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Journal of Clinical Medicine Research

Review

Volume 14, Number 2, February 2022, pages 88-94

A Literature Review of Factors Related to Postoperative Sore Throat

Postoperative sore throat (POST) is one of the most common postoperative complications. The incidence of POST ranges from 12.1% to 70% [1-3]. POST has been shown to decrease postanesthesia recovery and inpatient satisfaction [4]. In addition, POST can cause aspiration pneumonia [5-7]. The mechanisms of POST include damage to the epithelium and mucosal cells due to airway secretion, damage to the vocal cords, and congestive blood loss [8]. In recent years, research has been conducted on the factors that cause POST; and it has been reported that the shape of intubation tubes [6, 9], cuffs size [10], endotracheal intubation technique [8], cuff pressure [11, 12], and use of inhalation anesthesia [13] are among such factors. In addition, the efficacy of topical dexamethasone [7] and magnesium [14] as POST prophylaxis, as well as the ineffectiveness of lidocaine spray [15, 16], have been demonstrated. Complications were scored preoperatively to predict postoperative complications. For example, for postoperative nausea and vomiting (PONV), Apfel et al [17] scored the preoperative risk. However, no study has scored the preoperative risk factors for POST. Notably, pain as a sensation is related to attributes such as time, space, pressure, and temperature, and the emotional nature of pain as a sensation, including tension and fear, has been described. Furthermore, when confronted with pain, if we want to evaluate the organic cause of the pain, we must exclude pain as an emotion to evaluate it; however, if the pain is strong despite little organic damage, we may have to focus on pain as an emotion. In pain assessment, it is often useful to divide pain into sensory and emotional pain. Therefore, we focused on the tension and anxiety of patients in response to POST and reviewed the literature to determine whether POST has an emotional nature, but we could not find any relevant studies [18]. Therefore, in this study, we aimed to systematically collect and integrate information through a review to clarify the patient factors associated with POST.

We searched PubMed for articles on patient factors associated with POST. For PubMed, the literature extraction period was 2010 - 2020, and the extraction keywords were “postoperative sore throat,” “anesthesia,” and “patient factors.” We excluded patients with “tonsillitis” and “pharyngitis” from our search. We expanded the search period and retrieved 19 cases from April 1990 to March 2020. Because there were not enough papers and cases, we also included references that were judged to be closely related to the list of citations of the retrieved references. The study designs included were randomized controlled trials (RCTs), clinical trials, meta-analyses, reviews, and systematic reviews.

The titles and abstracts were reviewed to determine if they described sore throat as a complication of surgical anesthesia. Finally, 15 articles that met the following criteria were selected for analysis: 1) studies investigating factors associated with PONV; and 2) those in which pharyngeal pain related to anesthesia was evaluated.

A total of 120 articles were identified using the keyword search. Of these, 20 were RCTs, clinical trials, meta-analyses, reviews, and systematic reviews with human subjects in the study design. Then, seven articles were excluded based on the exclusion criteria, leaving 13 articles that met all the criteria. Finally, two hand-searched articles were added to create a total of 15 articles in this study (Fig. 1). The common patient characteristics in the literature were American Society of Anesthesiologists (ASA) grades I - III in adults, height, weight, and sex. There were 10 device factors for securing the airway, and five of them had significant differences in sore throat. Among them, “tube insertion time” was extracted as a factor in four articles. Among the articles that showed significant factors associated with a sore throat, “age” was extracted as a factor in two articles, and “female” and “smoking history” were also extracted in two articles (Table 1 [2, 19-32]).

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Figure 1. Flowchart of literature review.

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Table 1. Studies Included in the Analysis

Regarding the relationship between anesthesia technique and POST, the incidence of POST associated with different types of airway management tubes, cuff pressures, and cuff contents has been reported. In nine articles, the incidence of POST was associated with different types of airway management tubes. Depending on the type of airway management tube, the average time to successful airway clearance ranged from 12 to 60 s, and the incidence of POST ranged from 6.8% to 50% [19-26, 33] (Table 2 [19-24, 30]). Two articles examined the incidence of POST associated with differences in cuff pressure and cuff contents (Table 3) [27, 28].

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Table 2. Relationship Between Anesthesia Techniques and Postoperative Sore Throat

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Table 3. Relationship Between Cuff Pressure and Postoperative Sore Throat

Regarding the relationship between POST and characteristics of patients undergoing surgery, the incidence of POST according to sex and age, according to the ASA preoperative status classification (ASA physical status), and due to previous respiratory disease and smoking have been reported. Biro et al [29] evaluated the incidence of POST by using a visual analog scale at 12 to 24 h postoperatively and found that 40% of the patients had POST. There were significant differences in age, sex, presence of airway or lung disease, smoking history, pharyngeal temperature sensor, PONV, and anesthesia duration. Logistic analysis revealed seven significant factors: female sex, bloodstains on the intubation tube after extubation, use of dentures, history of respiratory disease, young age, PONV, and anesthesia duration. Higgins et al [1, 2] evaluated the incidence of POST in the postanesthesia care unit 24 h postoperatively in the tracheal intubation, laryngeal mask airway (LMA), and facemask (FM) groups. The incidence of POST was higher in the endotracheal tube (ETT) group (45.5%), followed by the LMA group (17.5%) and FM group (3.3%). Predictors of POST included female sex, age (mean 47 years), current smoker status, ASA, and gynecological and ophthalmic surgery (Table 4 [2, 29]).

