A study on the effectiveness of a gel containing

betamethasone 0.05%, lidocaine 2%, and tetracaine 1%

in reducing postoperative sore throat, hoarseness, cough,

and coughing on the tube during emergence from

anesthesia

Soto-Hopkins Sergio 1, Milla Hector2, Hernández Oros Karina3, Gualajara Figueroa Cesar Jared2.

1 Department of Anesthesiology, TJ Plast Advanced Center for Plastic Surgery, Tijuana.

2 Department of Surgery, TJ Plast Advanced Center for Plastic Surgery, Tijuana.

3 Department of Pharmacology, TJ Plast Advanced Center for Plastic Surgery, Tijuana.

Critical Care and Emergency Medicine

https://doi.org/10.58281/ccem24120905

Abstract

Postoperative sore throat is a common complaint and an un-

desirable outcome. It is often a side effect of general anes-

thesia, reported by 30% to 70% of patients following

tracheal intubation.

Despite advancements in laryngoscopy equipment, post-

operative sore throat remains a common issue, requiring ad-

ditional pharmacological interventions and negatively

affecting patient satisfaction. This highlights the continued

need for effective strategies to tackle this challenge in clinical

practice.

This study is a retrospective cohort analysis involving 101

patients who underwent elective plastic surgery with orotra-

cheal intubation under general anesthesia. The research

compares the incidence of postoperative sore throat, hoarse-

ness, and cough, as well as coughing upon emergence from

anesthesia, between two types of lubricated endotracheal

tubes: one coated with a gel containing 0.05% betametha-

sone, 2% lidocaine, and 1% tetracaine, and another with 2%

lidocaine jelly.

At the 8-hour mark after extubation, the incidence of post-

operative sore throat was significantly lower in the experimen-

tal group at 17.6%, compared to 58% in the 2% lidocaine jelly

group (P<0.001). Over the 24-hour evaluation, the experi-

mental group consistently showed a lower incidence of post-

operative sore throat at all measured time points.

The 2% lidocaine group had an OR 2.0 CI 95% (1.482.93),

2.28 CI 95% (1.543.3), and 2.4 CI 95% (1.643.5) for postop-

erative sore throat at post-anesthesia care unit, 8 hours and

24 hours after surgery evaluation respectively.

Our research highlights the potential benefits of applying

a gel that contains corticosteroids and local anesthetics to

the tracheal tube. This application may help reduce postop-

erative complications associated with tracheal intubation,

including sore throat, coughing, irritation from the tube, and

hoarseness.

Keywords

Postoperative Sore Throat, General Anesthesia, Endotracheal

Intubation, 2% Lidocaine Jelly, 0.05% Betamethasone,

Coughing at Emersion.

Introduction

Postoperative sore throat (POST) is a common complaint

and an undesirable outcome. Still, it is a common side-effect

Investigación

2 Volumen 3

of having a general anesthetic, which is reported by between

30% and 70% of patients after tracheal intubation1, 2.

After extubation, the highest incidence of POST usually

occurs after six hours. This is because the first few hours may

be masked by residual analgesic effects or postoperative pain

control. Currently, the use of 10% lidocaine spray for oral pha-

ryngeal anesthesia before intubation is no longer recommend-

ed, as it appears to increase the incidence of POST3.

POST is thought to result from inflammation caused by

laryngoscopy trauma and endotracheal tube (ETT) cuff inju-

ry. Medications with analgesic and anti-inflammatory effects

may be the best option for preventing POST after ETT intu-

bation during general anesthesia4.

Some of the risk factors that can cause sore throat are the

size of the ETT, ETT cuff pressure, female sex, duration of

anesthesia, positioning during surgery, concurrent use of na-

sogastric tubes, and aggressive oropharyngeal suctioning5.

A variety of non-pharmacological and pharmacological

methods have been used to reduce POST with variable re-

sults; some of the non-pharmacological methods include us-

ing smaller-sized ETTS, monitoring the ETT cuff pressures,

and the use of video laryngoscopes, etc.5.

Many patients don’t seek medical advice for POST. That’s

why most anesthesiologists may not be aware of the inci-

dence in their practice; it’s a minor complication, but attenu-

ating the symptoms is a worthwhile goal6.

