Neuromuscular blockade techniques reduce postoperative airway complications: A meta-analysis of intervention effects

Yan Wang1, 2, 3, 4, #, Mingyu Kong1, 2, 3, 4, #, Kuiying Qin1, 2, 3, 4, #, Zheng Zhu1, 2, 3, 4, Na Qiu5, Yuanyuan Teng1, 2, 3, 4, Qiang Zhang1, 2, 3, 4, *, Yan Sun1, 2, 3, 4, *

1Department of Otorhinolaryngology, Head and Neck Surgery, Yantai Yuhuangding Hospital, Qingdao University, Yantai, Shandong Province, China;

2Shandong Provincial Key Laboratory of Neuroimmune Interaction and Regulation, Yantai, Shandong Province, China;

3Shandong Provincial Clinical Research Center for Otorhinolaryngologic Diseases, Yantai, Shandong Province, China;

4Yantai Key Laboratory of Otorhinolaryngologic Diseases, Yantai, Shandong Province, China;

5University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA

*Correspondence to: Yan Sun, PhD, entsunyan@126.com; Qiang Zhang, MS, Dr_qiangzhang@163.com.

#These authors contributed equally to this work.

Funding: This work was supported in part by the National Natural Science Foundation of China, Nos. 82371153 and 82571317, and the Natural Science

Foundation of Shandong Province, Nos. ZR2022QH073 and ZR2025MS1188 (all to YS).

Objectives: Anesthesia using neuromuscular blocking agents is widely used in surgeries. It is of great significance to determine whether neuromuscular blocking agents used for airway management during anesthesia can reduce postoperative complications (such as pharyngeal discomfort). This meta-analysis aims to explore the association between the use of neuromuscular blocking agents during surgery and postoperative pharyngeal discomfort, and to infer the role of neuromuscular blocking agents in the recovery of nerves and tissues after surgery.

Methods: PubMed, Embase, the Cochrane Library, and Web of Science were searched for relevant articles published from January 1990 to December 2024. The search terms included “neuromuscular blocking agents,” “central muscle relaxants,” “muscle relaxants,” “voice disorders,” “laryngeal diseases,” “hoarseness,” and “sore throat.” The quality of included studies was assessed for risk of bias using the

Cochrane RoB 2 tool, and a meta-analysis was then conducted using RevMan 5.4 software.

Results: Ten randomized controlled trials (with a total of 1358 patients) were included in this meta-analysis. The overall risk of bias in the literature was low. The trial group received a muscle relaxant intervention, while the control group received a saline intervention. The risks of pharyngalgia and cough were lower in the trial group than in the control group (risk ratio [RR] = 0.67, 95% confidence interval [CI]: 0.53 to 0.86, P = 0.002; RR = 0.053, 95% CI: 0.007 to 0.381, P = 0.004). Risks of sore throat and hoarseness were not significantly different between the two groups (RR = 0.92, 95% CI: 0.68 to 1.23, P = 0.65; RR = 1.01, 95% CI: 0.81 to 1.27, P = 0.92). The preoperative first pass success was significantly higher in the trial group than in the control group (RR = 0.37, 95% CI: 0.14 to 0.98, P = 0.05).

Conclusion: Overall, the use of neuromuscular blocking agents during surgery can effectively reduce the occurrence of upper airway complications after airway

management anesthesia, which also rules out a negative effect of muscle relaxants in some patients with postoperative upper airway complications. However, the incidence of postoperative sore throat and hoarseness is quite high, necessitating further in-depth research. This meta-analysis was registered in the PROSPERO database (registration No. CRD42022356359) on August 27, 2022.

Key Words: adjunctive anesthetic agents; anesthesia; hoarseness; intraoperative; neuromuscular blocking agents; pharyngalgia; pharyngeal; preoperative preparation; technique; upper airway complications