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Year: 2005

Complaints of sore throat after tracheal intubation: a prospective

evaluation

Biro, P; Seifert, B; Pasch, T

Biro, P; Seifert, B; Pasch, T (2005). Complaints of sore throat after tracheal intubation: a prospective evaluation.
European Journal of Anaesthesiology, 22(4):307-311.
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Posted at the Zurich Open Repository and Archive, University of Zurich.

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Originally published at:

European Journal of Anaesthesiology 2005, 22(4):307-311.
Complaints of sore throat after tracheal intubation: a prospective
evaluation

Abstract

BACKGROUND AND OBJECTIVE: Sore throat and hoarseness rank, besides pain and nausea, among
the most frequent subjective complaints after tracheal intubation for general anaesthesia. Our intention
was to determine the incidence of postoperative sore throat from a large sample of patients and thus to
identify the most important associated factors. METHODS: We prospectively followed up 809 adult
patients who underwent elective surgical interventions and examined their history, the applied
anaesthetic techniques, perioperative course and the occurrence, intensity and duration of postoperative
throat complaints. The assignment and professional experience of the involved intubators were also
assessed. The influence of a multitude of variables on postoperative throat complaints was statistically
analysed. RESULTS: Postoperative sore throat was present in 40% overall being significantly higher in
female than in male (44% vs. 33%; P = 0.001). The mean pain intensity in the affected patients (n =
323) was 28+/-12 mm on a visual analogue scale where 0 = no pain and 100 = extreme pain. The
average duration was 16+/-11 h. Main factors associated with throat complaints were female sex; history
of smoking or lung disease, duration of anaesthesia, postoperative nausea, bloodstain on the
endotracheal tube and natural teeth. We could find no influence on the occurrence or intensity of throat
complaints by the professional assignment or the length of professional experience of the personnel
involved. CONCLUSIONS: Postoperative throat complaints frequently arise after tracheal intubation for
general anaesthesia in the first 2 postoperative days, but they are of limited intensity and duration.
 European Journal of Anaesthesiology 2005; 22: 307–311
© 2005 European Society of Anaesthesiology
ISSN 0265-0215

Original Article

Complaints of sore throat after tracheal intubation:

a prospective evaluation

P. Biro*, B. Seifert†, T. Pasch*

*
University Hospital Zurich, Institute of Anaesthesiology; †University of Zurich, Institute for Social
and Preventive Medicine, Division of Biostatistics, Zurich, Switzerland

Summary
Background and objective: Sore throat and hoarseness rank, besides pain and nausea, among the most frequent
subjective complaints after tracheal intubation for general anaesthesia. Our intention was to determine the inci-
dence of postoperative sore throat from a large sample of patients and thus to identify the most important asso-
ciated factors.
Methods: We prospectively followed up 809 adult patients who underwent elective surgical interventions
and examined their history, the applied anaesthetic techniques, perioperative course and the occurrence, inten-
sity and duration of postoperative throat complaints. The assignment and professional experience of the
involved intubators were also assessed. The influence of a multitude of variables on postoperative throat com-
plaints was statistically analysed.
Results: Postoperative sore throat was present in 40% overall being significantly higher in female than in
male (44% vs. 33%; P  0.001). The mean pain intensity in the affected patients (n  323) was 28  12 mm
on a visual analogue scale where 0  no pain and 100  extreme pain. The average duration was 16  11 h.
Main factors associated with throat complaints were female sex, history of smoking or lung disease, duration of
anaesthesia, postoperative nausea, bloodstain on the endotracheal tube and natural teeth. We could find no
influence on the occurrence or intensity of throat complaints by the professional assignment or the length of
professional experience of the personnel involved.
Conclusions: Postoperative throat complaints frequently arise after tracheal intubation for general anaesthesia
in the first 2 postoperative days, but they are of limited intensity and duration.

Keywords: POSTOPERATIVE COMPLICATIONS, sore throat, aetiology, intensity, duration; INTUBATION,

INTRATRACHEAL, complications.

