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British Journal of Oral and Maxillofacial Surgery 50 (2012) 732735

First do no harm: should routine tracheostomy after oral


and maxillofacial oncological operations be abandoned?
Margaret Jean Coyle a, , Andrew Shrimpton b , Charles Perkins a , Adekunmi Fasanmade c ,
Daryl Godden a
a
b
c

Department of Oral and Maxillofacial Surgery, Gloucester Royal Hospital, Great Western Hospital, Gloucestershire GL1 3NN, United Kingdom
Bristol Dental Hospital, Lower Maudlin Street, Bristol BS1 2LY, United Kingdom
Department of Oral and Maxillofacial Surgery, John Radcliff Hospital, Oxford, OX3 9DU, United Kingdom

Accepted 5 January 2012


Available online 10 February 2012

Abstract
Tracheostomy is traditionally used to secure the airway after major oral and maxillofacial oncological operations. In our unit, as an alternative,
patients are intubated overnight without tracheostomy. We reviewed the case notes of 55 patients who had had a major intraoral resection,
neck dissection, and reconstruction with a free flap. All patients were extubated and fit for transfer to the ward the following morning. We
conclude that overnight intubation is a safe alternative to tracheostomy, and that the routine use of tracheostomy for oral and maxillofacial
oncological operations should be used only for a few selected cases.
2012 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Oral and maxillofacial oncology; Airway management; Tracheostomy

Introduction
Tracheostomy is commonly used to secure the airway during
the immediate postoperative period in maxillofacial oncological operations even though controversy exists about
the optimal management of postoperative airways in these
cases.1,2 The American Academy of Otolaryngology listed
adjunct to manage head and neck surgery as one of their
indications for tracheostomy in 2000, but failed to give any
more specific details about the type or scale of head and neck
operations that would warrant its use.3 In 2009 Marsh et al.4
made a national survey of practice of early postoperative care
after free flap surgery in the head and neck and received data
from 57 units who did such operations. The study found that
39% of units would almost always and 30% would usually do an elective tracheostomy for an uncomplicated free

Corresponding author. Tel.: +44 7765220247.


E-mail address: coylem@eircom.net (M.J. Coyle).

flap. A total of 28% of patients were almost always and


26% were usually ventilated postoperatively. The study
found that only 7% of patients would almost always have
planned overnight intubation to manage the airway immediately postoperatively.
Tracheostomy is, however, associated with appreciable
morbidity, with reported complication rates of 845%.2,57
These complications include bleeding, injury to adjacent
structures, surgical emphysema, pneumothorax, or pneumomediastinum, blockage of the tracheostomy cannula,
displacement of the cannula, tracheitis, cellulitis, pulmonary
atelectasis, tracheoinnominate fistula, tracheo-oesophageal
fistula, tracheocutaneous fistula, tracheomalacia, granulation, excessive scarring, and failure to decannulate. In
one case a displaced tracheostomy tube was inadvertently
replaced outside the trachea and resulted in cardiorespiratory
arrest.5 For maxillofacial trauma these complications have
led authors to consider alternatives to tracheostomy such as
submental intubation,8 but less has been written about alternatives to tracheostomy for oncological cases.

0266-4356/$ see front matter 2012 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.bjoms.2012.01.003

M.J. Coyle et al. / British Journal of Oral and Maxillofacial Surgery 50 (2012) 732735
Table 2
Details of patients (n = 55).

Table 1
The tracheostomy scoring system.
Factor scored
Site of tumour
Buccal mucosa
Maxilla
Mandibular alveolus
Anterior tongue
Floor of mouth
Soft palate
Anterior pillar
Posterior pillar
Hypopharynx
Mandibulectomy
No
Yes
Bilateral neck dissection
No
Yes
Reconstruction
None
Radial forearm free flap
Other

733

Score
0
0
1
1
2
3
3
4
4
0
1

Variable

No. (%) or mean, range

Mean age (years)


Range
Sex
Male
Female
American Society of Anesthesiologists grade
I
II
III
Smoker
Yes
No
Mean duration of stay in hospital (days)
Range

