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Reducing postsurgical sore throat and dysphagia

Christiaan Keijzer MD PhD
Department of Anaesthesiology and Intensive Care,
The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital,
Amsterdam, the Netherlands
Sore throat is a common  postoperative complaint for patients in whom a tracheal tube or laryngeal mask has been used for airway management. The incidence of sore throat varies from 14.4–50%(1) after tracheal intubation and from 5.8% to 34% after laryngeal mask insertion.1 This demonstrates a lower incidence of sore throat using a laryngeal mask compared with tracheal intubation. However, a recent publication(2) demonstrated postoperative sore throat complaints in 16.8% and 22.6% patients using the supraglottic devices ProSeal® and Classic® laryngeal mask, respectively. It was hypothesised that the inflatable cuff in both devices could be responsible for these postoperative complaints. The i-gel® supraglottic airway (i-gel®) is a newly developed supraglottic device with a small, non-inflatable, anatomically shaped cuff. It is hypothesised that the use of this device could significantly reduce the incidence of postoperative throat and neck complaints. 
Incidence of postoperative sore throat and dysphagia 
In a study using the Classic® laryngeal mask, Brimacombe and colleagues(2)  found sore throat percentages of 22.6% for patients in the postanaesthesia care unit and 21.8% 18–24 hours postoperatively. For dysphagia, these numbers were 15.8% and 11.7%, respectively. For the Proseal® laryngeal mask, incidences were 16.8% and 24.6% for sore throat and 13.6 and 14.4% for dysphagia. In another study by the same authors using the cuffed oropharyngeal airway, complaints of sore throat and dysphagia were observed in 5.0% and 26.7% and 8.4 and 8.7% patients, respectively.(3) A study by van Zundert et al(4) demonstrated sore throat incidences of 20.5% two hours postoperatively and 22.3% 24 hours postoperatively for the LMA-Classic® and 10.2% and 14.7% for the Soft Seal® laryngeal mask. Another study published by the same authors(5) showed only the incidence of sore throat complaints at two hours postoperatively. Here, sore throat occurred in 7.9% of patients using the LMA-Unique® and 10.5% using the Cobra-PLA®; for dysphagia the percentages were 1.9% and 8.6%.
i-gel® versus La Premiere® 
We investigated the usability of the i-gel® supraglottic airway and the disposable laryngeal mask (La Premiere®) in 244 patients at the Department of Anaesthesiology and Intensive Care of the Netherlands Cancer Institute Antoni van Leeuwenhoek Hospital (NKI-AVL) in Amsterdam. Patients were randomly assigned to one of the two devices, and several functional parameters including mean time to insertion, leak pressure and anatomical positioning of the device related to the larynx were measured. The latter was established by grading the view of the larynx through a flexible bronchoscope. These functional parameters scored better overall in the i-gel® group. After surgery, patients were interviewed by trained recovery personnel at 1, 24 and 48 hours postoperatively, either at the patient ward or at home by telephone. Patients were asked about sore throat, dysphagia, dysphonia, neck pain, numb tongue and any other complaints. These symptoms were graded as none, mild, moderate or severe and scored as 0, 1, 2 or 3, respectively. Recovery personnel were not informed about the type of device used. The results of this study were published by Keijzer  and colleagues in Anesthesia and Analgesia in October 2009.(6) 
The most important findings were the observed differences in incidence in postoperative sore throat and dysphagia between the two devices. After 1, 24 and 48 hours, the percentages of postoperative sore throat for the i-gel® were 6%, 6% and 5% respectively, and for the disposable laryngeal mask were 32%, 47% and 24%, respectively. For dysphagia, these percentages were 4%, 4% and 3% for the i-gel® and 21%, 32%  and 20% for the laryngeal mask. After comparing the number of postoperative complaints in the two patient groups, the authors demonstrated a significantly lower incidence of postoperative sore throat and dysphagia complaints in the i-gel® group compared with the laryngeal mask investigated in this study and all other supraglottic devices described in other studies. The only exception to this was found in the study using the LMA-Unique®(5), where a lower incidence of complaints of dysphagia after two hours was found. However, in this study these complaints were registered only at the time interval of two hours postoperatively; a possible increase of the incidence after 24 hours (as seen with other devices(3,6) was not measured. 
The reported incidence of postoperative sore throat in this NKI-AVL study is also much lower for the i-gel® group than in studies investigating the postoperative sore throat complaints after endotracheal intubation.(7–9) The authors of the i-gel® study therefore concluded that the use of the i-gel® results in a very low incidence of postoperative throat and neck complaints when compared to other studies using supraglottic devices or endotracheal intubation. 
The NKI-AVL study group hypothesised that the lower number of postoperative complaints in the i-gel® group was a result of the smaller size of this device compared with an inflated laryngeal mask. Also, the absence of an inflatable cuff could prevent possible tissue trauma around this device in the supraglottic area resulting from high cuff pressures.
Postoperative sore throat and dysphagia are common complaints after the use of endotracheal intubation or supraglottic devices. The study from the NKI-AVL demonstrates that the use of the i-gel® as a supraglottic device can significantly reduce the incidence of these postoperative complaints. 
  1. McHardy FE, Chung F. Postoperative sore throat: cause, prevention and treatment. Anaesthesia 1999;54:444–53.
  2. Brimacombe J et al. A multicenter study comparing the ProSeal and Classic laryngeal mask airway in anaesthetised, nonparalysed patients. Anesthesiology 2002;96:289–95.
  3. Brimacombe JR et al. A comparison of the laryngeal mask airway and cuffed oropharyngeal airway in anaesthetised adult patients. Anesth Analg 1998;87:147–52.
  4. Van Zundert AA et al. Comparison of the LMA-classic with the new disposable soft seal laryngeal mask in spontaneously breathing adult patients. Anesthesiology 2003;99:1066–71.
  5. van Zundert A et al. Comparison of three disposable extraglottic airway devices in spontaneously breathing adults: the LMA-Unique, the Soft Seal laryngeal mask, and the Cobra perilaryngeal airway. Anesthesiology 2006;104:1165–69.
  6. Keijzer C et al. A comparison of postoperative throat and neck complaints after the use of the i-gel and the La Premiere disposable laryngeal mask: a double-blinded, randomised, controlled trial. Anesth Analg 2009:104:1092–95.
  7. Higgins PP, Chung F, Mezei G. Postoperative sore throat after ambulatory surgery. Br J Anaesth 2002;88:582–84.
  8. Biro P, Seifert B, Pasch T. Complaints of sore throat after tracheal intubation: a prospective evaluation. Eur J Anaesthesiol 2005;22:307–311.
  9. Monroe MC et al. Postoperative sore throat: effect of oropharyngeal airway in orotracheally intubated patients. Anesth Analg 1990;70:512–516.