Tracheal intubation is a standard technique in general
anaesthesia, which, despite its undisputed advantages
including prevention of aspiration, reduction of dead
space, accessibility of the airway for suction and con-
trolled ventilation, is not free from side effects. Sore
throat and hoarseness rank, besides pain and nausea,
Correspondence to: Peter Biro, Institute of Anaesthesiology, University Hospital
Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland. E-mail: peter.biro@
usz.ch; Tel:
41 1 2551111; Fax:
41 1 2554409
Accepted for publication July 2004 EJA 1944
amongst the most frequent subjective complaints
expressed by patients, after tracheal intubation
[1–12]. Although post-anaesthetic throat complaints
are often regarded as minor complications, they are
distressing for the patient and often remain as unpleas-
ant memories. Therefore, a lessening of the symp-
toms is worth striving for. Causal factors mentioned,
amongst others, are size and shape of the endotra-
cheal tube (ETT) or respectively its cuff, the use of
lubricants, cuff pressure, relaxation with succinyl-
choline and long duration of intubation. The degree
308 P. Biro et al

of difficulty of laryngoscopy and/or intubation, and Table 1. Incidence of sore throat as related to patient
the course of extubation have not yet been examined and clinical factors.
as causes of postoperative throat complaints. The goal
No sore
of this study was to determine the actual and pre- throat Sore throat P-value
vailing incidence of postoperative sore throat after
undergoing anaesthesia and intubation in a large Total number of 486 (60%) 323 (40%)
sample of patients, and thus to identify the most patients
important associated factors. Male 209 (43%) 102 (32%) 0.001
Female 277 (57%) 221 (68%)
Respiratory tract or 8 (2%) 16 (5%) 0.01
Methods lung disease
Dentures 107 (22%) 46 (14%) 0.006
Over the period from December 2001 until April Pharyngeal temperature 375 (77%) 269 (83%) 0.04
2002, a total of 809 patients of both gender, aged sensor probe
between 15 and 94 yr, undergoing elective surgery, Nasogastric tube 263 (54%) 197 (61%) ns
Bloodstain on tube 17 (3.5%) 39 (32%) 0.001
were recruited prospectively and questioned about at extubation
the occurrence of postoperative sore throat after tra- Postoperative nausea 110 (23%) 148 (46%) 0.006
cheal intubation. As this investigation was a non- and vomiting
randomized prospective study, the recruitment of Age (yr) 50.2  16.8 45.1  15.2 0.001
patients was part of the everyday routine and the Height (cm) 169  8 168  8 ns
Weight (kg) 72  13 73  16 ns
medical and organizational conditions remained Smoking 7.0  13.8 8.8  16.9 0.03
unchanged. Patients with preoperative hoarseness or (pack y1)
sore throat were excluded from the study. Further Intubation attempts 1.2  0.5 1.2  0.5 ns
criteria for exclusion were inability to obtain consent, Duration of 23  17 25  21 ns
age under 15 yr, emergency operations, and opera- intubation (s)
Duration of 158  77 180  88 0.001
tions within the area of the mouth, pharynx, larynx anaesthesia (min)
and throat. All included patients gave informed con- Postoperative vomiting 0.4  1.0 0.8  1.5 0.001
sent for the collection and analysis of their anonymized episodes
data. Premedication followed the routines of the Data are expressed as number (%) or mean  SD.
respective department and no constraint was placed ns: not significant.
on the technique of general anaesthesia so that the
anaesthetists were free to perform the procedures as
they intended to. All patients were intubated orally
under direct laryngoscopy by clinical members of a visual analogue scale (VAS) with a range from
the anaesthesia personnel. All the usual hypnotics, 0 mm  no pain to 100 mm  extreme pain.
anaesthetics and muscle relaxants were used, as in Continuous variables are presented as mean  SD.
previous investigations [13]. Females were usually The correlation between the incidence of sore throat,
intubated with a 7.5 mm and males with an 8.0 mm and the medication for its relief as a categorical vari-
ETT (high-volume/low-pressure SilkoClear®; Willy able was carried out with the 2-test and Fisher’s
Rüsch GmbH, D-71394 Kernen, Germany) [10]. exact test, respectively. The differences between con-
The cuff was filled with air up to a pressure of tinuous variables were examined with the U-test.
25 mbar until no escape of anaesthetic gases could be Multivariate analysis was followed by a stepwise logis-
heard [14–16]. tic regression. The correlation of intensity of sore
For the evaluation, details relating to the experi- throat with continuous variables was examined by
ence of the intubator, the course and degree of diffi- means of the Spearman’s rank correlation and with
culty of the intubation, the application of additional categorical variables using the U-test. Statistical sig-
devices into the pharynx, such as a temperature sen- nificance was set at the P  0.05 level.
sor and gastric tubing, as well as the process of the
extubation were taken into consideration. In addition,
Results
biometric and medical data of the patient (e.g. smok-
ing, prevailing airway or lung disease), duration of In our study, the overall incidence of postoperative
anaesthesia and postoperative nausea and vomiting sore throat was 40% and was significantly higher in
were evaluated. Within a postoperative time period of female than in male (44% vs. 33%; P  0.001)
12–24 h, the presence, duration and degree of hoarse- (Table 1).
ness and sore throat, as well as the need of medication The average pain score, calculated from all 809
for their relief, have been recorded. The measure- patients and expressed on a scale from 0 to 100 mm,
ment of sore throat intensity was accomplished with was 11  16. This very low result is misleading,

