European Journal of Cardiovascular Medicine

Postoperative nausea and vomiting (PONV) is one of the most common and distressing complications observed after general anesthesia, with a reported incidence ranging from 20% to 80%, depending on various risk factors and surgical procedures (1). In ear, nose, and throat (ENT) surgeries, the incidence tends to be higher due to factors such as surgical site stimulation, blood ingestion, and prolonged operative duration (2). Although often self-limiting, PONV can lead to serious consequences including wound dehiscence, dehydration, electrolyte imbalance, and delayed recovery, thereby increasing hospital stay and reducing patient satisfaction (3,4).

Several intrinsic and extrinsic factors influence the occurrence of PONV. Patient-related factors include female gender, nonsmoking status, history of motion sickness or prior PONV, and younger age (5). Surgical factors such as type and duration of surgery, as well as anesthetic techniques—particularly the use of volatile anesthetics, nitrous oxide, and opioids—are also implicated (6). Among airway management strategies, endotracheal intubation is known to induce higher airway stimulation and pharyngeal irritation, potentially contributing to increased PONV compared to less invasive alternatives like laryngeal mask airway (LMA) (7).

Total intravenous anesthesia (TIVA), utilizing agents such as propofol, has been demonstrated to significantly reduce PONV compared to inhalational agents (8). However, in ENT surgeries, where airway instrumentation and blood contamination of the pharynx are frequent, the influence of anesthetic type and airway management on PONV needs further elucidation. This study aims to investigate the incidence of PONV in ENT surgeries and to assess the impact of different anesthetic techniques and airway devices on its occurrence.

A total of 150 adult patients scheduled for elective ear, nose, and throat (ENT) surgeries under general anesthesia were enrolled.

Inclusion and Exclusion Criteria:
Patients aged between 18 and 65 years, with American Society of Anesthesiologists (ASA) physical status I or II, undergoing elective ENT surgeries were included. Patients with known allergies to anesthetic drugs, those with pre-existing gastrointestinal disorders, psychiatric illness, history of chemotherapy or radiation, or those on antiemetic therapy within 24 hours before surgery were excluded.

Preoperative Assessment:
Demographic details such as age, gender, body mass index (BMI), smoking status, and history of motion sickness or previous PONV were recorded. Each patient was evaluated and assigned a simplified Apfel risk score for PONV prediction.

Anesthetic Technique and Airway Management:
Patients were allocated into two groups based on the anesthetic maintenance technique used: Group A received inhalational anesthesia with sevoflurane, and Group B received total intravenous anesthesia (TIVA) using propofol infusion. The choice of airway instrumentation—endotracheal intubation or laryngeal mask airway (LMA)—was documented. All patients were induced with intravenous fentanyl (2 µg/kg) and propofol (2 mg/kg), followed by muscle relaxation with vecuronium (0.1 mg/kg).

Intraoperative Monitoring and Data Collection:
Standard monitoring, including electrocardiogram, non-invasive blood pressure, pulse oximetry, and capnography, was employed. Intraoperative parameters such as duration of surgery, estimated blood loss, and fluid administration were recorded.

Assessment of PONV:
Postoperative nausea and vomiting were assessed at intervals of 0–6 hours, 6–12 hours, and 12–24 hours using a 4-point scale: 0 = no nausea/vomiting, 1 = nausea only, 2 = one episode of vomiting, and 3 = more than one episode. Patients with a score ≥1 were considered to have experienced PONV.

Statistical Analysis:
Data were analyzed using SPSS software version 25.0. Continuous variables were expressed as mean ± standard deviation (SD), and categorical data were presented as frequencies and percentages. Chi-square test and unpaired t-test were used for univariate analysis. Multivariate logistic regression was performed to identify independent predictors of PONV. A p-value of <0.05 was considered statistically significant.