The potential mechanisms and etiology of sore throat are

thought to be irritation, mechanical trauma during laryngos-

copy, and inflammation secondary to the insertion of an en-

dotracheal tube. The cuff pressure may also influence the

prevalence and severity of POST. Despite advancements in

laryngoscopy equipment, POST persists as a prevalent issue,

necessitating additional pharmacological interventions and

adversely impacting patient satisfaction. This underscores

the ongoing need for effective strategies to address this

challenge in clinical practice7.

POST includes signs and symptoms such as pharyngitis,

pain and discomfort, laryngitis, tracheitis, hoarseness, cough, or

dysphagia. The average incidence of sore throat with a tracheal

tube is 45.4%, whereas during the placement of the laryngeal

mask airway, it is reported to be 5.8% to 34%8.

Multiple interventions have been proposed to reduce the

incidence and intensity of pain after laryngotracheal intuba-

tion. Some of them involve using lidocaine or benzydamine

spray on the outside portion of the tube or directly into the

pharynx until the lidocaine is instilled inside the endotracheal

tube, but none of them have been chosen as the best tech-

nique and the most effective9.

The control of ETT cuff pressure during surgery is an inte-

gral aspect of anesthesia; the prevention of regurgitant aspi-

ration and airway damage is possible by keeping the ETT cuff

pressure at 2030 cmH2O as the guidelines recommend10, 11.

If the cuff pressure on an ETT is more than 30 cmH2O, local

tracheal mucosa perfusion is greatly reduced, increasing the

risk of postoperative airway problems related to tracheal

mucosal erosion11.

The study aims to determine the frequency of POST and

other related complications in patients who have had elec-

tive plastic surgery and were intubated using an orotracheal

tube while under general anesthesia with either betametha-

sone, lidocaine, and tetracaine gel or 2% lidocaine jelly. We

hope that the results of our study can help anesthesiologists

refine their techniques and strategies and take preventive

measures to reduce incidence and severity.

Materials and Methods

This study is a retrospective cohort of 101 patients aged 1875

who underwent elective plastic surgery with orotracheal in-

tubation under general anesthesia from February 2023 to

March 2024. It compares the incidence of POST, hoarseness,

cough, and coughing at emersion when lubricating the endo-

tracheal tube with a gel that contains betamethasone 0.05%,

lidocaine 2%, and tetracaine 1% or 2% lidocaine jelly.

All patients were American Society of Anesthesiologists

(ASA) status III.

We excluded patients in whom laryngoscopy was at-

tempted more than once, patients with upper respiratory

tract infection up to 1 month before surgery, on steroid use

and analgesic therapy before surgery, and patients in whom

the anesthesiologist didn’t measure the intracuff pressure

using a manometer.

Two topical pharmacological agents used by anesthesiol-

ogists for preventing POST in our center were compared.

Group 1: Gel containing betamethasone 0.05%, lidocaine

2%, and tetracaine 1% (BLTG) applied over the tracheal tube.

Group 2: 2% Lidocaine jelly (LIDO) applied over the tra-

cheal tube.

According to the anesthesia reports, during anesthesia in-

duction, 3 ml of a gel mixture of betamethasone 0.05%, li-

docaine 2%, and tetracaine 1% or 2% lidocaine jelly alone

were applied with sterile precautions to the tracheal tube

from the distal part of the cuff to 15 cm from the tip. PVC

tracheal tubes (size 7.0 to 8.0 mm depending on the patient´s

size). Anesthesia was induced with Fentanyl 3 mcg/kg,

Propofol 12 mg kg. I.V. vecuronium bromide 0.1 mg kg, tra-

cheal intubation was performed using a video-laryngoscope

OnFocus® after 45 minutes with TOF 0% and entropy RE/

SE: 4050; only one anesthesiologist intubated all patients

and was blinded to postoperative evaluations.

Following intubation, the tracheal tube’s cuff was inflated

to a pressure between 2028 cmH2O. The patient was kept

under anesthesia with Sevoflurane 1 MAC in oxygen, FiO2

40%, and fentanyl. It’s worth noting that the investigator in

charge of the postoperative measures was unaware of the

patient’s group allocation, and the anesthesiologist who ap-

plied the gel was also blinded for the allocation.