© 2005 European Society of Anaesthesiology, European Journal of Anaesthesiology 22: 307–311

 Throat complaints after tracheal intubation 309

100 P  0.001) and for female (r  0.14; P  0.044).

90 There was a negative correlation between the dura-
tion of complaints and the lowest SPO2 during extu-
80
bation (r  0.36; P  0.001).
70 There was no correlation between the incidence of
Number of patients

60 sore throat and the professional grade of the intuba-

50
tor. Therapies for sore throat became necessary, when
the intubation had been accomplished by qualified
40
nurses in 8% (from n  101), with medical doctors
30 in training in 7.3% (from n  493) and with anaes-
20 thesia specialists in 9.5% (from n  190). No corre-
10
lation could be determined between the intubators
experience in months and the incidence or intensity
0
1–10 11–20 21–30 31–40 41–50 51–60 61–70 71–80
of sore throat. Medication was only needed by 64
Pain intensity (VAS) patients (7.9%), but significantly more of these were
female (P  0.001). Furthermore, treatment for sore
Figure 1. throat has been associated with the occurrence of
Intensity of sore throat in patients who had postoperative throat postoperative nausea (12% vs. 5.4%; P  0.001).
complaints (n  346). With gradual logistic regression of the univariate
variables, the following seven characteristics have
100
been proven as significantly associated with post-
90 operative throat complaints: female gender (odds
80
ratio, OR 1.66; P  0.003), visible bloodstain on
the ETT after extubation (OR 4.81; P  0.001),
Patients with sore throat (%)

70 natural set of teeth (OR 0.46; P  0.001), pre-exist-

60 ing respiratory tract disease (OR 3.12; P  0.02),
lower age group (by year OR 0.98; P  0.001),
50 duration of anaesthesia (OR 1.27; P  0.001) and
40 postoperative vomiting (per vomiting episode OR
0.29; P  0.001).
30

20
10
0 of approximately 40% lies in the middle of ranges of
1–10 11–20 21–30
40
Duration of pain (h)
Figure 2.
Time course of sore throat in patients who had postoperative throat
complaints (n  346).
as the data from the 486 patients who indicated no
complaints at all (value  0 mm), have been included.
More meaningful is the mean value (28  12) and
the median (28) of those 323 patients with com-
plaints (Fig. 1). The mean duration of sore throat, as
indicated by those patients, was 16  11 h (Fig. 2).
There was a positive correlation between the
intensity of sore throat and the duration of anaesthe-
sia (Spearman’s r  0.12; P  0.03) and a negative
correlation with the lowest SPO2 during extubation
(r  0.30; P  0.001). There were positive corre-
lations between the duration of sore throat and the
0 mm) is in
duration of anaesthesia (r  0.16; P  0.004), the
number of postoperative vomiting episodes (r  0.13;
P  0.02) and the size of the ETT for male (r  0.34;
Discussion
Our incidence of post-intubation throat complaints
31–40
comparable figures from the literature (14–75%)
[2–12]. Out of these 11 investigations, however, nine
had been performed with far fewer patients than in
our study. The results of those two studies, which
had a higher number of cases than ours (n  1325
and 5264, respectively), were 14.4% [4] and 45.5%
[17]. This shows clearly, that our results lie closely to
those in the largest study of Higgins and colleagues,
which used a similar technique of questioning. In con-
trast, Christiansen and colleagues did not purposely
specify the questioning concerning sore throat, but
merely considered the incoming reports passively,
which is known to have a substantial influence on
the results [18]. Likewise, our results concerning
intensity and duration of sore throat corresponded
well with the results found in the literature.
The average pain intensity of 28  12 (including
only patients indicating a pain level
the lower range of the 100 mm scale and the duration
of a maximum of two days. Strictly speaking, this is
a matter of comfort rather than perioperative

© 2005 European Society of Anaesthesiology, European Journal of Anaesthesiology 22: 307–311

