Near-fatal complications of tracheotomy infections and their prevention

Perioperative antibiotic prophylaxis in open tracheostomy: A preliminary randomized controlled trial

BACKGROUND

The efficacy of perioperative antibiotic prophylaxis for prevention of wound infection in open tracheostomy has been minimally studied and remains controversial.

METHODS

A preliminary double-blind, randomized, placebo-controlled trial was conducted. A total of 159 patients who underwent open tracheostomy were enrolled, and 88 patients were excluded because of lack of desire to participate in research, emergency condition, administration of other antibiotics, immunocompromise, or cervical skin infection. The remainings were randomly assigned to an antibiotic group or a control group. Another 11 patients were excluded after the randomization due to intraoperative contamination, death from the underlying disease, receiving other antibiotics, or lost to the follow-up. A total of 30 patients in each group were qualified for analysis. In the antibiotic group, clindamycin was intravenously administered 30 min before the incision and every 8 h after the operation for 24 h. In the control group, an equal volume of sterile saline was administered.

RESULTS

Wound infection developed in 2 patients (6.7%) in the antibiotic group and 7 patients (23.3%) in the control group (p = 0.08). In multivariate analysis, smoking and previous neck irradiation were the significant risk factors for wound infection (p = 0.042 and 0.019, respectively). The mean length of hospital stay after tracheostomy in patients with and without wound infection were 17 ± 2 days and 4 ± 2 days, respectively (p = 0.013).

CONCLUSION

The result of this preliminary study reveals that antibiotic prophylaxis reduced tracheostomy wound infection rate from 23.3% to 6.7% although it was not statistically significant. However, wound infection may lead to serious complications and prolonged postoperative length of hospital stay, and therefore proper perioperative antibiotics should be considered in patients who are not receiving other antibiotics, and particularly in patients with risk factors for wound infection.

An overview of complications associated with open and percutaneous tracheostomy procedures

Tracheostomy, whether open or percutaneous, is a commonly performed procedure and is intended to provide long-term surgical airway for patients who are dependent on mechanical ventilatory support or require (for various reasons) an alternative airway conduit. Due to its invasive and physiologically critical nature, tracheostomy placement can be associated with significant morbidity and even mortality. This article provides a comprehensive overview of commonly encountered complications that may occur during and after the tracheal airway placement, including both short- and long-term postoperative morbidity.

Sternoclavicular joint osteomyelitis following head and neck surgery

OBJECTIVES/HYPOTHESIS

To review all reported cases of sternoclavicular joint (SCJ) osteomyelitis following head and neck surgery.

STUDY DESIGN

Retrospective case review.

METHODS

PubMed search and one additional case from our institution.

RESULTS

Twelve cases were reviewed, and the following recommendations are suggested: risk factors for SCJ osteomyelitis should be identified; early and prompt diagnosis of SCJ osteomyelitis is warranted; tracheostoma care and careful examination of the skin should not be neglected; meticulous screening for cancer recurrence is imperative; if SCJ infection is suspected, cancer recurrence must be ruled out with biopsies; and surgical debridement is considered the gold standard of treatment. Administration of newer-generation antibiotics is a reasonable choice when the infection is detected early, as is maintaining a low threshold for surgical treatment if disease persists or progresses.

CONCLUSIONS

Osteomyelitis of the SCJ following head and neck surgery is uncommon and must be distinguished from malignancy with biopsies. Early diagnosis and treatment are imperative. Laryngoscope, 2010.

Necrotizing fasciitis of the chest wall with a retropharyngeal abscess: case report and literature review

We herein report a case of a diabetic 49-year-old woman with anterior chest wall necrotizing fasciitis that caused a retropharyngeal abscess and discuss the literature surrounding necrotizing soft tissue infections of the chest wall. The patient was treated with serial wound debridements, antibiotic therapy, and percutaneous drainage and serial irrigation of the retropharyngeal abscess with a silicone catheter. The resulting defect was grafted with a split thickness skin graft.

Clavicular osteomyelitis: a rare complication after surgery for head and neck cancer

Clavicular osteomyelitis (COM) is a rarely described disease entity, occurring especially after head and neck surgery. We herein report the ninth case according to the English language literature and describe the pertinent diagnostic and therapeutic measures to treat this complication. A 63-year-old Caucasian male underwent total laryngectomy and partial pharyngectomy for a post-radiotherapy recurrence of a T2 hypopharyngeal cancer. He presented multiple systemic (cardiovascular problems, previous pneumonectomy, malnutrition) and local-regional (previous radiotherapy, neck dissection, tracheostomy) factors favoring postoperative complications. Sixteen days after surgery, he developed a painful swelling with overlying erythematous skin at the level of the medial portion of the left clavicle. A purulent discharge from the adjacent stomal dehiscence was also noted. COM, suspected on the base of patient's history and clavicular inspection, was confirmed by CT scan. Surgical debridement allowed for definitive diagnosis, ruling out any possible suspicion of stomal recurrence or secondary localization to the clavicle. Cultures from the debrided bone sequestra grew Streptococcus pyogenes Group A and allowed for proper targeting of antibiotic therapy, which was carried out for 4 weeks after surgery. Four years after surgery the patient is tumor-free and does not show any sequela related to the COM or its treatment. COM is a rarely encountered complication after major head and neck surgery. Nevertheless, prompt diagnosis and treatment are mandatory due to the potential life-threatening evolution of this condition.

