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Bhatt N, Yang J, DeBaere L, Wang RS, Most A, Zhang Y, Dayanov E, Yang W, Santacatterina M, Kamberi M, Mojica J, Kamen E, Savitski J, Stein J, Jacobson A. Reducing Length of Stay in Reconstructive Head and Neck Surgery Patients: A Quality Improvement Initiative. Otolaryngol Head Neck Surg 2024. [PMID: 39118499 DOI: 10.1002/ohn.933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 06/14/2024] [Accepted: 06/24/2024] [Indexed: 08/10/2024]
Abstract
OBJECTIVE To investigate whether a new preoperative education and discharge planning protocol reduced unexpected discharge delays for patients undergoing reconstructive surgery for head and neck cancer. METHODS A quality improvement (QI) intervention was implemented in January 2021 with several components to address historically prolonged observed lengths of stay (LOS) with head and neck cancer patients. The intervention added a preoperative educational visit with a head and neck cancer advanced practice provider, a standardized preoperative speech and swallow assessment, a personalized patient care plan document, discussion of inpatient hospital stay expectations, and early discharge planning. The intervention group included patients who underwent the preoperative education protocol from February to December 2021. For comparison, an age and sex-matched control group was constructed from inpatients who had been admitted for similar procedures in the 2 years prior to the QI intervention (2019-2020) and received standard of care counseling. RESULTS Our study demonstrated a significant reduction in observed to expected LOS ratio after implementation of the intervention (1.24 ± 0.74 control, 0.95 ± 0.52 intervention; P = .012). DISCUSSION We discuss a preoperative education QI intervention at our institution. Our findings demonstrate that our intervention was associated with decreased LOS for patients undergoing head and neck reconstructive surgeries. IMPLICATIONS FOR PRACTICE This QI study shows the benefit of a new standardized preoperative education and discharge planning protocol for patients undergoing head and neck reconstructive surgeries.
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Affiliation(s)
- Nupur Bhatt
- Department of Otolaryngology-Head and Neck Surgery, NYU Langone Health, New York City, New York, USA
| | - Jackie Yang
- Department of Otolaryngology-Head and Neck Surgery, NYU Langone Health, New York City, New York, USA
| | - Lauren DeBaere
- Department of Otolaryngology-Head and Neck Surgery, NYU Langone Health, New York City, New York, USA
| | - Ronald Shen Wang
- New York University Grossman School of Medicine, New York City, New York, USA
| | - Allison Most
- Department of Otolaryngology-Head and Neck Surgery, NYU Langone Health, New York City, New York, USA
| | - Yan Zhang
- Department of Population Health, NYU Langone Health, New York City, New York, USA
| | - Elan Dayanov
- Department of Population Health, NYU Langone Health, New York City, New York, USA
| | - Wenqing Yang
- Department of Population Health, NYU Langone Health, New York City, New York, USA
| | | | - Maria Kamberi
- Department of Otolaryngology-Head and Neck Surgery, NYU Langone Health, New York City, New York, USA
| | - Jacqueline Mojica
- Department of Otolaryngology-Head and Neck Surgery, NYU Langone Health, New York City, New York, USA
| | - Emily Kamen
- Department of Otolaryngology-Head and Neck Surgery, NYU Langone Health, New York City, New York, USA
| | - Justin Savitski
- Department of Otolaryngology-Head and Neck Surgery, NYU Langone Health, New York City, New York, USA
| | - John Stein
- Department of Otolaryngology-Head and Neck Surgery, NYU Langone Health, New York City, New York, USA
| | - Adam Jacobson
- Department of Otolaryngology-Head and Neck Surgery, NYU Langone Health, New York City, New York, USA
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Patel S, Ninave S, Sagar S. Optimizing Anesthesia for Extensive Extraoral Fungating Lesions: Strategies and Considerations. Cureus 2024; 16:e62221. [PMID: 39006733 PMCID: PMC11244721 DOI: 10.7759/cureus.62221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Accepted: 06/11/2024] [Indexed: 07/16/2024] Open
Abstract
A large extraoral fungus, frequently seen in late head and neck cancers, poses serious difficulties for the management of anesthesia and surgery. Essential factors include preoperative optimization, airway assessment, intraoperative monitoring, and postoperative care. Risk mitigation and outcome optimization strategies are discussed, including appropriate airway management and hemodynamic monitoring. Ideal patient outcomes in situations of extensive extraoral fungation can be attained by a complete plan that integrates surgical expertise and anesthetic care. This case discusses the successful anesthetic management of a 55-year-old man undergoing composite resection with segmental mandibulectomy, appropriate neck dissection, free fibular flap, and scalp flap for squamous cell carcinoma of the lower labial mucosa with significant extraoral fungation.
