Scoring system for selective tracheostomy in head and neck surgery with free flap reconstruction

Airway management in pediatric patients undergoing microvascular free tissue transfer reconstruction after mandibulectomy

OBJECTIVES

Microvascular free tissue transfer (MVFTT) for head and neck reconstruction is infrequently performed in pediatric patients. There is a paucity of data on perioperative airway management in pediatric MVFTT, such as the need for tracheostomy, which can pose higher morbidity to young patients due to potential long-term effects on the softer, more pliable laryngotracheal cartilage. Our objective was to report airway outcomes on pediatric patients undergoing MVFTT after segmental mandibulectomy with or without tracheostomy.

METHODS

Retrospective chart review of pediatric patients who underwent MVFTT reconstruction after segmental mandibulectomy at a tertiary care center from 2014 to 2023. Demographic variables, surgical characteristics, and hospital clinical outcomes were recorded. Statistical analyses were performed with JMP Pro, Version 16.0.0 (2021) SAS Institute Inc., Cary, NC, 1989-2021.

RESULTS

Ten patients (median age 11.5 years old, IQR: 9.0-13.3) underwent fibular free flap reconstruction. Mandibular pathologies included 3 ameloblastoma, 2 mesenchymal chondrosarcoma, 2 desmoplastic fibroma, 1 Ewing sarcoma, 1 chondroblastic osteosarcoma, and 1 desmoid tumor. Two patients received upfront tracheostomy at time of initial surgery for a subtotal mandibulectomy and a sub-hemimandibulectomy, respectively. Both patients were decannulated within 1 week after surgery and prior to discharge. The median ICU and hospital length of stay for patients who underwent tracheostomy was 3.5 days [IQR: 3.0-4.0] and 8.5 days [IQR: 8.0-9.0] respectively. Of the remaining 8 patients without tracheostomy, surgical defects were hemimandibulectomy and anterior subtotal mandibulectomy. Median intubation duration was 1.0 day [IQR: 1.0-2.5]. The median ICU and hospital length of stay for these patients were 3.0 days [IQR: 2.0-6.3] and 8.5 days [IQR: 7.3-13.0], respectively. No patient had to be reintubated for respiratory failure following extubation or had long-term airway complications during the follow-up period.

CONCLUSIONS

Fibular free flap reconstruction without tracheostomy can be feasible in pediatric patients with mandibular defects, which can potentially reduce hospital resources required for fresh tracheostomy care needs and avoid additional surgical morbidity. Further studies in larger populations and prospective approaches are warranted.

Airway Management in Microvascular Reconstruction of the Oral Cavity: Is Immediate Extubation Possible?

BACKGROUND

A tracheostomy is routinely performed following free tissue transfer (FTT) for oral cavity reconstruction; however, its avoidance whenever possible is advocated to enhance patient recovery and reduce hospital length of stay (LOS).

PURPOSE

This study aims to measure and compare clinically relevant outcomes for patients who have endotracheal intubation versus tracheostomy for FTT for oral cavity reconstruction.

STUDY DESIGN, SETTING, SAMPLE

A retrospective cohort study was conducted to evaluate subjects undergoing FTT of the oral cavity for benign and malignant pathology at the University of Alabama at Birmingham from 2014 to 2021. Subjects with unresectable tumors or defects that were not primarily located in the oral cavity were excluded.

INDEPENDENT VARIABLE

The independent variable was perioperative airway management and was divided into 2 groups: 1) endotracheal intubation or 2) tracheostomy.

MAIN OUTCOME VARIABLE(S)

The main outcome measure was defined as a postoperative airway-related complication and required escalation of care to an intensive care unit. LOS and surgical complications were also analyzed.

COVARIATES

The covariates were classified as demographic, medical, pathologic, and operative.

ANALYSES

Bivariate and multivariate statistical analyses were conducted to compare the outcomes between subjects who were immediately extubated and tracheotomized. Subject demographics and operative parameters were also analyzed.

RESULTS

A total of 560 subjects met the inclusion criteria, with 122 subjects in the immediate extubation group and 438 subjects in the tracheostomy group. The mean age was 59.7 ± 16.3 years in the immediate extubation group and 59.3 ± 13.8 years in the tracheostomy group (P = .8). The proportion of males was 57.4% in the immediate extubation group and 60% in the tracheostomy group (P = .6). No postoperative airway-related complications occurred in the endotracheal intubation group. After controlling for confounding factors, tobacco use was associated with airway-related complications (odds ratio [OR]: 2.66; 95% confidence interval: 1.1-6.3; P = .03). LOS was shorter in the endotracheal intubation versus tracheostomy group (6.8 vs 9 days, P < .01).

CONCLUSION AND RELEVANCE

In subjects who underwent FTT for oral cavity reconstruction, postoperative airway-related complications were associated with a tracheostomy and tobacco use status.

