within 12 h of LMA use [56].. Anaesthesia 1994. Chung • Postoperative sore throat ... 50: spontaneously [41]... lateral neck radiographs taken after postoperative sore throat and to minimise the risk of recovery revealed that the epiglottis was posteriorly placed neuropraxia. injuries are likely to remain undiscovered......... Anaesthesia 1997.......... et al. Anaesthesia 1987.......... Because it is not routine practice to examine the larynx 7 Stride PC.. with an increased curvature.. One patient chosen. Lundby L. 54. Bishop MJ. White PF. cord may be treated by means of laryngeal microsurgery to 9 Dingley J........ Munster M.. Pedersen A... reducing 42: 1104–7.. likely to have been due to direct trauma on insertion. and are rabbit tracheal mucosa under normal conditions and under 䊚 1999 Blackwell Science Ltd 451 . Sparr HJ..... trating injuries caused by the laryngoscope blade....... has also been suggested that folding back of the tip of the Careful airway management technique is therefore essen- LMA on insertion may cause lifting of the arytenoid. with a gargle containing a drug such as benzydamine hydro. 1987...... Treatment of postoperative throat symptoms 4 Jorgensen LN. 1999.. Acta Anaesthesiologica Scandinavica 1987.. Knudsen J.. McVey FK.. Tracheal-tube cuffs that have minimal contact The LMA has been implicated as a cause of a case of with the tracheal mucosa should be used.... Wolgast M... 11 Wakeling HG..... the 10 Keller C. As with the tracheal-tube cuff. 85: 687–90. Anesthesiology has minimal systemic absorption.. Wareham K... E... Kruhoffer PK... which 6 Stout DM.. consider minimisation of LMA intracuff pressures. Prophylactic laryngo-tracheal aerosolized lidocaine against postoperative sore throat......... Benzydamine hydrochloride ambulatory anesthesia..

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