Intraoperative dislodgement of throat pack into esophagus and its management

Throat packs are commonly used in Intra-oral and Maxillofacial surgical procedures to prevent fluids, particulate matter as well as foreign bodies from entering into the aero-digestive tract. The pack is usually placed following endotracheal intubation which involves packing it around the Endotracheal tube (ETT) in the Oropharyngeal region as a reinforcement measure. The need for such a pack arises due to a variety of reasons such as, volumetric change in the airway resulting from a change in the tissue turgor and reducing pressure of the ETT cuff, which may result in the seepage of fluids into the airway, resulting in an emergency. If a throat pack has been inserted but not removed at the end of a procedure, then the obvious danger is that the retained pack may cause airway obstruction. We present an interesting case of a missing pharyngeal throat pack at the end of an operation. The insertion of the throat pack must be documented in the patient safety checklists well as prominently displayed to ensure proper removal at themed of surgery. If the pack is missing its location must be verified before extubating the patient as was in our case where the prudent and prompt action of the Anaesthetic and Surgical team prevented a major complication. This case report represents an interesting case of a missing pharyngeal throat pack at the end of an operation.