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Affiliation(s)
- Samarpan Patel
- Anesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Sanjot Ninave
- Anesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Shakti Sagar
- Pathology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
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Breda D, Martins S, Millán A, Bitoque S, Zagalo C, Gomes P. Is There an Over-Indication for Elective Tracheostomy in Patients With Oral Cavity Cancer? Cureus 2024; 16:e52544. [PMID: 38371034 PMCID: PMC10874489 DOI: 10.7759/cureus.52544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2024] [Indexed: 02/20/2024] Open
Abstract
OBJECTIVES Temporary tracheostomies (TT) are often used in oral oncologic surgery to secure the postoperative airway. Our primary objective was to determine if there was an over-indication for elective tracheostomy in our population. If so, our secondary objective was to ascertain which patients could have possibly avoided TT. MATERIALS AND METHODS We performed a retrospective study of patients with oral and oropharyngeal squamous cell carcinoma in which resection with curative intent and TT were performed. Variables collected included demographics, comorbidities, and complications. Additionally, we retrospectively applied the Cameron and TRACHY tracheostomy scoring systems to evaluate overall tracheostomy recommendations. RESULTS A total of 116 elective tracheostomies were performed between January 2019 and December 2020. According to the Cameron and TRACHY scoring systems, recommendations for tracheostomy coincided in only 54.3% and 45.7%, respectively. Tumor anatomy and type of reconstruction were associated with less time until decannulation. Additionally, in patients without TT recommendation determined by both scores with tumor anatomy and location, as well as T and N stages were also associated with less time until decannulation. CONCLUSION There appears to be an over-indication for elective tracheostomy in our patients with oral cavity and oropharyngeal cancer. The patients that could have potentially avoided elective TT were those with lateral anatomy, without flap or with fasciocutaneous flap, location in the mandibular alveolus or anterior tongue, as well as N0/N1 and T1/T2 patients.
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Affiliation(s)
- Diana Breda
- Department of Maxillofacial Surgery, Centro Hospitalar e Universitário de Coimbra, Coimbra, PRT
| | - Sara Martins
- Department of Maxillofacial Surgery, Centro Hospitalar e Universitário do São João, Porto, PRT
| | - Ana Millán
- Department of Head and Neck Surgery, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisboa, PRT
| | - Sandra Bitoque
- Department of Head and Neck Surgery, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisboa, PRT
| | - Carlos Zagalo
- Department of Head and Neck Surgery, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisboa, PRT
| | - Pedro Gomes
- Department of Head and Neck Surgery, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisboa, PRT
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Sakkas A, Weiß C, Zink W, Rodriguez CA, Scheurer M, Pietzka S, Wilde F, Thiele OC, Mischkowski RA, Ebeling M. Airway Management of Orofacial Infections Originating in the Mandible. J Pers Med 2023; 13:950. [PMID: 37373939 DOI: 10.3390/jpm13060950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 05/31/2023] [Accepted: 06/02/2023] [Indexed: 06/29/2023] Open
Abstract
The primary aim of this study was to assess the incidence of a difficult airway and emergency tracheostomy in patients with orofacial infections originating in the mandible, and a secondary aim was to determine the potential predictors of difficult intubation. This retrospective single-center study included all patients who were referred between 2015 and 2022 with an orofacial infection originating in the mandible and who were surgically drained under intubation anesthesia. The incidence of a difficult airway regarding ventilation, laryngoscopy, and intubation was analyzed descriptively. Associations between potential influencing factors and difficult intubation were examined via multivariable analysis. A total of 361 patients (mean age: 47.7 years) were included in the analysis. A difficult airway was present in 121/361 (33.5%) patients. Difficult intubation was most common in patients with infections of the massetericomandibular space (42.6%), followed by infections of the mouth floor (40%) and pterygomandibular space (23.5%). Dyspnea and stridor were not associated with the localization of infection (p = 0.6486/p = 0.4418). Multivariable analysis revealed increased age, restricted mouth opening, higher Mallampati scores, and higher Cormack-Lehane classification grades as significant predictors of difficult intubation. Higher BMI, dysphagia, dyspnea, stridor and a non-palpable mandibular rim did not influence the airway management. Patients with a difficult airway were more likely to be admitted to the ICU after surgery than patients with regular airway were (p = 0.0001). To conclude, the incidence of a difficult airway was high in patients with orofacial infections originating in the mandible. Older age, limited mouth opening, a higher Mallampati score, and a higher Cormack-Lehane grade were reliable predictors of difficult intubation.
