Bleeding during rhinoplasty/septoplasty - Is it not always necessary to use throat packing?

Question

Bleeding during rhinoplasty I wonder why some anesthetists put throat packs in the throat during surgery and not others and if you don't put these packs how are the tracheas protected from blood aspiration during surgery apart from the tube you put in the throat. Is it not always necessary to use throat packing during rhinoplasty/septoplasty?

Semih Yildiz, MD, FEBOPRAS · Answer

A properly positioned cuffed endotracheal tube is the main protection for the lower airway during rhinoplasty or septoplasty. The inflated cuff forms a seal below the vocal cords, while the anesthesia and surgical teams also use pharyngeal suction, nasal pledgets, vasoconstrictors, careful hemostasis, and positioning to limit blood and secretions. A throat pack can absorb fluid and debris that reaches the pharynx, so some teams use one when substantial bleeding or irrigation is expected. It is not a perfect seal and is not required in every case. Packs can cause sore throat, mucosal or dental injury, swallowing discomfort, and—most importantly—serious harm if inadvertently left in place. When used, placement and removal should be clearly announced, documented, and confirmed before extubation. The choice therefore depends on the operation, expected blood loss, airway plan, and the surgeon-anesthesiologist team’s protocol rather than one universal rule.

Eric M. Joseph, MD · Answer

In the overwhelming majority of cases, we do not experience significant bleeding during rhinoplasty surgery, and we do not utilize a throat pack in anybody, since we have found that this can be associated with a sore throat. When we put our patients to sleep, the breathing tube has a small inflatable balloon at the end, that prevents any blood from getting into the airway, thus preventing an aspiration pneumonia. This is what we have used for over 26 years. Thank you for this excellent question. Sincerely, Dr Joseph

Lucian Ion, FRCS · Answer

Using throat packs in rhinoplasty is a common approach, and the anaesthetist that I work with systematically does this without me having to ask for throat packs.

It is technically possible to avoid using the throat packs by using laryngeal masks, but sometimes the seal that these masks produce is not very good.

Ronald J. Edelson, MD · Answer

Sone surgeons use throat packs and others do not. I usually use a throat pack to prevent blood in the trachea but I know many who don’t. I don’t think it’s a basis for selecting one surgeon over another.  I am aware of a case where there was an airway problem after rhinoplasty and the fact that a throat pack was not used became a major issue ( not my case) . Since then I usually use a throat pack. There is nothing  bad about using one.

Richard G. Reish, MD, FACS · Answer

Hello and thank you for your question. In my practice, I prefer to place a throat pack. I always do this myself. I recommend that you seek consultation with a qualified board-certified rhinoplasty surgeon who can evaluate you in person.

Best wishes and good luck.

Richard G. Reish, M.D.
Harvard-trained plastic surgeon

Best wishes and good luck.

Richard G. Reish, M.D.
Harvard-trained plastic surgeon

Jacob Carlson, MD · Answer

Using a throat pack during rhinoplasties is fairly common, but it's not absolutely necessary. The throat pack is intended to prevent blood from entering both the airway and the esophagus. Blood that enters the esophagus during surgery can cause the patient to experience post-operative nausea and vomiting. If the patient is still sedated when this happens, then they could aspirate the blood and/or stomach contents. The endotracheal tube usually does a good job of protecting the airway and prevents blood from entering the airway. It is also very common for surgeons/anesthesiologists to pass a nasogastric or orogastric tube into the esophagus/stomach before the patient wakes up from anesthesia to remove any blood that may have entered the upper GI tract during the surgery.

Edward Buckingham, MD · Answer

Both approaches are safe. Some surgeons elect to place a throat pack during surgery to physically block and absorb blood run down that occurs during the procedure. Others elect against this and rely on the endotracheal tube balloon, which is generally sufficient to protect against blood entry into the airway. Any blood that bypasses the wind pipe and enters the stomach should be suctioned out at the end of the case.

Bleeding during rhinoplasty/septoplasty - Is it not always necessary to use throat packing?

Answers (7)

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