Airway decision making in major head and neck surgery: Irish multicenter, multidisciplinary recommendations

Major head and neck surgery poses a threat to perioperative airway patency. Adverse airway events are associated with significant morbidity, potentially leading to hypoxic brain injury and even death. Following a review of the literature, recommendations regarding airway management in head and neck surgery were developed with multicenter, multidisciplinary agreement among all Irish head and neck units. Immediate extubation is appropriate in many cases where there is a low risk of adverse airway events. Where a prolonged definitive airway is required, elective tracheostomy provides increased airway security postoperatively while delayed extubation may be appropriate in select cases to reduce postoperative morbidity. Local institutional protocols should be developed to care for a tracheostomy once inserted. We provide guidance on decision making surrounding airway management at time of head and neck surgery. All decisions should be agreed between the operating, anesthetic, and critical care teams.

Three-Dimensional Morphological Changes in the Upper Airway After Maxillary Reconstruction With an Anterolateral Thigh Flap

BACKGROUND

Reconstruction of maxillary defects may lead to changes in the upper airway. These changes may cause postoperative airway obstruction issues.

PURPOSE

The purpose was to evaluate the postoperative changes in the upper airway following maxillary reconstruction with an anterolateral thigh flap (ALTF) and to identify the factors associated with these changes.

STUDY DESIGN, SETTING, SAMPLE

This retrospective cohort study involved 26 patients who underwent maxillectomy for maxillary tumors, followed by reconstruction using an ALTF. Patients with a history of upper respiratory system disease and sleep-disorder breathing were excluded.

PREDICTOR VARIABLE

The predictor variable was the residual rate of ALTF volume (ALTF-RS), calculated as the ratio of ALTF volume at 6 months postsurgery (T2) to that at 2 weeks postsurgery (T1).

THE OUTCOME VARIABLES

The outcome variables were the upper airway parameters. The upper airway was assessed at 3 time points: 1 week preoperatively (T0), T1, and T2. Ratios were used to represent airway changes over time.

COVARIATES

The covariates are age, sex, Brown classification, body mass index, hypertension, neck dissection, and tracheostomy, etc. ANALYSES: Airway measurement differences between the three time points were analyzed by one-way analysis of variance. Pearson correlation and Spearman correlation analysis were used to analyze the correlation coefficients between airway changes and ALTF-RS. Statistical significance was established at a P value < .05.

RESULTS

The sample included 26 subjects with a mean age of 55.6 ± 15.2 years and 15/26 (57.7%) were male. Compared to T0, the nasopharyngeal and retropalatal airway volumes at T1 significantly decreased (P < .05) but recovered or surpassed preoperative levels by T2. The minimum cross-sectional airway area significantly decreased by T1 (P < .05), but increased by T2 (P < .05). The narrowest airway section was predominantly in the palatopharyngeal airway. The airway changes of T2/T1 and ALTF-RS were not correlated (P > .05) except for anterior-inferior point of the 4th cervical vertebra cross-sectional area (P < .05).

CONCLUSION AND RELEVANCE

The volumetric changes in the airway were not associated with ALTF-RS. The substantial narrowing of minimum cross-sectional airway area at T1 emphasized the need for vigilant airway management in these patients.

Airway-Associated Complications With and Without Primary Tracheotomy in Oral Squamous Cell Carcinoma Surgery

PURPOSE

This study analyzes postoperative airway management, tracheotomy strategies, and airway-associated complications in patients with oral squamous cell carcinoma in a tertiary care university hospital setting.

MATERIAL AND METHODS

After institutional approval, airway-associated complications, tracheotomy, length of hospital stay (LOHS), and length of intensive care unit stay were retrospectively recorded. Patients were subdivided in primarily tracheotomized and not-primarily tracheotomized. Subgroup analyses dichotomized the not-primarily tracheotomized patients into secondary tracheotomized and never tracheotomized. Associations were calculated using regression analyses. A multivariate regression model was used to determine risk factors for secondary tracheotomy.

RESULTS

A total of 207 patients were included. One hundred fifty-three patients (73.9%) were primarily tracheotomized. Primarily tracheotomized patients showed longer LOHS [odds ratio (OR) 1.04, 95% confidence interval (CI) 1.01-1.07, P =0.008] but decreased need for reventilation within the intensive care unit stay (OR 0.39, 95% CI 0.15-0.99, P =0.05) compared with not-primarily tracheotomized patients. Within the not-primarily tracheotomized patients, secondary tracheotomized during the hospital stay was needed in 15 of 54 patients (27.8%). In secondary tracheotomized patients, airway management due to respiratory failure was required in 6/15 (40%) patients resulting in critical airway situations in 3/6 (50%) patients. Multivariate regression model showed secondary tracheotomy-associated with bilateral neck dissection (OR 5.93, 95% CI 1.22-28.95, P =0.03) and pneumonia (OR 16.81, 95% CI 2.31-122.51, P =0.005).