A total of 150 patients undergoing elective ENT surgeries were included in the study. The demographic and baseline characteristics are summarized in Table 1. The mean age of participants was 39.6 ± 12.4 years, with 82 (54.6%) males and 68 (45.3%) females. A history of motion sickness was reported in 26 (17.3%) patients, and 36 (24%) had a history of PONV.

Table 1: Baseline Demographic and Clinical Characteristics of Study Participants (n=150)

The overall incidence of PONV within the first 24 hours postoperatively was 58 out of 150 patients (38.6%). PONV incidence was significantly higher in the inhalational anesthesia group (Group A, 47.3%) compared to the TIVA group (Group B, 24.0%) (p=0.003). Similarly, patients who received endotracheal intubation had a significantly higher PONV incidence (44.6%) than those with laryngeal mask airway (28.3%) (p=0.02), as shown in Table 2.

Table 2: Incidence of PONV Based on Anesthetic Technique and Airway Instrumentation

*Significant at p < 0.05

Multivariate logistic regression analysis showed that inhalational anesthesia (OR: 2.8; 95% CI: 1.4–5.6; p=0.002), endotracheal intubation (OR: 2.2; 95% CI: 1.1–4.3; p=0.01), and female gender (OR: 1.9; 95% CI: 1.02–3.6; p=0.04) were independent predictors of PONV (Table 3).

Table 3: Multivariate Logistic Regression Analysis of Risk Factors for PONV

*Statistically significant at p < 0.05

These findings confirm the significant influence of anesthetic modality and airway management technique on the likelihood of developing PONV in ENT surgeries (Tables 2 and 3).

This study evaluated the incidence and associated risk factors of postoperative nausea and vomiting (PONV) in patients undergoing ENT surgeries, with a focus on anesthetic technique and airway instrumentation. The overall incidence of PONV in our study population was 38.6%, which aligns with previously reported rates of 30%–70% in ENT procedures due to increased pharyngeal stimulation, blood ingestion, and longer surgical durations (1,2).

The results indicate a significantly higher incidence of PONV in patients receiving inhalational anesthesia compared to those managed with total intravenous anesthesia (TIVA). This finding supports earlier research demonstrating that volatile anesthetics, particularly sevoflurane and isoflurane, are emetogenic and significantly contribute to early postoperative nausea (3,4). In contrast, propofol-based TIVA has been associated with reduced PONV risk due to its intrinsic antiemetic properties (5,6). Meta-analyses have confirmed that propofol decreases the relative risk of PONV by 20%–30% compared to inhalational agents (7,8).

Airway management was another key factor influencing PONV. Endotracheal intubation was found to be an independent risk factor, with a higher incidence of PONV than laryngeal mask airway (LMA). This is likely due to greater airway irritation and pharyngeal trauma associated with endotracheal tubes (9,10). LMAs, being less invasive, reduce sympathetic stimulation and pharyngeal contact, contributing to better postoperative comfort and lower PONV rates (11). Similar findings were reported by Brimacombe et al., who emphasized that LMA use significantly reduces airway-related postoperative complications (12).

Among patient-specific variables, female gender emerged as a significant predictor of PONV, consistent with established evidence (13,14). Hormonal influences, particularly estrogen and progesterone, are believed to modulate the central emetic pathways, increasing susceptibility in females (15). History of motion sickness and previous PONV were also observed more frequently among those who developed PONV, although these did not retain statistical significance in multivariate analysis. Nonetheless, these are widely accepted as key risk factors and are incorporated into predictive models like the Apfel score (6,7).

Surgical factors such as duration and type of ENT surgery also play a role in PONV. While our study did not find a statistically significant difference among various procedures, previous literature highlights that middle ear surgeries and tonsillectomies are particularly high-risk due to the proximity to the vomiting center and vagal nerve stimulation (8,9).

In conclusion, the findings of this study are consistent with global literature that highlights inhalational agents and endotracheal intubation as modifiable risk factors in the development of PONV. Adopting propofol-based anesthesia and less invasive airway devices can improve postoperative outcomes and patient satisfaction.

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