A Comparison between Conventional Throat Packs and Pharyngeal Placement of Tampons in Rhinology Surgeries

Objective: the aim is to evaluate the incidence of postoperative throat pain, nausea and vomiting in patients that have been packed with either conventional gauze or pharyngeal tampons. Methods: We included adult patients who were booked for a rhinology surgery that needed throat packs. They were allocated into two groups, pharyngeal tampons, and conventional ribbon gauze. They were then assessed using visual analog scales and Post-operative nausea and vomiting impact scale respectively in the 1st, 4th, and 24th hour. Data was analyzed using SPSS software version 25. Results: There is evidence to suggest that using pharyngeal tampons reduces the mean VAS score at 4 hours compared to using Gauze. [t87=3.294, p=0.001), the is no statistical evidence that show a difference in the other Visual analogue scores or post-operative nausea and vomiting scores. Conclusion: The study shows that the use of pharyngeal tampons is associated with decreased pain scores, however, it also shows that there no difference in postoperative nausea and vomiting.


Introduction
The nose and para nasal sinuses are anatomically known to be highly vascular therefore a substantial amount of bleeding is expected from rhinology surgeries [1,2]. Ingested blood is known to be a powerful emetic [1,2]. And the risk of aspirating blood into the lungs is present due to the fact that an endotracheal tube is not 100% effective in protecting the airway [3,4]. Post-operative nausea and vomiting (PONV) is a frequent problem that is encountered in surgical patients with a 4 to 6-fold increase in nasal and endoscopic sinus operations [1,4].
Posterior throat packs are often-used in rhinology surgery to help in protecting the airway against aspiration and in the reduction of ponv [5]. However, many studies concluded that posterior throat packs are associated with higher amounts of post-operative pain, nausea [2,6,7], vomiting, and in some rare cases even forgotten in the patient leading to mortality [8]. Despite poor evidence in the literature, the placement of posterior throat packs is commonly practiced by surgeons and anesthetists because the possible risk of aspiration is worrisome [9].
A conventional throat pack consists of gauze, but an alternative practice involves the pharyngeal placement of tampons. The aim of this study is to evaluate and compare the post-operative throat pain, nausea, and vomiting in patients that have been packed with either conventional gauze throat packs or pharyngeal tampons.

Material and methods:
Our sample size was calculated based on the population of patients that are covered by the hospital catchment area and we tried to include a size that would allow us to achieve a confidence interval of 95 % In this prospective clinical trial, all surgeries were done by a single surgeon as to decrease variability in the management of each patient. Patients were randomly divided into two groups, one that received the conventional gauze throat packs and those that received pharyngeal tampons   The allocation of patients was done on the day of the surgery dependant on the first patient that was admitted in the morning, the allocation of the first patient was decided by coin toss, if the first patient was kept in the pharyngeal tampon group the subsequent patient was kept in the conventional guaze throat pack group and it alternated till the end of the list. This allowed for randomisation and equal distribution among the 2 groups.
Our study population included all adult patients above the age of 18 that underwent rhinology procedures that required the use of a throat pack between January of 2018 to January of 2019. Minors below the age of 18 and rhinology procedures that required no throat pack were excluded from the study these procedures were often too short and did not have involve enough bleeding to warrant the use of a throat pack. The Institutional review board provided ethical approval for approved the study, and signed informed consent was obtained from all patients.
Post-operative pain was assessed using the visual analogue scale[10] , (figure 1.3) patients were asked on a scale of 1 to 10 on the amount of pain they were experiencing in various post op periods, where 1 was the lowest amount of pain and 10 was the highest amount of pain. Patients were seen at 1 hour and on the 4 th hour post operatively and were called via phone 24 hours later to assess the amount of pain they were experiencing.  It includes 2 questions, one of which is whether the patient had experienced any dry retching or vomiting, and the second one being if they experienced nausea. A final score (PONV Impact scale) was calculated using the responses to the previous two questions. A PONV Impact Score of ≥5 defines clinically important PONV. Patients were seen at 1 hour and on the 4 th hour post operatively and were called via phone 24 hours later, to assess the amount of nausea and vomiting they were experiencing.
The reason these time were chosen was because it represented the different stage of a patients post-operative journey where the 1 hour mark was when the patient was shifted to the ward post operation, the 4 hour mark was the time the patient was discharged from the hospital and the 24 hour mark was included to check to see if the symptoms has subsided or increased.
Our sample size was calculated based on the population of patients that are covered by the hospital catchment area and we tried to include a size that would allow us to achieve a confidence interval of 95 %.All data collected was recorded in an excel sheet and t-test was the statistical mode used to interpret it. All data was analyzed using SPSS Statistics software version 25.

