LAUSR

In a small size randomized clinical trial assessing the effects of stylet use during tracheal intubation on early postoperative pharyngeal pain in anesthetized patients, Komasawa et al. [1] show that stylet use results in an increased incidence of early postoperative pharyngeal pain. To differentiate the effects of one factor on primary study endpoint, however, all of other factors have to be standardized for avoidance of potential biases. In this study, postoperative pharyngeal pain was evaluated when patients leaved operation room after sufficient recovery. We noted that remifentanil-based anesthesia was used. It was unclear whether two groups were comparable with intraoperative remifentanil dosages. The available evidence indicates that remifentanil can induce postoperative hyperalgesia and remifentanil-based anesthesia is associated with worse pain-related outcomes reported by patients [2]. Moreover, fentanyl was used for postoperative analgesia and the doses of fentanyl were determined by anesthesiologists based on the patient's age or condition. The readers were not provided the timing of fentanyl administration in relation to the assessment of early postoperative pharyngeal pain. In the absence of comparison of intraoperative remifentanil dosages and timing of postoperative fentanyl administration, we argue that the secondary outcome findings and their subsequent conclusions should be interpreted with caution, as they may have been determined using incomplete methodology. The authors did also not provide whether the times required to achieve sufficient recovery were comparable between groups. It has been shown that in adult patients, the incidence of postoperative pharyngeal pain may change with time in the early postoperative period [3–5]. We are concerned that an inconsistent observed time point would have interfered accuracy and precision of their assessment. In addition, use of single observed time point in the early postoperative periodmay havemissed the valuable data regarding dynamic differences in changes of postoperative pharyngeal pain with time between groups. Finally, this study only assessed incidence of early postoperative pharyngeal pain judged by asking the subjective symptom of the patients, but did not evaluate the severity of postoperative pharyngeal pain. According to the data presented in this study, thus, it is unclear