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Print ISSN: 2754-3242 Online ISSN: 2754-1304
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March-April 2026 Volume 6 Issue 2

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Cardiac arrest complicating routine throat pack insertion in oral and maxillofacial surgery under general anesthesia: A case report

  • Authors:
    • Kana Yamada
    • Makoto Adachi

  • View Affiliations / Copyright

    Affiliations: Department of Anesthesiology, Nagoya Tokushukai General Hospital, Kasugai, Aichi 487‑0016, Japan, Department of Oral and Maxillofacial Surgery, Nagoya Tokushukai General Hospital, Kasugai, Aichi 487‑0016, Japan
    Copyright: © Yamada et al. This is an open access article distributed under the terms of Creative Commons Attribution License [CC BY 4.0].
  • Article Number: 17
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    Published online on: February 11, 2026
       https://doi.org/10.3892/mi.2026.301
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Abstract

Throat packs are routinely inserted during oral and maxillofacial surgery and are generally considered safe. However, severe vagally mediated cardiovascular reflexes can rarely occur during airway or oropharyngeal manipulation. The present study describes a rare case of cardiac arrest directly attributed to throat pack insertion. A healthy 54‑year‑old male patient underwent third molar extraction under general anesthesia. Immediately following throat pack placement, he developed sudden cardiac arrest with complete electrical asystole lasting ~20 sec. Spontaneous circulation returned rapidly following the intravenous administration of ephedrine (8 mg) without the need for chest compressions. This event was most consistent with a vagal reflex‑mediated response. The present case report indicates that vigilant hemodynamic monitoring, adequate ventilation and appropriate anesthetic depth are essential even during routine adjunctive steps, such as throat pack insertion.
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Figure 1

Intraoperative anesthetic chart demonstrating the timeline of anesthetic management, including medication administration and the occurrence of cardiac arrest immediately following throat pack insertion. The chart illustrates the progression from normal vital signs to cardiac arrest and subsequent recovery following ephedrine administration. Crosses mark the start and end of anesthesia; T, intubation; E, extubation; double circles, indicate the start and end of surgery; circled numerals ①-④ indicate: ① throat pack insertion, ② cardiac arrest, ③ ephedrine (8 mg) administration, ④ return of spontaneous circulation. Heart rate values represent trend-averaged monitor data; transient electrical asystole is therefore depicted as an interruption of the HR trace rather than a numerical value of zero. SpO2, peripheral oxygen saturation; HR, heart rate; BP, blood pressure; DBP, diastolic blood pressure; SBP, systolic blood pressure.

Figure 2

Intraoperative electrocardiographic monitoring findings during throat pack insertion (lead II, paper speed 25 mm/s, gain 10 mm/mV). The three consecutive strips demonstrate: (Upper panel) baseline sinus rhythm before throat pack insertion; (middle panel) complete electrical asystole with absence of all electrical activity; (lower panel) low-amplitude irregular waveform preceding recovery of sinus rhythm after ephedrine administration and stimulus cessation. The asystolic period lasted ~20 sec.

Figure 3

Neural reflex pathway of pharyngeal-stimulation-induced cardiac arrest. Sagittal schematic diagram illustrating sensory afferents from the glossopharyngeal nerve (CN IX, blue; posterior pharyngeal wall) and the internal branch of the superior laryngeal nerve (CN X, red; pharyngeal surface of the epiglottis) entering the nucleus tractus solitarius (NTS, gray) in the medulla separately. Signals from the NTS activate medullary vagal efferent nuclei, the nucleus ambiguus and dorsal motor nucleus, whose parasympathetic fibers (green) project via the vagus to the heart; excessive vagal activation during airway manipulation can precipitate sinus arrest and high-grade atrioventricular block. This illustration was generated using ChatGPT-4 (OpenAI).
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Spandidos Publications style
Yamada K and Adachi M: Cardiac arrest complicating routine throat pack insertion in oral and maxillofacial surgery under general anesthesia: A case report. Med Int 6: 17, 2026.
APA
Yamada, K., & Adachi, M. (2026). Cardiac arrest complicating routine throat pack insertion in oral and maxillofacial surgery under general anesthesia: A case report. Medicine International, 6, 17. https://doi.org/10.3892/mi.2026.301
MLA
Yamada, K., Adachi, M."Cardiac arrest complicating routine throat pack insertion in oral and maxillofacial surgery under general anesthesia: A case report". Medicine International 6.2 (2026): 17.
Chicago
Yamada, K., Adachi, M."Cardiac arrest complicating routine throat pack insertion in oral and maxillofacial surgery under general anesthesia: A case report". Medicine International 6, no. 2 (2026): 17. https://doi.org/10.3892/mi.2026.301
Copy and paste a formatted citation
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Spandidos Publications style
Yamada K and Adachi M: Cardiac arrest complicating routine throat pack insertion in oral and maxillofacial surgery under general anesthesia: A case report. Med Int 6: 17, 2026.
APA
Yamada, K., & Adachi, M. (2026). Cardiac arrest complicating routine throat pack insertion in oral and maxillofacial surgery under general anesthesia: A case report. Medicine International, 6, 17. https://doi.org/10.3892/mi.2026.301
MLA
Yamada, K., Adachi, M."Cardiac arrest complicating routine throat pack insertion in oral and maxillofacial surgery under general anesthesia: A case report". Medicine International 6.2 (2026): 17.
Chicago
Yamada, K., Adachi, M."Cardiac arrest complicating routine throat pack insertion in oral and maxillofacial surgery under general anesthesia: A case report". Medicine International 6, no. 2 (2026): 17. https://doi.org/10.3892/mi.2026.301
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