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Affiliation(s)
- Andreas Sakkas
- Department of Cranio-Maxillo-Facial-Surgery, University Hospital Ulm, 89081 Ulm, Germany
- Department of Cranio-Maxillo-Facial-Surgery, German Armed Forces Hospital Ulm, 89081 Ulm, Germany
| | - Christel Weiß
- Medical Statistics and Biomathematics, Mannheim Medical Faculty of the Heidelberg University, 68167 Mannheim, Germany
| | - Wolfgang Zink
- Department of Anesthesiology and Intensive Care Medicine, Ludwigshafen Hospital, 67063 Ludwigshafen, Germany
| | | | - Mario Scheurer
- Department of Cranio-Maxillo-Facial-Surgery, German Armed Forces Hospital Ulm, 89081 Ulm, Germany
| | - Sebastian Pietzka
- Department of Cranio-Maxillo-Facial-Surgery, University Hospital Ulm, 89081 Ulm, Germany
- Department of Cranio-Maxillo-Facial-Surgery, German Armed Forces Hospital Ulm, 89081 Ulm, Germany
| | - Frank Wilde
- Department of Cranio-Maxillo-Facial-Surgery, University Hospital Ulm, 89081 Ulm, Germany
- Department of Cranio-Maxillo-Facial-Surgery, German Armed Forces Hospital Ulm, 89081 Ulm, Germany
| | - Oliver Christian Thiele
- Department of Cranio-Maxillo-Facial-Surgery, Ludwigshafen Hospital, 67063 Ludwigshafen, Germany
| | | | - Marcel Ebeling
- Department of Cranio-Maxillo-Facial-Surgery, German Armed Forces Hospital Ulm, 89081 Ulm, Germany
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Dash S, Bhalerao N, Gaurkar A, P S, Chandak A. Anaesthetic Challenges in a Case of Oral Carcinoma With Anticipated Difficult Airway Posted for Tumour Excision and Reconstruction Surgery. Cureus 2023; 15:e34599. [PMID: 36883095 PMCID: PMC9985923 DOI: 10.7759/cureus.34599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 02/03/2023] [Indexed: 02/05/2023] Open
Abstract
Mandibular surgery, edentulous jaw, denture wear, and ageing are all risk factors for persistent mandibular ridge resorption and weakening. The tongue occludes the upper airway due to the mandible's edentulous condition. All of these factors contribute to the difficulties in regulating the airway. An adequate preoperative review assisted in classifying this index patient as having a high risk of difficult airway management, and appropriate actions were made to facilitate effective airway care. A 60-year-old male presented to casualty with a complaint of squamous cell carcinoma of the right buccal mucosa and was posted for wide local excision of the tumour, segmental mandibulectomy, bilateral modified radical neck dissection, and reconstruction with a fibular free flap. He had a restricted mouth opening and a heavy jaw, with Mallampati grade 4 and had an anticipated difficult airway. Hence, awake endotracheal intubation was done by flexible fibreoptic bronchoscope following airway blocks and an 8.0 mm cuffed flexometallic armoured tube was secured at 28 cm at the angle of the nose. Bilateral modified radical neck dissection and wide local excision of the tumour were done followed by mandibulectomy and its reconstruction by fibular free flap and anastomosis was performed. Tracheostomy was performed and the patient was shifted to the intensive care unit and kept knocked out with injection vecuronium and injection midazolam infusion. The patient was gradually weaned off the ventilator the following day and discharged on postoperative day 12 with minimal postoperative complications. A thorough pre-anaesthetic plan, simple and skilled anaesthetic management strategy, and well-organized teamwork aided in the effective anaesthetic care of this challenging airway patient.