60
1778
33 (60)
22 (40)
10 (18)
34 (62)
11 (20)
26 (47)
29 (53)
13
625

0
3
0
2
3

Pulmonary complications are common in patients who


have major head and neck surgery which involves a tracheostomy; Morton et al.9 reported a rate of 45% in
these patients, quoted by Ong et al.10 who found that
34/47 of head and neck patients who had had a tracheostomy developed pulmonary complications, even when
given prophylactic antibiotics. Rao et al.11 also reported the
presence of a tracheostomy as a risk factor for pulmonary
complications.
The awareness of these potential risks and complications
led Cameron et al.12 to develop a scoring system to help
identify patients likely to require an elective tracheostomy
as part of their head and neck surgery (Table 1). Four key
domains were identified that attracted a score: tumour site,
mandibulectomy, neck dissection, and type of reconstruction.
A score of 5 was regarded as the threshold at which elective
tracheostomy should be considered.
In our unit patients are intubated overnight postoperatively as an alternative to routine tracheostomy. They are
examined the following morning for any swelling that might
compromise the airway, and extubated if there is no excessive oedema. The purpose of this study was to find out if
the practice of overnight intubation was associated with any
complications to the airway when used routinely, and whether
or not it could be considered as an alternative to routine
tracheostomy.

Patients and methods


We reviewed the case notes of 55 patients who were treated
for head and neck cancers. Only patients who had had
a major intraoral resection, a unilateral or bilateral neck
dissection, and reconstruction with a radial forearm or

Table 3
Site of tumour (n = 55).
Site

No. (%)

Anterior tongue
Floor of mouth
Mandible/alveolus
Buccal mucosa
Palate
Retromolar trigone

25 (45)
12 (22)
6 (11)
6 (11)
5 (9)
1 (2)

fibular free flap were included. All patients were given


dexamethasone 8 mg intravenously at induction and 2 doses
postoperatively. They were intubated overnight in the intensive care unit (ICU) without a tracheostomy. The following
variables were recorded: age and sex, American Society of
Anesthesiologists grade, smoking, site of tumour, type of
neck dissection, use of mandibulotomy/mandibulectomy,
type of reconstruction, duration of stay in ICU, and total
hospital stay. Any postoperative complications associated
with the airway were also recorded.

Results
Fifty-five patients were included, and their details are given
in Table 2. The sites of the tumours are shown in Table 3, and
operations and reconstructions in Table 4.
Table 4
Types of operation and reconstruction (n = 55).
Procedure
Neck dissection
Unilateral
Bilateral
Mandibulectomy
Mandibulotomy
Reconstruction
Radial forearm free flap (soft tissue)
Fibular free flap
Radial forearm free flap (composite)

No. (%)
48 (87)
7 (13)
12 (22)
14 (25)
46 (84)
8 (14)
1 (2)

734

M.J. Coyle et al. / British Journal of Oral and Maxillofacial Surgery 50 (2012) 732735

All patients returned to the ITU and were intubated and


lightly sedated without tracheostomy for their first postoperative night. After examination of the site of resection, flap,
and airway the following morning, all patients were extubated and fit for transfer to the maxillofacial/ENT ward. Five
patients (9%) were treated for an infection of the lower respiratory tract during the early postoperative period. The mean
duration of hospital stay was 13 days (range 625).
Discussion
Tracheostomy-related complications are common,2,511 they
can be distressing for patients, and are potentially lifethreatening. Chest infections are more common in patients
who have had a tracheostomy.9 In addition, those patients
who do develop a tracheostomy-related complication spend
longer in the ICU and have a longer total hospital stay;
Castling et al.2 found that they spent a mean of 4 days in
the ICU compared with 2 days for all patients. They also
reported that patients with a tracheostomy-related complication had a mean total hospital stay of 25 days compared
with 14 days for all patients. The mean duration of hospital
stay for our patients was 13 days. Despite this, the routine
use of tracheostomy remains commonplace, with 39% units
almost always and 30% usually doing a tracheostomy for
a hypothetical patient with an uncomplicated free flap when
questioned by Marsh et al.4 The same study found that only
9% of units would almost never do a tracheostomy for these
patients.
We think that the group of patients chosen for our study
(major intraoral resection, plus neck dissection, plus reconstruction with a free flap) are a group who would traditionally
have had a tracheostomy as part of their treatment. Using the
tracheostomy scoring system developed by Cameron et al.12
24 of our patients (44%) would have attracted a score of 5 or
more, which was considered to be the score at which elective
tracheostomy should be considered for the management of
the airway. Other studies have documented the management
of patients with maxillofacial cancer without tracheostomy;
Mathew et al.14 found only 1.7% of 117 patients had a tracheostomy. In their study group, however, 53.8% of patients
had a primary closure and only 8.5% had free flap reconstruction, so their patients had less complex procedures than those
in our group.
These results have shown that overnight intubation is a
safe alternative to tracheostomy for the management of the
airway in the immediate postoperative period, and that tracheostomy may be unnecessary. In addition to a shortened
operation, we think that not doing a tracheostomy allows for
improved recovery with quicker return to function. Patients
are able to speak, cough, and clear secretions sooner, and
also avoid the potential risks and 845% morbidity associated
with tracheostomy.
One potential argument for the continued use of tracheostomy is that if a patient is given a tracheostomy he
or she can be cared for on a specialist ward, which means