A STUDY ON THE EFFECTIVENESS OF A GEL CONTAINING BETAMETHASONE 0.05%, LIDOCAINE 2%, AND TETRACAINE 1% 3

At the end of the surgery, any remaining neuromuscular

block was reversed and oral suction was performed. All pa-

tients received the same postoperative analgesia treatment

with NSAIDs.

After surgery, the investigator in charge of the postopera-

tive care unit assessed patients for postoperative symptoms,

including sore throat, hoarseness of voice, and cough, at 1, 8,

and 24 hours and coughing at emersion.

The intensity of POST was carried out as follows: 0) No

sore throat at any time since the operation, 1) Mild sore

throat; less than a sore throat from a cold, 2) Moderate sore

throat, just like a sore throat from a cold, 3) Severe sore

throat; worse than the sore throat from a cold. Sore throat

intensity was higher in the 2% lidocaine group compared

with the BLTG group (P<0.001) (Fig 2).

The data collected in the study were consistent with a

normal distribution. Continuous variables were expressed as

means with standard deviation, while percentages were

used for categorical variables. Data were statistically tested

with the Student’s t-test or Chi-square when appropriat. P

values of less than 0.05 were considered statistically signifi-

cant. We calculated Odds Ratio (OR) using contingency tables

and built a logistic regression mode. The statistical analyses

and calculations were conducted using SPSS Statistics ver-

sion 21.0 (IBM, New York, USA).

The results of a prior study showed an incidence of 5% for

sore throat after lubrication with betamethasone gel and

27.8% with 2% lidocaine. We calculated that 50 patients

would be required in each group to detect a difference of

25% in the incidence with a power of 80% and a=0.05.

Table 1. Baseline data: comparison between BTLGel, 2% Lidocaine and Overall

Overall Group 1: BTLGel Group 2: LIDO 2% P Value

Age, years 42±13 43±12.8 41.6±13.3 0.59

Sex, female/male 91/10 46/5 45/5 0.97

Comorbid conditions

Diabetes

Hypertension

Hypothyroidism

Asthma

2 (2%)

11 (10.9%)

2 (2%)

1 (1%)

0 (0%)

7 (13.7%)

1 (2%)

1 (2%)

2 (4%)

4 (8%)

1 (2%)

0 (0%)

0.43

ASA classification I/II 81/20 41/10 40/10 0.96

Type of surgery

Breast Lift

Rhinoplasty

Rhytidectomy

Liposuction

26 (38.5%)

14 (50.8%)

29 (9.2%)

32 (1.5%)

11(21.6%)

6 (11.8%)

17 (33.3%)

17(33.3%)

15(30%)

8 (16%)

12(24%)

15(30%)

0.59

Intubation time,min 340.2±109.3 358.1±113.6 322±102.6 .097

Total dose of Fentanyl, mcg 299.2±65.9 299.5±61.3 299±71 0.96

Results

One hundred and one patients met the inclusion criteria and

were enrolled. Table 1 shows the characteristics of the study

groups. The incidence of POST at the 8-hour time interval

after extubating was significantly lower in the BLTG group,

with only 17.6% compared to a much higher incidence of

58% in the 2% lidocaine group (P<0.001). These were the

highest incidences for both groups during the 24-hour evalu-

ation period; Group 1 had a lower incidence of POST com-

pared with the 2% lidocaine group at each time point (Fig 1).

The 2% lidocaine group had an OR 2.0 CI 95% (1.48-

2.93), 2.28 CI 95% (1.543.3), and 2.4 CI 95% (1.643.5) for

POST at PACU, 8 hours and 24 hours after surgery evaluation

respectively.

BTLGel

Score Throat at PACU

Score Throat after 8 hours

Score Throat after 24 hours

Incidence %

100

LIDO2%

(P<0.001).

Figure 1. Incidence of postoperative Score Throat.

4 Volumen 3

intubation procedure, movement of the tracheal tube during

surgery, coughing on the tube, and excessive pharyngeal

suctioning during extubation. These factors have been noted

to have an impact on the incidence12.

Focusing on prevention instead of treatment is crucial for

enhancing the quality of care and patient satisfaction in ad-

dressing this anesthesia-related issue. The development of

POST is believed to be caused by inflammation caused by

injury from the tracheal tube’s cuff to the mucosa of the

pharynx and trachea. That’s why, unlike most studies con-

ducted on POST, we were very careful to include patients

where the anesthesiologist maintained tracheal tube’s cuff

pressures between 20 and 28 cmH2O13.

