Lidocaine Delivery Systems for Preventing Postoperative Sore Throat: From Direct Spray to Soft Mist

Postoperative sore throat (POST) is common after tracheal intubation, with pooled estimates of 32.4% at 1 hour and 16.4% at 24 hours in a recent systematic review. This narrative review examines how lidocaine delivery systems influence airway deposition, tolerability, duration of exposure, and safety. PubMed/MEDLINE and Crossref-indexed records were searched from inception through July 20, 2026, with backward citation tracking. Randomized trials, systematic reviews, pharmacology studies, and device or aerosol studies relevant to POST prevention or airway topicalization were prioritized. Direct spray is rapid, familiar, and inexpensive but produces operator-dependent deposition and may provoke coughing. Nebulization is gentler and useful for awake airway management, although delivered dose and anatomic coverage vary with the device and breathing pattern. Alkalinized intracuff lidocaine provides sustained exposure at the cuff-tracheal interface; in one 90-patient trial, POST occurred in 13% versus 67% of placebo recipients at 24 hours. Soft-mist delivery may reduce plume-related irritation, but its evidence base remains preliminary: a single-center 100-patient trial reported 24-hour POST in 4% versus 38% of controls, without comparison against optimized spray or nebulization. These estimates should not be compared as treatment rankings because populations and protocols differed. Lidocaine is best used selectively within a multimodal bundle that includes appropriate endotracheal-tube sizing, atraumatic intubation, cuff-pressure control, cumulative-dose accounting, and standardized outcome assessment. No delivery system has yet been shown to be definitively superior or most cost-effective.