there is no need for a bed in ITU so avoiding the cancellation


of other operations because of lack of availability of these
beds.12 Godden et al.15 established that it was acceptable
to resect cancers of the head and neck without transferring
patients to the ICU immediately postoperatively. Despite this,
when questioned about the location of patients on the first
postoperative night after major intraoral resection and reconstruction with a free flap, Marsh et al.4 found that in 54% of
57 units patients return to the ITU whilst 33% return to the
high dependency unit (HDU). Only 7% returned to a specialist head and neck ward with 3.5% and 1.8%, respectively,
returning to the recovery room and a general ward. Murray and Dempster16 found that following free tissue transfer
54% of patients returned to the ITU and 26% to the HDU. It
would seem, therefore, that even though these patients can in
theory return to a specialist ward, in practice most return to
the ITU or HDU postoperatively, so the adoption of a policy
of overnight intubation instead of tracheostomy would not
greatly increase demand on these beds. Obviously in units
where patients do not return to ITU or HDU careful discussion and collaboration with anaesthetic and ITU colleagues
would be required locally because of the implications for
demand for beds.
Cost is another factor to consider and again studies have
cited the economic benefits of not using intensive care unit
following surgery.13 The cost of an ITU bed with singleorgan support is 812/night (in 2011). It is difficult to quantify
the cost of a tracheostomy in absolute terms, but it has the
potential to increase costs in the following ways: increased
time in theatre, tracheostomy kits, increased hospital stay
if complications occur,2 and cost of treating an excess of
chest infections with expensive antimicrobial drugs. Complications also increase demands on the services of allied
health professionals such as physiotherapists and speech and
language therapists. Obviously monetary costs alone fail to
take into account the adverse effect on the patients wellbeing
if a complication occurs. In addition to this, both the paper
by Marsh et al.4 and that by Murray and Dempster16 suggest
that ITU and HDU beds are used for these patients anyway,
so a move away from routine tracheostomy would not necessarily increase demand on ITU or HDU beds, and therefore
cost.
The use of overnight intubation rather than routine tracheostomy would, of course, lead to reduced opportunities
for trainees to learn the technique, but the continued use of
a technique if there is another that is safe and less invasive
would of course be unethical. Tracheostomy will continue to
be needed for the management of airways in patients who
have not had major operations and for ITU patients who have
had prolonged intubation for conditions other than cancer.
Training in the technique will still be available.
The data for this study were collected retrospectively,
which could be regarded as a weakness, but the quality of
note-keeping was high and the information required was
available in the notes. There was no control group as we
thought that overnight intubation offered a safe alternative,

M.J. Coyle et al. / British Journal of Oral and Maxillofacial Surgery 50 (2012) 732735

and tracheostomy would therefore be unethical. A future


study that prospectively compares outcomes from units who
routinely do tracheostomies with those who do not could
generate more data and greater numbers, and would also
allow a direct comparison of outcomes between the two
groups.

Conclusion
As surgeons we should constantly question our practice and
examine the necessity for performing any procedure. The
overriding consideration above all others must be that we
do what is best and least damaging for the patient. There
should be a clear benefit for any procedure performed and
it should be the least invasive option available. We believe
that overnight intubation is a safe and more patient friendly
alternative to tracheostomy. We would hope that this paper
would make clinicians at the very least question the need
for a tracheostomy and at best use overnight intubation as
an alternative. We believe that each case should be considered individually and the need for a tracheostomy carefully
considered rather than tracheostomy automatically forming
part of the case. Finally we believe that the routine use of
tracheostomy in maxillofacial oncology cases should only
be considered when overnight intubation is not available, or
when multiple returns to theatre are anticipated.
Conict of interest
There is no conflict of interest.
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