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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 15  |  Issue : 1  |  Page : 61-63

Intraoperative dislodgement of throat pack into esophagus and its management


1 Department of Dental Surgery and Oral Health Sciences, Division of Oral and Maxillofacial Surgery, Armed Forces Medical College, Pune, Maharashtra, India
2 Department of Dental Surgery and Oral Health Sciences, Armed Forces Medical College, Pune, Maharashtra, India
3 Armed Forces Dental Clinic, Pune, Maharashtra, India
4 Classified Specialist, Oral & Maxillofacial Surgery, Command Military Dental Centre (Southern Command), Pune, Maharashtra, India

Date of Submission10-Feb-2020
Date of Acceptance23-Jan-2021
Date of Web Publication09-Mar-2021

Correspondence Address:
Yuvraj Issar
Department of Dental Surgery and Oral Health Sciences, Division of Oral and Maxillofacial Surgery, Armed Forces Medical College, Wanowrie, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JODD.JODD_5_20

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  Abstract 


Throat packs are commonly used in Intra-oral and Maxillofacial surgical procedures to prevent fluids, particulate matter as well as foreign bodies from entering into the aero-digestive tract. The pack is usually placed following endotracheal intubation which involves packing it around the Endotracheal tube (ETT) in the Oropharyngeal region as a reinforcement measure. The need for such a pack arises due to a variety of reasons such as, volumetric change in the airway resulting from a change in the tissue turgor and reducing pressure of the ETT cuff, which may result in the seepage of fluids into the airway, resulting in an emergency. If a throat pack has been inserted but not removed at the end of a procedure, then the obvious danger is that the retained pack may cause airway obstruction. We present an interesting case of a missing pharyngeal throat pack at the end of an operation. The insertion of the throat pack must be documented in the patient safety checklists well as prominently displayed to ensure proper removal at themed of surgery. If the pack is missing its location must be verified before extubating the patient as was in our case where the prudent and prompt action of the Anaesthetic and Surgical team prevented a major complication. This case report represents an interesting case of a missing pharyngeal throat pack at the end of an operation.

Keywords: Endotracheal intubation, general anesthesia, maxillofacial surgery, oropharynx, throat pack


How to cite this article:
Issar Y, Bhandari S K, Roy ID, Bagga DS. Intraoperative dislodgement of throat pack into esophagus and its management. J Dent Def Sect. 2021;15:61-3

How to cite this URL:
Issar Y, Bhandari S K, Roy ID, Bagga DS. Intraoperative dislodgement of throat pack into esophagus and its management. J Dent Def Sect. [serial online] 2021 [cited 2021 Apr 18];15:61-3. Available from: http://www.journaldds.org/text.asp?2021/15/1/61/310965




  Introduction Top


Throat packs are commonly used in intraoral and maxillofacial surgical procedures to prevent fluids, particulate matter as well as foreign bodies from entering into the aerodigestive tract.[1] The pack is usually placed following endotracheal intubation which involves packing it around the endotracheal tube (ETT) in the oropharyngeal region as a reinforcement measure. The need for such a pack arises due to a variety of reasons such as volumetric change in the airway resulting from a change in the tissue turgor and reducing pressure of the ETT cuff, which may result in the seepage of fluids into the airway, resulting in an emergency.

However, as stated by Knepil and Blackburn, proper justification must be exercised when a surgeon decides to use a throat pack. The responsibility for removal of the pack rests with the person who inserted it;[2] the National Patient Safety Agency recommends that a label be placed on the patient's head to prevent the pack being forgotten.[3] If a throat pack has been inserted but not removed at the end of a procedure, then the obvious danger is that the retained pack may cause airway obstruction. We present an interesting case of a missing pharyngeal throat pack at the end of an operation.


  Case Report Top


A 12-year-old female patient with a residual alveolar cleft of the left side was taken up for secondary alveolar cleft grafting with corticocancellous iliac crest graft under general anesthesia in the supine position. Two teams were operating: one at the cleft site and the other at the graft harvesting site at the right iliac crest region. As a regular practice at our institution, a throat pack was inserted around the ETT of our patient using Magill forceps, following administration of a standard general anesthesia. The “throat pack in” notification was mentioned in the anesthetic notes, taped on the patients' forehead as well as recorded in the swab count. On completion of the surgery, reversal was initiated followed by a direct laryngoscopy to remove the inserted throat swab. However, the throat pack was nowhere to be seen in the oropharynx, even after repeated searching and suctioning by the anesthetist as well as surgeon. Inadvertent removal of the throat pack by the surgeon was ruled out and a conscious decision to defer extubation was taken.