Tracheostomy after anterior cervical spine fixation

BACKGROUND

Patients with cervical spine injury may require both anterior cervical spine fusion and tracheostomy, particularly in the setting of associated cervical spinal cord injury (SCI). Despite the close proximity of the two surgical incisions, we postulated that tracheostomy could be safely performed after anterior spine fixation. In addition, we postulated that the severity of motor deficits in patients with cervical spine injury would correlate with the need for tracheostomy.

METHODS

A retrospective review was undertaken of all adult trauma patients diagnosed with cervical spine fractures or cervical SCI admitted between June 1996 and June 2001 at our university Level I trauma center. Demographic data, severity of neurologic injury based on the classification of the American Spinal Injury Association (ASIA), complications, and use and type of tracheostomy were collected. In the subgroup of patients with unstable cervical spine injury that underwent anterior stabilization and tracheostomy, data regarding timing and technique of these procedures and wound outcomes were also collected. Categorical data were analyzed using chi analysis using Yates correction when appropriate, with p <0.05 considered significant.

RESULTS

During this time period, 275 adult survivors were diagnosed with cervical spinal cord or bony injury. Forty-five percent of patients with SCI (27 of 60) and 14% of patients without SCI (30 of 215) underwent tracheostomy (p <0.001). Moreover, on the basis of the ASIA classification system, 76% of ASIA A and B patients, 38% of ASIA C patients, 23% of ASIA D patients, and 14% of ASIA E patients were treated with tracheostomy (p <0.001). In the subgroup that underwent both anterior spine fixation and tracheostomy (n=17), the median time interval from spine fixation to airway placement was 7 days (interquartile range, 6-10 days), with 71% of these tracheostomies performed percutaneously. No patient developed a wound infection or nonunion as a consequence of tracheostomy placement, and there were no deaths because of complications of either procedure.

CONCLUSION

These data support the safety of tracheostomy insertion 6 to 10 days after anterior cervical spine fixation, particularly in the presence of cervical SCI. The presence of severe motor neurologic deficits was strongly associated with the use of tracheostomy in patients with cervical spine injury. Percutaneous tracheostomy, which is our technique of choice, may be advantageous in this setting by virtue of creating only a small wound. The optimal timing and use of tracheostomy in patients with cervical spine injury requires further study.

Tracheotomy complications: a retrospective study of 1130 cases

BACKGROUND

Tracheotomy is one of the most frequently performed surgical procedures in the critically ill patient. It is frequently performed as an elective therapeutic procedure and only rarely as an emergency procedure. Complications occur in 5% to 40% of tracheotomies depending on study design, patient follow-up, and the definition of the different complications. The mortality rate of tracheotomy is less than 2%. Numerous studies demonstrate a greater complication and mortality rate in emergency situations, in severely ill patients, and in small children.

METHODS

A retrospective study of 1130 consecutive tracheotomies performed during 1 decade (January 1987 through December 1996) is presented. We studied the indications for surgery, the major complications of tracheotomy, and their treatment and outcome. We also noted the overall mortality rate and the specific complications that led to these deaths.

RESULTS

In total, 1130 tracheotomies were performed. Major complications occurred in 49 of the cases, and 8 deaths were directly attributed to the tracheotomy. The most common complication was tracheal stenosis, which occurred in 21 cases. Hemorrhage was the second most common complication, which occurred in 9 cases.

CONCLUSION

This is one of the largest series of consecutive tracheotomies compiled. We found a relatively low overall complication and mortality rate compared with other large series. Tracheal stenosis was the most common complication in contrast to other series. Our opinion is that this may reflect tracheal damage originally caused by prolonged intubation before the tracheotomy. We believe that all other complications of tracheotomy may be prevented or minimized by careful surgical technique and postoperative tracheotomy care.

Cervical osteomyelitis after percutaneous transtracheal ventilation and tracheotomy

BACKGROUND

Percutaneous transtracheal ventilation has proven useful in emergent airway management.

METHODS

A report of a case is presented. Results. A 42-year-old woman who developed laryngospasm required emergency airway intervention She developed massive subcutaneous emphysema and required emergent cricothyroidotomy which was immediately converted to a tracheotomy. Although she was quickly decanulated, she developed late cervical osteomyelitis which resolved with intravenous antibiotic therapy.

CONCLUSIONS

Cervical osteomyelitis has not been previously reported as a complication of percutaneous transtracheal ventilation or tracheotomy Contamination of the deep neck spaces facilitated by pressure dissection of the fascial planes may have led to this complication.