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A missing throat pack

2001; Wiley; Volume: 56; Issue: 4 Linguagem: Inglês

10.1046/j.1365-2044.2001.01976-19.x

1365-2044

Edward W.H. To, W.M. Tsang, Francis S. Y. Yiu, Matthew T.V. Chan,

Airway Management and Intubation Techniques

Throat packs (pharyngeal packs) are commonly employed to prevent saliva or blood from tracking down into the pharynx and the respiratory tract during otorhinolaryngeal, dental and oral surgical procedures [1]. We present an unusual case of a pharyngeal throat pack inadvertently left behind at the end of an operation. The pack was subsequently identified by chest and abdominal radiographs and was retrieved successfully. A 61-year-old woman with an infected mandibular titanium mesh tray underwent a removal operation under nasotracheal general anaesthesia. The operation was planned to remove the titanium mesh-tray extra-orally with a potential risk of opening up the oral mucosa. A piece of raytec gauze (5 cm × 20 cm) was placed in the oropharynx to serve as a pharyngeal pack. The titanium tray was removed uneventfully and general anaesthesia was reversed as usual. The patient was extubated without any complications. The vital signs were continuously monitored. The patient was breathing spontaneously and remained well oxygenated in the recovery room without any sign of respiratory distress. When it was confirmed that the throat pack was missing and had not been accounted for in the final swab count, an endoscopic examination of the airway down to the vocal cords was carried out in the recovery room. There was no sign of the throat pack or any foreign body impacted in the airway. A chest radiograph was taken to trace the radio-opaque Raytec gauze. A suspicious linear wavy shadow was found in the lower midline above the diaphragm (Fig. 6). A further abdominal radiograph confirmed that the retained Raytec gauze had passed into the stomach (Fig. 7). While the patient was being prepared for endoscopic retrieval of the ingested pack, the patient vomited and the pack was regurgitated in the vomitus. The throat pack was easily identifiable. The rest of her recovery was unremarkable. Postero-anterior chest radiograph showing an ambiguous wavy shadow in the midline obscured by the thoracic spine. Abdominal radiograph demonstrating the radio-opaque marker of the throat pack in the upper left quadrant among the area of gastric bubbles. A retained surgical pack in the immediate postoperative extubation phase is potentially catastrophic in obstructing the airway [2]. Fortunately, the pack was ingested into the gastrointestinal tract instead of being impacted or aspirated into the laryngo-tracheal-bronchial tree. In this case, the pack was expelled spontaneously by natural body mechanisms and no significant morbidity was inflicted upon the patient. The throat pack could have caused intestinal obstruction if not identified. The 'forgotten' throat pack was probably swallowed at the time of extubation while the patient was still in postanaesthetic stupor. The equivocal shadow in the chest radiograph was likely due to the underexposure of the film, superimposition with the thoracic spine and the reclining position of the patient in the recovery room. The abdominal radiograph with the correct radiation exposure and appropriate supine positioning of the patient allow definitive identification of the throat pack. A variety of techniques have been proposed in the literature to prevent retention of throat pack [3, 4]. They include measures such as labelling the forehead of the patient, attaching a label at the end of the tracheal tube or fixing the pack onto the tracheal tube at a predetermined site. However, residual throat packs still occur from time to time, leading to complications in the immediate recovery period [5, 6]. A radio-opaque marker within the gauze pack (Raytec gauze which is incorporated with a radio-opaque strip) is essential for identification in case of the pack being accidentally left behind in the patient as illustrated in this case. The anaesthetist and scrub team must be kept well informed about the insertion and removal of the throat pack. Reversal of anaesthesia must not be started until the counting of swabs is confirmed. Alertness to the danger to the airway and a strict protocol in handling of surgical packs by the theatre staff, the surgical team and the anaesthetists are critically important for prevention of similar mishaps.