Background: A sore throat is a discomfort, itching, quiet voice, or irritation of the throat that frequently gets worse when swallowed. Up to 62 percent of patients worldwide experience postoperative sore throat after general anesthesia. Postoperative sore throats reduce patient satisfaction and it can also increase the demand for adjuvant pain medication in the post- anesthesia care unit to minimize postoperative sore throat. Despite its status as most of the time self-limited, it has the potential to cause severe postoperative morbidity and patient unhappiness

Methods: Evidence was searched by using the keyword to access current and reliable information on risk stratification, prevention, and management of postoperative sore throat from May 2023 to October 2023.A literature search was conducted in different databases. The articles were searched using the Boolean operators. Randomized controlled trials (RCT), guidelines, systematic reviews, and meta-analyses.

Conclusions and recommendations: POST is linked to mental states like anxiety as well as to the most common patient characteristics, such as age, gender, and smoking. Anesthetists should act accordingly to minimize post-operative sore throat.

Keywords: sore throat, postoperative, anesthesia, management, guideline

Sore throat is a discomfort, itching, quiet voice or irritation of the throat that frequently gets worse when swallow.¹ One of the most common mild to severe complications and disturbing side effects seen by patients receiving general anesthesia with tracheal intubation is postoperative sore throat (POST).² Despite its status as most of the time self-limited, it has a potential to cause severe postoperative morbidity and patient unhappiness.² Postoperative sore throats reduce patient satisfaction and it can also increase the demand for adjuvant pain medication in the post-anesthesia care unit to minimize postoperative sore throat,³ Variety of treatments are used; however, no single intervention has proven to be totally successful.^3,4

Up to 62 percent of patients worldwide experience postoperative sore throat after general anesthesia.⁵ Sex being Female, advanced age, pre-existing lung disease, prolonged anesthesia &surgery and the presence of a blood stained tracheal tube during intubation all are highly associated with the POST.⁵ A cross sectional study conducted in Korea among of 207 the 119 (57.5%) develops POST. Cough during emergence and an Intracuff pressure greater than 17 cmH2O were found to be risk factors for POST in a multivariate study.⁶

Follow up study carried out in Niger reveal that the prevalence of POST was (63%).⁷ Both males and females had the same rate of sore throat.⁷ The incidence and complications of POST was statistically significant on ENT surgery and application of oro-pharyngeal pack and aggressive suctioning were associated with POST.⁵ A hospital based cross sectional study conducted at Debretabor University, Amhara Northwest Ethiopia showed that the incidence of POST was 48.8%. Sex being female, endotracheal tube size, and number of attempts had significant association with POST.⁸

A hospital-based cross-sectional study done at the University of Gondar's specialized hospital revealed that a total of 143 out of 240 patients (59.6%) patients had developed POST within 48 hours following surgery under GA. Sex being female and, many attempts to intubate and the use of a nasogastric tube were associated with postoperative sore throat.⁹

Postoperative sore throat can be caused by a variety of reasons and the incidence has been observed to vary depending on the airway management approaches.¹⁰ The incidence is highest after tracheal intubation and ranges from 14.4% to 50%,² whereas the incidence after laryngeal mask airway insertion ranges from 5.8% to 34%, and it is significantly lower(<1.5%) when a face mask anesthetic maintenance was used.¹⁰

The postulated mechanism of POST is damage to the epithelium, the vocal cord and mucosal cells caused by airway securement and a lot of airway securement factors are contribute to postoperative sore throat such as an excessively big tube, cuff form, cuff pressure, congestion and blood clots are highly contribute to the occurrence of postoperative sore throat.¹¹ Routine tracheal intubation can result in pathological changes, trauma, and nerve injury which could all account for postoperative throat discomfort.¹² Several practice modifications that have demonstrated a reduction in the incidence of POST such as the utilization of smaller internal diameter ETTs and the routine measuring of intracuff pressure is too important to reduce the POST.¹³

A typical side effect of general anesthesia is postoperative sore throat (POST).¹⁴ Even though POST is most common in patients who have been tracheally intubated it can also happen when a laryngeal mask airway (LMA) and even individuals who are handled with a facemask are susceptible to develop POST secondary mucosal dryness by the air.¹⁵ POST is preventable anesthesia and surgery related problem and the magnitude POST can be reduced by using different prevention strategies since “prevention is better than cure”. Once this clinical problem is happened, it must be identified and treated early.¹⁶ If it remains untreated it may result in major respiratory complications.¹⁷ Anesthetists and other professionals should be aware about of this clinical problem and postoperative sore throat prevention and management strategies should be planned ahead of anesthesia and surgery.