310 P. Biro et al
morbidity. Nevertheless, there are isolated cases
with higher intensity of pain, particularly from sub-
stantially longer duration of intubation. In these
cases, additional symptoms such as hoarseness or
even dysphagia can occasionally be found. In this
connection, Jones and colleagues stated that about
3% of intubated patients had complaints lasting
longer than 1 week and on laryngoscopy had laryn-
geal lesions, pharyngeal haematomas or granulomas
of the vocal cords [6].
The aetiology of throat complaints is multi-
factorial. With our evaluation using gradual logistic
regression, we intended, by using a large study with
many different intubators of varying professional expe-
rience and without mandating any particular anaes-
thetic method during the study to identify as many
causal factors of postoperative throat complaints as
possible.
All authors, who had examined the relevance of
gender stated without exception that females are
more frequently and strongly affected by intubation-
related complaints, [4,5,7,11,17,19,20], which corre-
sponds well with our results. The cause of this,
however, is still unclear. In our studies, nausea and
vomiting arose more frequently with female which
has been confirmed elsewhere [19,20]. Beattie and
colleagues examined the influence of the menstrual
cycle on postoperative nausea and vomiting follow-
ing gynaecological laparoscopy [21]. Postoperative
nausea and vomiting occurred 2.9 times more often
in female who were in the first 8 days of their men-
strual cycle. We found that sore throat correlated
with postoperative nausea and vomiting (r  0.21;
P  0.001). The choice of ETT size (8.0 mm for
males and 7.5 mm for females) does not fairly fit the
actual anatomical and functional conditions [8,22,23].
It needs to be examined separately, whether an ETT
with an internal diameter of 7.0 mm is a better alter-
native for female adults.
Our finding that smoking is increasingly accom-
panied by a sore throat with a longer duration is not
particularly surprising. This, however, cannot be ver-
ified from other sources and the two studies which
found no relation between these were based only on
a small number of cases (n  200) [7,10]. Persons
wearing dentures have more space in the oral cavity
and a better view can be achieved during laryn-
goscopy when the denture is removed. Less force may
need to be exerted with the blade. However, it can-
not clearly be differentiated whether the throat com-
plaints can be put down to the laryngoscopy alone or
additionally to the passage and insertion of the ETT.
It is interesting to note that the insertion of temper-
ature sensors into the hypopharynx, even thought
they are relatively small and flexible, still makes a
contribution to the development of sore throat.
© 2005 European Society of Anaesthesiology, European Journal of Anaesthesiology 22: 307–311
In our study, as well as in other comparative evalu-
ations, cuff pressure was of lesser significance since
cuffs of the ‘high-volume/low-pressure’ type were
used. In addition, the cuffs were inflated to the mini-
mum volume to prevent a leak up to an airway pres-
sure of 25 mbar. An increase of the cuff pressure which
may occur by diffusion of nitrous oxide was not rele-
vant since this gas was not used. We did not apply
preventive measures routinely, such as filling of the
cuff with lidocaine (instead of air), topical application
of local anaesthesia or beclomethasone as recom-
mended by some authors [9,24]. Such measures should
be left for special cases only, such as patients having
operations on the respiratory tract and those who are
professionally dependent on their voice. In particular
the choice of a thinner ETT should be considered.
The number of intubation attempts as well as the
duration of anaesthesia have both been proven as
causative factors for throat complaints, which is in
agreement with the results of Kloub [7] and Rieger
and colleagures [10] and is actually self-explanatory.
This, however, has not been confirmed by all authors
[3,4,6,18]. The limited correlation between throat
complaints and the amount or length of professional
experience is probably attributed to the fact that
after 1 yr, no substantial improvement in intubation
skills can be expected [25].
The extubation procedure has been considered in
none of the comparative investigations. Furthermore,
the duration of the extubation procedure and the
occurrence of coughing and gagging have not previ-
ously been considered. We showed, nevertheless, that
a sore throat must be expected alongside a blood-
stained ETT during extubation.
Postoperative sore throat is a frequent finding
after general anaesthesia with tracheal intubation,
which usually is not of vital importance but remains
a significant cause for discomfort. Relevant factors
associated with throat complaints were female sex,
natural dentition, smoking, long anaesthesia dura-
tion and postoperative nausea and vomiting. Thus
further improvement in patient comfort could be
expected by focusing on prevention such as choice of
narrower ETTs and better prophylaxis and treatment
of postoperative nausea and vomiting.
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