CONCLUSION

Primary tracheotomy was associated with extended LOHS, whereas secondary tracheotomy was associated with increased complications rates resulting in extended length of intensive care unit stay. Especially in not-primarily tracheotomized patients, careful individualized patient evaluation and critical re-evaluation during intensive care unit stay is necessary to avoid critical airway events.

A comparative study of three-dimensional airway changes after fibula flap reconstruction for benign and malignant tumours in the anterior mandible

Surgical treatment of tumours in the anterior mandible and surrounding tissues may result in defects which can be restored by a fibula free flap. The upper airway may change during this process. The purpose of this retrospective study was to evaluate upper airway changes after fibula free flap reconstruction. A total of 37 patients who underwent anterior mandibulectomy and fibula free flap reconstruction between 2012 and 2020 were recruited. Patients with benign and malignant tumours involving the anterior mandible were included. Spiral computed tomography was performed 1 week preoperatively, 1 week postoperatively, and at> 1 year (range 12-23 months) after surgery. Cross-sectional areas and volumes of the upper airway were measured. Data were analysed by two-way analysis of variance. The upper airway in the malignant tumour group showed an increasing trend, especially at the soft palate and tongue base levels (P < 0.01). In the benign tumour group, the upper airway showed no significant changes. The location of the minimum cross-sectional area moved downwards in both groups, and the area increased in the malignant tumour group during long-term follow-up. Upper airway obstruction is less likely to occur in the long term after surgical resection of anterior mandible malignancies and fibula free flap reconstruction.

Immediate postoperative non-invasive positive pressure ventilation following midface microvascular free flap reconstruction

BACKGROUND

There is a rare need for postoperative non-invasive positive pressure ventilation (NIPPV) following microvascular reconstruction of the head and neck. In midface reconstruction, the free flap vascular pedicle is especially vulnerable to the compressive forces of positive pressure delivery.

CASE

A 60 year old female with Amyotrophic Lateral Sclerosis (ALS) presented with squamous cell carcinoma of the anterior maxilla, for which she underwent infrastructure maxillectomy and fibula free flap reconstruction. To avoid tracheotomy, the patient was extubated postoperatively and transitioned to NIPPV immediately utilizing a full-face positive pressure mask with a soft and flexible sealing layer. The patient was successfully transitioned to NIPPV immediately after extubation. The free flap exhibited no signs of vascular compromise postoperatively, and healed very well.

CONCLUSION

Postoperative non-invasive positive pressure ventilation can be successfully applied following complex microvascular midface reconstruction to avoid tracheotomy in select patients without vascular compromise of the free flap.

Tracheostomy in free-flap reconstruction of the oral cavity: can it be avoided? A cohort study of 187 patients

BACKGROUND

Head and neck surgeons are moving away from routine tracheostomy in free-flap reconstruction. We reviewed prophylactic tracheostomy use in patients undergoing oral cavity or oropharynx free-flap reconstruction to identify patient groups who avoided tracheostomy. Secondary aims were to describe complications associated with and without tracheostomy.

METHODS

A retrospective cohort study was undertaken, using a prospectively maintained database. Inclusion criteria was free-flap reconstruction for an oral cavity or oropharyngeal defect, excluding partial or total laryngectomy. Variables collected included demographics, comorbidity, American Society of Anesthesiologists grade, Charlson Comorbidity Index, tumour site and subsite, extent of resection, surgery duration, tracheostomy, complications, return to theatre and re-intubation.

RESULTS

A total of 344 head and neck free-flap reconstructions were performed between January 2017 and July 2019. A total of 164 (87.7%) oral cavity and 23 (12.3%) oropharyngeal reconstructions were included totalling 187 free flaps. A total of 107 (57.2%) were males and 80 (42.8%) females, mean age 62.4 years (range 21-89). Of 187 patients, 100 (53.5%) underwent prophylactic tracheostomy at time of reconstruction. Longer operative time (P < 0.001), resection site (P < 0.001), number of subsites resected (P = 0.007), segmental mandibulectomy (P = 0.04), lip-split (P = 0.05), floor of mouth resection (P < 0.001), lingual release (P = 0.007), glossectomy (P < 0.001), extent of tongue resection (P < 0.001), extent of hard palate resection (P = 0.04), soft palate resection (P < 0.001) and double free-flap reconstruction (P = 0.04) were associated with tracheostomy use.

CONCLUSION

A personalized approach to postoperative airway management allowed almost half of our cohort to avoid tracheostomy. In high-volume institutions with the necessary expertise and support, appropriately selected patients may be safely managed without routine tracheostomy.

Major head and neck reconstruction during the COVID-19 pandemic: The University of Pittsburgh approach

The 2019 novel coronavirus (COVID-19) pandemic has created significant challenges to the delivery of care for patients with advanced head and neck cancer requiring multimodality therapy. Performing major head and neck ablative surgery and reconstruction is a particular concern given the extended duration and aerosolizing nature of these cases. In this manuscript, we describe our surgical approach to provide timely reconstructive care and minimize infectious risk to the providers, patients, and families.