A fiber-optic bronchoscopy was performed through the ETT by the anesthetist with the patient still under anesthesia, which did not reveal the presence of a foreign body in the airway. Hence, the throat pack was still missing and its dislodgement into the esophagus or stomach was considered, following which the gastroenterologist was requested to perform a rigid endoscopy. A rigid endoscopy promptly revealed the presence of the throat pack in the upper esophagus [Figure 1], which was subsequently removed by the gastroenterologist. The patient was subsequently extubated and postoperative recovery was uneventful.
Figure 1: Throat pack located in the lower esophagus by rigid endoscopy

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  Discussion Top


The insertion of throat pack during surgeries of the head-and-neck region is a common practice, although airway obstruction due to retained throat packs.[4] At our center, throat packs are regularly placed during maxillofacial surgical interventions. As inferred by Bisase et al., throat packs are usually placed by the anesthetist; they were found to be placed by surgeons as well as anesthetists in different surveys in the United Kingdom. In spite of being a routine practice, there are no well laid out policies for the insertion and removal of throat packs.[5] However, at our institution as a protocol, throat packs are placed and removed by the Anesthetist.

The placed throat pack should be secured with a tape or anchored to prevent its dislodgment into the aerodigestive tract Although the throat pack is used, it should be anchored or taped[6] so that it is not inadvertently displaced. However, this is not possible in most maxillofacial surgeries as maxillomandibular fixation is required. A radiopaque strip incorporated in the pack can aid in detecting its position radiographically.[7],[8] Removal of the throat pack may be missed at the end of very lengthy surgeries or due to the occurrence of multiple critical events intraoperatively,[9] hence special consideration to throat pack must be given in lengthy and critical procedures. Maxillofacial surgeons must pay special attention to the insertion as well as its removal as we share the airway with the anesthetists.


  Conclusion Top


The throat pack may be displaced due to the swallowing and respiratory movements before extubation. The insertion of the throat pack must be documented in the patient safety checklists well as prominently displayed to ensure proper removal at the theme of surgery. If the pack is missing, its location must be verified before extubating the patient as was in our case where the prudent and prompt action of the anesthetic and surgical team prevented a major complication.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Knepil GJ, Blackburn CW. Retained throat packs: Results of a national survey and the application of an organisational accident model. Br J Oral Maxillofac Surg 2008;46:473-6.  Back to cited text no. 1
    
2.
Stone JP, Collyer J. Aide-memoir to pharyngeal pack removal. Anesth Analg 2003;96:304.  Back to cited text no. 2
    
3.
Curran J, Ward M, Knepil G. Reducing the risk of retained throat packs after surgery. Natl Patient Saf Agency 2009;1:1-12.  Back to cited text no. 3
    
4.
Smith M, Turnbull D, Andrzejowski J. Throat packs in neuroanaesthesia. Anaesthesia 2012;67:804-5.  Back to cited text no. 4
    
5.
Bisase B, Matthews NS, Lan C. Current practice and opinions regarding the use of oropharyngeal throat packs in the United Kingdom. J Patient Saf 2011;7:162-4.  Back to cited text no. 5
    
6.
Najjar MF, Kimpson J. A method for preventing throat pack retention. Anesth Analg 1995;80:208-9.  Back to cited text no. 6
    
7.
Scheck PA. A pharyngeal pack fixed onto the tracheal tube. Anaesthesia 1981;36:892-5.  Back to cited text no. 7
    
8.
To EW, Tsang WM, Yiu F, Chan M. A missing throat pack. Anaesthesia 2001;56:383-4.  Back to cited text no. 8
    
9.
Burden RJ, Bliss A. Residual throat pack – A further method of prevention? Anaesthesia 1997;52:806.  Back to cited text no. 9
    


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