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Table 4. Predictors of Postoperative Sore Throat

In this study, we reviewed patient factors related to POST. Most of the studies we identified were concerned with devices and anesthesia techniques for securing the airway, but there were also some references to patient factors.

The results of the present study reveal that the devices and procedures necessary for securing the airway can cause POST [19-21, 24, 25, 30]. Physical agents such as tubes irritate the airway during intubation and surgery, causing sore throat [34, 35]. The cuff of the tube, dryness of the mucosa, and abrasion of the airway mucosa during intubation, caused by the rubbing of the intubation tube against the airway mucosa, are thought to be the etiological factors of POST. In addition, the damage to the airway mucosa caused by the strong stimulation by the laryngoscope and the movement of the intubation tube excites the C fibers related to secondary pain, and the subsequent release of neurotransmitters is related to POST. El-Boghdadly et al [3] also cited blood contamination of the tube after removal as a risk factor for sore throat. Therefore, we believe that the persistence of physical irritation from intubation to the completion of surgery may cause POST. To address this, we believe that minimizing physical stimulation, for example, choosing a device that takes into account the operative time and intubation as well as extubation techniques, can help prevent the risk of sore throat. The insertion time of the tube was also mentioned as a factor in these studies [19-21, 24, 29]. Hsu et al [36] found that the shorter the time to secure the airway, the lower the incidence of POST in their study using a video laryngoscope to insert a double-lumen endotracheal tube into the correct position. Hence, a short time to airway clearance can minimize the invasion of the airway mucosa [24, 30]. This may have been a factor causing POST in much of the current literature. There was a difference in the incidence of POST depending on the shape and nature of the device used to secure the trachea. However, we were not able to clarify the relationship between the number of risk factors (number of physical stimuli and procedural factors) and the occurrence of POST as well as the severity and duration of POST.

The patient factors were “smoking history,” “female sex,” and “age.” The relationship between smoking and respiratory diseases has been clarified in many studies [37, 38]. The mechanism is generally known to be inflammation of the bronchi and alveoli and eventual destruction of the alveoli. As reported by Tanaka et al [1] and Piriyapatsom et al [39], POST is thought to be triggered by material stimuli (device factors) to the airways where chronic inflammation occurs, causing abrasion of the airway mucosa and release of neurotransmitters. Pain, on the other hand, is a sensation felt when one’s own body is injured and is subjective. Anxiety and psychological stress have been reported to increase pain [40], and the threshold of pain varies from person to person. Feine et al [41] stated that when men and women are given the same pain stimulus, women evaluate the degree of pain more strongly. Lautenbacher et al [42] measured pain tolerance thresholds and found that men tended to have higher thresholds than women. This suggests that “women” became a factor influencing POST by recognizing and expressing POST. However, Jaensson et al [25] did not find any significant difference in the occurrence of POST between men and women, suggesting that POST is more likely to occur when several factors overlap. As for age, “young age” has been cited as a factor associated with POST. The experimental pressure pain detection thresholds showed that the intensity and unpleasantness of the pain stimulus were significantly rated lower in the older than in the younger patient population [43]. After investigating changes in pain perception, Lautenbacher et al [44] also found that aging decreases pain sensitivity and intensity. These findings suggest that age is a factor in POST.

In this study, we conducted a literature review to clarify patient factors associated with the occurrence of POST. We found factors related to the anesthesia technique and patients, but these factors were not independent of each other and worked in combination to cause POST. However, it was not clear how many of these factors worked in combination to cause POST and whether the combination of factors affected the severity and duration of POST. In addition, since pain is related to both sensory and emotional aspects, it was not clear whether the emotional aspect was a factor causing POST or whether it affected the severity and duration. The present review did not find any reports related to POST or emotional factors. Therefore, there is a need for further research on POST and psychological factors.

In this study, we reviewed the literature and examined the factors contributing to POST. Besides the most common patient factors like woman, smoking, and age, this study found that POST may be associated with mental states such as anxiety.

Acknowledgments

None to declare.

Financial Disclosure

This work was supported by JSPS KAKENHI Grant (number: JP1919577).

Conflict of Interest

The authors declare no conflict of interest.

Author Contributions

YY designed the study. KN, TI, and TY participated in data acquisition, extraction, and analysis, and drafted the final work. KK and YB supervised this manuscript’s preparation and writing. The authors reviewed the final version of the manuscript and approved it for publication.

Data Availability

The data supporting the findings of this study are available from the corresponding author upon reasonable request.

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