In my clinical practice, I have seen that most anesthetists use high size of ETT and LMA in the absence of standard manometer which may increase the risk of POST. Additionally we inflate the ETT/LMA with air. A randomized control trial study done in Australia and a systematic review and meta –analysis recommend that inflation with saline and lidocaine is more important to basing and alkalization which creates a moisture to prevent mucosal damage.¹⁸ The incidence of early- and late-phase postoperative sore throat (coughing, agitation, hoarseness and dysphasia) decreased significantly (1a) (1c).^19,20 So this gap of clinical practice may contribute for the increment the magnitude of POST.

A cross sectional study conducted in university of Gondar specialized compressive hospital shows that 59.6% of patients experienced postoperative sore throat within 48 hours of surgery.⁹ POST is highly associated with dysphasia, decrease patients satisfaction, increase hospital stay, increase analgesics consumption leads to additional costs for the patients & health institution and increase work load for health givers this sum total have a great effect on national and global economy.²¹

After setting eligibility criteria for the evidence to be used and choosing the best methodological approach, an extensive search for evidence was carried out. Different evidence was searched by using the keyword to access current and reliable information on risk stratification, prevention and management of post-operative sore throat from May 2023 to October 2023.A literature search was conducted in different data bases. The articles were searched using the Boolean operators. Randomized controlled trials (RCT), guidelines, systematic reviews, and meta-analyses (Table 1).

Resources from the PRISMA 2019 flow diagram database showing the prevention and treatment of post-operative sore throat were used.²²

In order to treat postoperative sore throat (POST) non-steroidal anti-inflammatory drugs (NSAIDs),corticosteroids, lidocaine, and N-methyl-d-aspartate (NMDA) receptor antagonists are frequently used as topical medicines (including ketamine and magnesium) but which one is more ideal preventive drug is still controversial.²³

A meta-analysis of RCT by Wang, Qi et al.²⁴ suggested that glycyrrhizin; corticosteroids, NSAIDs, and NMDA receptor antagonists reduced postoperative pharyngeal pain across the postsurgical time intervals studied. 24,25 However, no difference was found between the lidocaine and the placebo during the early extubation, 4 to 6 hours’ time interval, and 24 hours’ time interval (1a).²⁵

A systematic review and meta-analysis study done by Grigoryan et al.²⁶ and Makkar et al.,²⁷ the overall incidence of POST was higher in the lidocaine group than in the normal saline group (58%) vs (39%). The overall incidence of cough for 24 hours postoperatively is higher in the lidocaine group than the saline because that the topical lidocaine may cause the irritation of the mucosal of the airway (1a). So the irritation feature of lidocaine after spray to oro pharyngeal is has been supported by systematic review and meta-analysis so it is better to avoid lidocaine topically.²³

A randomized control trial study done by Tanaka et al.²⁸ study shows that topical and systemic lidocaine therapy appeared to reduce the risk of postoperative sore throat .The severity of sore throat as measured on a visual‐analogue scale (VAS) was reduced on systemic lidocaine than topical lidocaine therapy (36%) vs (79%) respectively (1c).²⁸ So, it is better to use systemic lidocaine.^29,30

The new style of ETT (Taper Guard ETT) would reduce or increase the occurrence of POST is general anesthetists issues when compared to the cylindrical shaped ETT which one more related to POST and respiratory complication associated with endotracheal intubation currently still controversial.³¹

A single blind randomized study done by Choi et al.³² the cuff pressure was higher in the taper guard ETT than in the cylindrical ETT and the incidence of POST was greater in the taper guard ETT than in the cylindrical ETT©. However a double blind randomized study done by Kim 2018 shows that though the cuff pressure difference among the taper guard ETT than in the cylindrical ETT there is no significant difference the incidence of POST(1c).³³ A systematic review showed there is no difference between cuff and uncuff ETT at the occurrence of post-operative air way complications like sore throat and hoarseness (1b).³⁴

A meta-analysis conducted at Guangzhou in China concluded that there is significant difference between cuffs and uncuffed ETT for the occurrence of post-operative airway complications.³¹ Cuffed ETTs have lower complications and uncuffed tub are highly associated with sore throat and hoarseness of voice. ³⁴ This is supported by RCT study showed that the use of uncuffed tubes results significantly higher incidence of sore throat than the use of cuffed tubes.³⁵ The possible reason is that the air leaks created during spontaneous respiration and controlled ventilation in patients with uncuffed tracheal tubes allow air leak and loss of humidity to upper airway mucosa, causing some dehydration and damage to these cells (1a).³⁶