Results
The total number of patients included in this study was 89, with 46 (51.6%) being placed in the pharyngeal tampon group and 43 (49.4%) in the conventional throat pack group. The average age of the patients was 32.8 years (ranging from 18-72). Out of the 89 patients, 49 patients were male, and 40 patients were female, with a ratio of 1.225:1.
The mean PONV score at 1 hour for the tampon group was 0.28 and the mean score for the gauze group was 0.54. Mean difference between the groups was 0.264. The mean PONV score at 4 hours for the tampon group was 0.37, and the mean score for the gauze group was 0.41. Mean difference between the groups was 0.41. The mean PONV score at 24 hours for the tampon group was 0.21 and the mean score for the gauze group was 0.26. Mean difference between the groups was 0.52. ( The mean VAS score at 1 hour for the tampon group was 1.51 and the mean score for the gauze group was 2.28. Mean difference between the groups was 0.771. The mean VAS score at 4 hours for the tampon group was 1.28, and the mean score for the gauze group was 2.85. Mean difference between the groups was 1.569. The mean VAS score at 24 hours for the tampon group was 2.00, and the mean score for the gauze group was 2.17. Mean difference between the groups was 0.174. (

Discussion
The pattern of data shows that the tampon is better than gauze in terms of VAS. 25 out of 43 patients using tampons had low VAS scores after 24 hours, whereas 23 out of 46 patients using gauze had low VAS scores after 24 hours. In terms of PONV. 36 out of 43 patients using tampons had a low PONV score after 24 hours, and 39 out of 46 patients using gauze showed similar scores.
There is limited research on the use of pharyngeal tampons in rhinology procedures. Marais and Prescott showed that the use pharyngeal tampons are associated with a decreased amount of post-operative throat pain, when compared to conventional gauze throat packs [12]. A research paper by Green et al advises against the use of conventional pharyngeal packs due to higher incidences of post-operative pain [9]. Our study shows that pharyngeal tampon placement is associated with decreased amount of pain and could be suitable alternative to conventional ribbon gauze packs.
We could not find any studies that compared the post-operative nausea and vomiting in the two different types of throat packs, however in Basha et al they established that packing the patient with conventional ribbon gauze was associated with a higher chance of post-operative nausea and vomiting immediately post-operation [13]. Piltcher et al compared postoperative nausea and vomiting in packed and unpacked procedures and came to the conclusion that there is no difference in throat pain or PONV [1]. Our study concluded that use of tampons is equivalent to gauze in terms of PONV.
Our study had several limitations of which that it was dependent on subjective methods of assessment thus each patient experienced a different degree of pain and PONV. Patients around the 1-hour postoperative mark were still under the residual effects of anesthesia and analgesia which would Heavily skew their assessment. Also, although the cases were done under the care of a single surgeon, the anaesthetic management was not. The method of throat pack application was not standardized for the study and as in adding an unforeseen variable to the scoring of the. Our study would have benefited from a larger population and further studies should be carried out in order to confirm our results.

Conclusion
Our study shows that the use of pharyngeal tampons is associated with decreased pain scores, however, it also shows that there are no differences in post-operative nausea and vomiting. We believe that pharyngeal tampons are a suitable alternative -if not replacement -for conventional ribbon gauze.