Case Reports

CASE REPORT – Dental braces bracing a throat pack to cause difficulty in its removal

Mansoor Aqil, MBBS, FCPS

Associate Professor Anesthesiology, College of Medicine, King Saud University / Consultant anesthesiologist, King Abdul Aziz University Hospital, Riyadh 11411, (Saudi Arabia)

Correspondence: Dr. Mansoor Aqil, P.O box 245, Riyadh 11411, (Saudi Arabia); Phone: 0096614775703 (office); 00966507221058 (mobile); Fax: 0096614786100 Ext. 7525; Email:


We present an unusual case of dental braces entangled into a throat pack, thus making it impossible to remove it from the mouth cavity of a patient. The patient, who was emerging from anesthesia, had to be reanesthetised, to enable removal of the pack.

Key words: Throat pack; anesthesia complication; dental braces

Citation: Aqil M. Dental braces bracing a throat pack to cause difficulty in its removal. Anaesth Pain & Intensive Care 2011;15(1):51-53.


Throat packs are commonly used in patients undergoing oral, nasal and dental procedures. We encountered difficulty in its removal at the time of extubation of trachea in a patient who was having dental braces fixed to lingual surface of her teeth. We found our throat pack was entangled in a hook of the braces that led to difficulty in its retrieval. The cause of this difficulty in removal of the throat pack is unusual and to our knowledge no such event has been reported in the literature. This case report emphasizes the need of extra care while removing the throat pack to avoid damage to these costly braces that may result in embarrassment to the anaesthetist and/or lead to a compensation claim.


A 23 years old female patient presented to our hospital with nasal deformity secondary to road side accident. She was scheduled for elective open septorhinoplasty under general anaesthesia. Her weight was 74Kg and height 157cm. Her airway examination and neck movements were normal. She was wearing lingual dental braces as part of her treatment for dental deformity. All baseline investigations e.g. haemoglobin, haematocrit, platelet count, urea, creatinine, prothrombin and APTT were within normal limits. She was graded as ASA 1 physical status. She was advised to be fasting from midnight and was premedicated with 2mg tab. lorazepam two hours before surgery with a sip of water.

On arrival in the holding area of the operating room, an IV line was established with a 20G cannula on the dorsum of the hand. In the operating room, ECG electrodes, pulse oximeter probe and non invasive blood pressure cuff were applied. She was pre-oxygenated with oxygen 6 l/min for about 3 minutes. Anesthesia was induced with inj. propofol in the dose 2 mg/kg and fentanyl 2 µg/kg. For endotracheal intubation, neuromuscular block was attained with cisatracurium in the dose of 10 mg. She was intubated without any difficulty with 7.5 mm internal diameter RAE (Portex®) cuffed endotracheal tube (ETT). After confirmation of proper position of the ETT, it was fixed at 21 cm in the midline and intermittent positive pressure ventilation of the lungs was started with anesthesia machine (Datex Ohmeda AS 5). To avoid soiling of the airway, the throat of the patient was packed around the ETT with a cotton ribbon gauze pack by one of our trainee doctor and the tail of the pack was left outside the mouth and tied to the ETT. To remind the presence of pack in the throat, a sticker was applied to the ETT connector quoting “Caution! throat pack inside”. The placement of the throat pack was notified in the anesthesia record sheet and also endorsed to the circulating nurse. Anesthesia was maintained with sevoflurane in oxygen-air mixture and intermittent doses of fentanyl. The intraoperative course was uneventful and duration of surgery was 110 minutes.

At the end of the surgery, residual neuromuscular block was reversed. On establishment of adequate breathing we planned to extubate the trachea. The oral cavity was cleared of any blood clot by using a flexible suction catheter size 14F and removal of throat pack was attempted by applying a gentle traction on the tail of the throat pack. We noticed unusual resistance in retrieving the throat pack. We planned to retrieve it under direct vision with the help of a Mc Intosh laryngoscope and Magill’s forceps. To get a deeper plane of anaesthesia, inspiratory sevoflurane concentration was increased to get its end tidal concentration 3-4%. On attaining adequate depth of anaesthesia, laryngoscope was placed in the oral cavity and found that the threads of the throat pack were entangled in a hook of the lingual dental braces near the second molar tooth. Throat pack was gently freed from the hook and was removed after some difficulty. Residual blood clots were removed and trachea was extubated. The patient was sent to post anesthesia care unit where she stayed for about 40 minutes and was shifted to the ward with full recovery.


Lingual braces are used by orthodontists to straighten the tooth position. They consist of wire brackets that are attached to the lingual side of the teeth. They are usually invisible from outside and very costly. This is an unusual and unexpected cause of difficulty in removal of throat pack and should be considered in the patients with lingual dental braces, undergoing surgery under general anesthesia requiring endotracheal intubation and throat pack.