Risk stratification for postoperative sore throat

A systematic review and meta-analysis done at Wolaita Sodo, Ethiopia in 2022 showed that advanced age, sex being female more worsens during pregnancy, smokers, weight more than 70 kg are highly risky to develop postoperative sore throat underwent surgery under general anesthesia.¹⁰ Additionally a prospective cohort study in Asmara showed that prolonged duration of anaesthesia more than 100 minutes, use of double-lumen tube, large size of ETT and LMA, multiple of attempts of intubation, the presence of blood on ETT during intubation, use of NGT, aggressive suctioning and use of suxamethonium are highly linked to the occurrence of postoperative sore throat (Table 2).^5,17 A RCT conducted in Singapore in 2022 showed that use of pharyngeal packs was highly associated with postoperative sore throat (Table 2).²⁹

37,38

Prevention of postoperative sore throat

According to the British and Irish Association of Anesthetists adjusting the cuff pressure guided by objective measurement rather than subjective measurement or observation of the pressure value alone is highly beneficial in preventing the sore throat.¹⁴ A prospective randomized study shows that the use of HME filter which serve heat and moisture during expiration to prevent mucosal dryness and cell damage and reduce the occurrence of POST.³⁸ Another meta- analysis study suggests that intravenous dexamethasone can effectively reduce the incidence of POST both at 1 and at 24 hours postextubation.³⁹ Topical method of application which involved soaking the ETT in a dexamethasone solution or gargling the dexamethasone solution 10 min prior to induction.¹ These methods demonstrated a clinically significant reduction in POST from 63% to 26% and 63% to 33% at 24 hrs. postoperatively.^39,40

A systematic review and meta-analysis of randomized controlled trials conducted in Shenyang, China by 2021 regarding covering topical prophylactic medications with NMDA receptor antagonists ketamine and magnesium showed magnesium demonstrated greater benefit than ketamine at 24 hours post intubation in terms of magnitude developing POST.⁴¹ Additionally, aonother study showed that gargling of (40 mg in 30 ml of saline) ketamine 5 min before induction of general anesthesia effectively reduced the severity of POST (Table 3).²⁶

Management of postoperative sore throat

According to the American and European sore throat guidelines recommend that oral penicillin is the first-line treatment of post-operative acute sore throat.⁴⁰ Additionally a systematic review of randomized-controlled trials (RCTs) shows that non-steroidal anti-inflammatory drugs diclofenac and ibuprofen and paracetamol are more effective than placebo for reducing acute sore throat symptoms.^41–45 Another systematic review also showed that ibuprofen 200-300mg and paracetamol depending on the severity of grading if score of grading less than <2 10-15mg/kg and grade of coring 3, 15-20mg/kg are more effective than placebo for reducing acute sore throat.⁴⁶ Additionally a double-blind randomized control trial demonstrates that administering honey and lemon in tea after surgery greatly decreased POST.⁴⁷ The severity of a sore throat was graded as follows: 0 means there has never been a sore throat since the operation; 1 means it is minimal and less severe than a cold; 2 means it is moderate and more severe than a cold; and 3 means it is severe and more severe than a cold (Table 4).^48–50

In this study, the literature has been reviewed and the factors impacting POST were addressed. This study showed that POST may be linked to mental states like anxiety as well as to the most common patient characteristics, such as age, gender, and smoking. Anesthetists should act accordingly to minimize post-operative sore throat.

Not required.

None.

This work was carried out in collaboration among all authors. Atalay Eshetie Demilie and Endale Gebreegziabher Gbremedihin contributed to the conception of the review and interpreted the literatures based on the level of evidence and revised the manuscript. Yosef Belay Bizuneh, Habtu Tsehayu Bayu and Zewditu Abdissa Denu participate in reviewing preparation of the manuscript. Both authors participate in preparation and critical review of the manuscripts. In addition, all authors read and approved the manuscript

Atalay Eshetie Demilie, Habtu Tsehayu Bayu, Zewditu Abdissa Denu, Yosef Belay Bizuneh, Endale Gebreegziabher Gbremedihin.

None.

The authors declare that there are no conflicts of interest.

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