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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
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
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
60
1778
33 (60)
22 (40)
10 (18)
34 (62)
11 (20)
26 (47)
29 (53)
13
625
0
3
0
2
3
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)
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
M.J. Coyle et al. / British Journal of Oral and Maxillofacial Surgery 50 (2012) 732735
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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