Endoscopic Removal of a Retained Throat Pack: A Profound Lesson

Abstract

Throat packing/pharyngeal packing is typically applied in all oral and maxillofacial surgeries. It prevents the entry of saliva, blood, disinfectant, other liquids, and oral foreign objects (brackets) into the trachea or esophagus. The retention of throat packing results in severe complications such as airway obstruction and digestive tract symptoms. We present a case of postextubation throat pack ingestion. The pack was identified and retrieved successfully from the gastrointestinal tract.

Throat packs are applied to absorb blood and secretions during oral-maxillofacial surgery procedures.1 They minimize air leaks around the tracheal tubes during the induction of general anesthesia and surgery.2 A retained surgical pack in the immediate postoperative extubation phase results in airway obstruction. Within 4 to 6 hours, it may enter the intestine, necessitating exploratory laparotomy. On the basis of a short review of the literature on the use of throat packing, we present a case of postextubation throat pack ingestion that give us a profound lesson.

CASE PRESENTATION

A 40-year-old woman with titanium plate remnants in the mandible was referred to our department. Computed tomography revealed 2 fixed titanium plates in the chin region. The titanium plates were removed surgically under general anesthesia. After the nasotracheal intubation, one of the surgeons placed a packing gauze in the pharynx. However, the patient woke up and swallowed the gauze intraoperatively. Postoperatively, the patient had spontaneous breathing and was successfully extubated. Upon transferring to the recovery room, she noted throat discomfort, suggestive of foreign body ingestion. The members of the operating team then remembered that the throat pack had not been removed. A thorough investigation of the patient’s oral cavity after suctioning revealed that the throat pack was not intact. Chest x-ray was immediately performed, and a radiopaque band of packing gauze was identified in the esophagus (Fig. 1A). The packing gauze was retained in the patient’s stomach. Its removal during the surgery was not confirmed by the nurse’s swab count before extubation. The patient and her family members were informed regarding the situation, and endoscopic removal of the packing gauze was performed. A flexible endoscope was inserted transorally into the stomach under sedation, and the gauze was located endoscopically in the stomach (Fig. 1B). The gauze was removed successfully without complications (Fig. 1C). After the patient recovered, she was transferred to the ward for monitoring. The postoperative course was uneventful, and the patient was discharged 2 days later.

FIGURE 1.

(A) Chest X-ray showing a radiopaque band of packing gauze (arrows). (B) Endoscopic view of packing gauze in the stomach. (C) Throat pack after removal.

DISCUSSION

Throat packs are applied to absorb blood and secretions during oral-maxillofacial surgery procedures. They minimize air leaks around the tracheal tubes during the induction of general anesthesia and surgery.2 A retained surgical pack in the immediate postoperative extubation phase results in airway obstruction. Within 4 to 6 hours, it may enter the intestine, necessitating exploratory laparotomy.

Several cases of missing throat packs have been previously reported earlier in literature. In our case, the retention of the gauze pack was realized after the patient had been extubated and transferred to the recovery area. The pack had been swallowed during extubation, but it was successfully retrieved. The radiopaque strip of the pack was useful for identifying it on intraoperative radiography. Some reasons for this surgical complication in our patient are as follows. First, the intraoperative application of the pharyngeal gauze was not recorded by the circuit nurse. Second, the operation was declared over before the swab count was conducted. Third, the surgeon was not attentive and careful as it was a minor operation. Finally, the operating rules were not strictly regulated among the doctors and nurses.

The retention of a gauze pack is a fatal complication with medicolegal implications on the operating team. Proper precautions should be taken to adequately mark and promptly record all inserted oral packs as part of the safety checklist to ensure their removal before extubation. The surgeon is responsible for the removal of the foreign pack. The circulating nurse should record the time of insertion and removal of the pack on the whiteboard as well as the surgical count. Alterations to applied throat packs or insertions of additional packs by the operating team should be clearly communicated and documented. Postoperatively, the surgeon/anesthesiologist should call out the removal of the pack to the team. Last but not least, a radiopaque strip in the pack should be used to detect its position on the C-arm,3–6 and in cases involving missing oral packs, a thorough investigation should be conducted without compromising the safety of the patient.