Throat packs are commonly used under general anesthesia in the surgery in the oral or nasal cavity and procedures on nasolacrimal duct. The common purpose of their use is to absorb blood or debris, body secretions or external fluids and prevent the seepage into respiratory tract.1-3 Occasionally, they are used to provide seal around the ETT or to stabilise the ETT or supraglottic devices.4-6 We tried to search the literature to find out the reported complications of throat pack but did not find any report of difficulty in its retrieval due to entanglement in a hook of a dental brace. The reported complications are pain in the throat1, 7-10, injury to lingual and hypoglossal nerve11, unilateral laryngeal and hypoglossal paralysis12, soft palate paresis13, forgotten throat pack leading to airway obstruction14-24 and unilateral pharyngeal plexus injury.25

We recommend that during pre-anesthesia assessment, we must enquire about the presence of dental braces, especially the lingual braces, and have more thorough inspection to find out any uncovered hook. Throat packs, if used, should be gently removed under direct vision, as an undue traction on it out may result in damage to the costly braces. Such incident may be an embarrassment to the anaesthetist and is likely to result in a compensation claim.


  1. Jaiswal V, Bedford GC. Review of the use of throat packs in nasal surgery. J Laryngol Otol. 2009;123(7):701-4.
  2. Al-Mazrou KA, Abdullah KM, ElGammal MS, Ansari RA, Turkistani A, Abdelmeguid ME. Laryngeal mask airway vs. uncuffed endotracheal tube for nasal and paranasal sinus surgery: paediatric airway protection. Eur J Anaesthesiol. 2010;27(1):16-9.
  3. Hill EE, Rubel B. A practical review of prevention and management of ingested/aspirated dental items. Gen Dent. 2008;56(7):691-4.
  4. Kim CS, Lee BH, Shim JY, Chung WH. Clinical Study of Pharyngeal Throat Pack – Cases of V-pack Application to the Endotracheal Tubes. Korean J Anesthesiol. 1980;13(3):38-43.
  5. Gordon R. H, and Renae T. Tracheal Injury: A Cause for Unexplained Endotracheal Cuff leak During Mediastinal Dissection. Anesth Analg 1997;84:684-5.
  6. Weber T, Salvi N, Orliaguet G, Wolf A. Cuffed vs non-cuffed endotracheal tubes for pediatric anesthesia. Paediatr Anaesth. 2009;19 Suppl 1:46-54.
  7. Erkalp K, Korkut YA, Meric A, Kahya V, Gedikli O, Su OK, Saitoglu L. Pharyngeal packing is a predisposing factor for postoperative aphthous stomatitis in nasal surgery. Otolaryngol Head Neck Surg. 2010;142(5):672-6.
  8. Griffiths DPG, Lindop MJ, Samuels SI, Roberts GDD. Pharyngeal packs and the incidence of post-operative sore throat. Anaesthesia 1973;28:320–30
  9. Fine J, Kaltman S, Bianco M. (1988) Prevention of sore throat after nasotracheal intubation. Journal of Oral and Maxillofacial Surgery 46:946–7.
  10. Basha S, McCoy E, Ullah R. The efficacy of pharyngeal packing during routine nasal surgery – a prospective randomised controlled study. Anaesthesia 2006;61:1161–5.
  11. Evers KA, Eindhoven GB, Wierda JM. Transient nerve damage following intubation for trans-sphenoidal hypophysectomy. Can J Anaesth. 1999;46(12):1143-5
  12. Tesei F, Poveda LM, Strali W, Tosi L, Magnani G, Farneti G. Unilateral laryngeal and hypoglossal paralysis (Tapia’s syndrome) following rhinoplasty in general anaesthesia: case report and review of the literature. Acta Otorhinolaryngol Ital. 2006;26(4):219-21.
  13. Berendes J. Rhinolalia aperta after the use of a postnasal pack as a medico-legal problem. HNO. 1979;27(11):377-9.
  14. NHS Evidence – National Library of Guidelines formerly a Specialist Library of the National Library for Health. Accessed on 10.06.2010.
  15. Ozer C, Ozer F, Sener M, Yavuz H. A forgotten gauze pack in the nasopharynx: an unfortunate complication of adenotonsillectomy. Am J Otolaryngol. 2007 May-Jun;28(3):191-3.
  16. Scheck P. A pharyngeal pack fixed on to the tracheal tube. Anaesthesia 1981;(36):892–5.
  17. Najjar MF, Kimpson J. A method for preventing throat pack retention. Anesthesia and Analgesia 1995;80:204–12.
  18. To EWH, Tsang WM, Yiu F, Chan M. (2001) A missing throat pack. Anaesthesia 56:383–4.
  19. Walton SL. Post-extubation foreign body aspiration: a case report. American Association of Nurse Anaesthetists Journal 1997;65:147–9
  20. Burden RJ, Bliss A. (1997) Residual throat pack – a further method of prevention. Anaesthesia 52:811.
  21. Stone, JP, Collyer J. Aide-memoir to pharyngeal pack removal. Anesthesia and Analgesia 2003;96:301–8.
  22. Preeti K. Manghnani PK, Shinde V. S, Chaudhari L. S. Critical incidents during anaesthesia; An Audit. Indian J. Anaesth 2004;48:287-294.
  23. Sixth Report of the Victorian Consultative Council on Anaesthetic Mortality and Morbidity page 4/7. Available from URL Accessed on 10.06.2010
  24. Knepil GJ, Blackburn CW. Retained throat packs: results of a national survey and the application of an organisational accident model. Br J Oral Maxillofac Surg 2008;46(6):473-6.
  25. Robert W. M, David Z, Andrew M, Charles B. B. Unilateral pharyngeal plexus injury following use of an oropharyngeal pack during third-molar surgery. Journal of oral and maxillofacial surgery 1990;48(10):1102-1104.