Our logistic regression model for POST at PACU, 8 hours

and 24 hours in 2% lidocaine group, shows the odds radio

(Exp (B)) of 10.2% CI 95% (3.0334.47) P<0.001, 8.29

CI 95% (2.8823.79) P<0.001 and 8.00 CI 95% (3.02211)

P< 0.001 respectively.

BTLGel

Without Score Throat

Mild

Moderate

Proportion of patiens %

100

70.6%

27.5% 22%

50%

18%

2% 10%

LIDO2%

(P<0.001)

Severe

Figure 2. Score Throat Severity.

Figure 3. Incidence of Hoarseness of voice.

Figure 4. Incidence of Cough.

The incidence of hoarseness of voice and cough was low-

er in the BTLG group compared to the 2% lidocaine group

(P<0.05) (Fig 3 and Fig 4).

The incidence of coughing at extubation was significantly

lower in the BTLG group, OR 0.20 CI 95% (0.0690.58)

(P<0.001) (Fig 4).

We did not find any evidence of adverse events related to

either of the anesthetic gels that we used.

Discussion

This research showed that using a gel that includes beta-

methasone, lidocaine, and tetracaine on a tracheal tube

could potentially lower the occurrence and intensity of POST,

hoarseness of voice, cough, and coughing on the tube at ex-

tubation compared to using only 2% lidocaine jelly. BTLG

Group reports an odds ratio for POST at 8 hours of 0.35

(95% CI 0.190.64) (p<0.001). The OR for hoarseness of

voice for the BTLG group was 0.11 CI 95% (0.0290.42)

(p<0.001).

These results are associated with the findings of P. A. Su-

mathi et al. (2008). The betamethasone group showed a

significantly lower incidence of sore throat, cough, and

hoarseness of voice compared to the lidocaine group

(p<0.05). As they also mention, consideration of several fac-

tors linked to the process of inflammation is crucial, including

the diameter of the tracheal tube, cuff design, and pressure,

BTLGel

Hoarseness at PACU

Hoarseness after 8 hours

Hoarseness after 24 hours

Incidence %

100

LIDO2%

(P<0.05)

BTLGel

Coughing at extubation

Cough after 8 hours

Cough after 24 hours

Incidence %

100

LIDO2%

BTLGel

LIDO2%

BTLGel

LIDO2%

(P<0.001)

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Based on a Cochrane systematic review, we specifically

chose to compare 2% topical lidocaine jelly, because it has

consistently demonstrated a significant reduction in the risk

and severity of POST RR 0.64, 95% CI (0.48 to 0.85)14.

In our center, the anesthesiology department uses the

combination of local anesthetics (lidocaine and tetracaine)

with the corticosteroid betamethasone. This is based on evi-

dence from a systematic review and meta-analysis by A. Kuri-

yama in 2018, which showed that corticosteroids applied to

tracheal tubes were associated with a reduced incidence of

POST with a relative risk of 0.39 and a CI 95% (0.320.46)15.

In contrast to our findings, it was observed that there was

no reduction in postoperative hoarseness of voice when

comparing corticosteroids to analgesic agents applied to tra-

cheal tubes. However, a reduction in the incidence of post-

operative cough was found with a relative risk of 0.33 CI

95% (0.170.65)15.

The presence of a sore throat following anesthesia can

lead to patient dissatisfaction and hamper their recovery and

return to normal function despite anesthesiologists catego-

rizing this as a minor complication16.

Our study has several strengths and demonstrates an

association between the use of a gel containing local anes-

thetics and corticosteroids with less incidence of multiple

postoperative outcomes (cough, POST, hoarseness of voice,

and coughing on the tube at emersion) compared to 2% lido-

caine jelly applied to the tracheal tube. Also measured the

cuff pressure during surgery in all the patients.

We have limitations; controlling patients’ conditions and

the amount of analgesic administration during the first

postoperative hours is difficult due to varying levels of pain

experienced in different surgeries.

Conclusion

Our research demonstrates the potential benefits of using a

gel containing corticosteroids and local anesthetics applied

to the tracheal tube to reduce postoperative complications

related to tracheal intubation, such as sore throat, cough,

coughing on the tube, and hoarseness of voice.

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