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

Abstract

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.

Survey on the Awareness of the Use of Oropharyngeal Throat Packs in Dental Anesthesia: An International Online Survey

“…OPTPs have been commonly used during general anesthesia and head and neck surgeries, including dental and oral procedures, and have perceived benefits for patients, surgeons, and anesthesiologists [ 2 , 6 , 7 ]. These advantages include 1) preventing accidental ingestion and aspiration of dropped water and/or solid foreign bodies [ 1 - 3 ], 2) reducing postoperative nausea and vomiting (PONV) caused by increased gastric contents [ 2 , 3 ], and 3) stabilizing the airway during general anesthesia by preventing gas leaks and displacement of tracheal tubes or supraglottic devices (particularly in pediatric patients using cuffless endotracheal tubes or procedures requiring frequent head movement for surgical maneuvers) [ 2 , 3 , 8 ].…”

“…These complications are probably related to the material of the OPTPs and/or its insertion method (such as the use of sharp instruments and/or rough insertion methods), and whether OPTPs are an effective barrier depends on the packing method [ 2 , 7 , 15 , 16 ]. We believe that the incidence of these disadvantages can be reduced by using a soft material for the OPTPs, inserting it softly using appropriate instruments such as Magill forceps, and packing it carefully around the endotracheal tube [ 6 ]. Furthermore, we believe that the appropriate use of OPTPs will reduce the incidence of PONV due to blood intake.…”

“…A questionnaire consisting of 13 questions in three sections was developed using an online survey tool with Google Forms (Table 7 of Appendix). The questionnaire was originally created with reference to the questionnaire on the actual use of OPTPs in cleft centers developed by Curran et al [ 6 ]. Section 1 involved obtaining consent to participate in the study.…”

“…In recent years, there has been growing momentum to review the use of OPTPs because of their potential effectiveness below expectations and the risk of inadvertent retention [ 4 - 6 ]. We have expressed our opinion that OPTPs remain important in clinical dental anesthesia despite this growing concern [ 2 ].…”