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Affiliation(s)
- Sambit Dash
- Department of Anesthesiology, Jawaharlal Nehru Medical College, Acharya Vinoba Bhave Rural Hospital, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Nikhil Bhalerao
- Department of Anesthesiology, Jawaharlal Nehru Medical College, Acharya Vinoba Bhave Rural Hospital, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Aditi Gaurkar
- Department of Anesthesiology, Jawaharlal Nehru Medical College, Acharya Vinoba Bhave Rural Hospital, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Shiras P
- Department of Anesthesiology, Jawaharlal Nehru Medical College, Acharya Vinoba Bhave Rural Hospital, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Aruna Chandak
- Department of Anesthesiology, Jawaharlal Nehru Medical College, Acharya Vinoba Bhave Rural Hospital, Datta Meghe Institute of Higher Education & Research, Wardha, IND
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Ritschl LM, Niu M, Pippich K, Schuh P, Rommel N, Fichter AM, Wolff KD, Weitz J. Superficial Temporal Artery and Vein as Alternative Recipient Vessels for Intraoral Reconstruction With Free Flaps to Avoid the Cervical Approach With the Resulting Need for Double Flap Transfer in Previously Treated Necks. Front Oncol 2022; 12:879086. [PMID: 35875163 PMCID: PMC9300821 DOI: 10.3389/fonc.2022.879086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 06/10/2022] [Indexed: 11/28/2022] Open
Abstract
Background Microvascular reconstruction remains challenging in previously operated and irradiated patients, especially when double flaps seem to be the only solution due to osteoradionecrosis. An alternative reconstructive option could be microvascular anastomosis to the temporal vessels to avoid the obligatory cervical incision. Methods and Materials All consecutive cases between January 2013 and 2020 that underwent either mandibular resection and reconstruction with a free fibula flap (FFF) and another soft tissue flap (group I) or pure intraoral resection and reconstruction with an FFF or radial forearm flap (RFF) with temporal microvascular anastomosis (group II) were included. Patients’ general information, indication and extent of surgery, time of ischemia, time of total surgery, and duration of hospital stay as well as incidence of complications were retrospectively recorded and analyzed. Results Seventeen (group I) and 11 (group II) cases were included. In group I, FFF was combined with RFF (n = 9), anterolateral thigh flap (ALT, n = 7), or latissimus dorsi flap (n = 1). Group II consisted of six FFFs and five RFFs. Operation time and hospitalization duration were significantly shorter in group II (p < 0.001 and p = 0.025), whereas ischemic time of FFF was significantly shorter in group I (p = 0.002). All patients in group I required a tracheostomy, while only four cases in group II did (p = 0.004). The complication rate regarding hematoma removal, revision of anastomosis, flap loss, delirium, sepsis, pleural effusion, pneumonia, and pulmonary artery embolism showed no significant differences between the two groups. Conclusions The superficial temporal vessels served as versatile recipient vessels for intraoral mandibular and soft tissue reconstruction and led to reduced operation time, hospitalization duration, and indication for a primary tracheostomy. Thus, this approach may help to avoid cervical incision for reconstruction in irradiated patients.
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Affiliation(s)
- Lucas M. Ritschl
- Department of Oral and Maxillofacial Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
- *Correspondence: Lucas M. Ritschl,
| | - Minli Niu
- Department of Oral and Maxillofacial Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Katharina Pippich
- Department of Oral and Maxillofacial Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Philia Schuh
- Department of Oral and Maxillofacial Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Niklas Rommel
- Department of Oral and Maxillofacial Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Andreas M. Fichter
- Department of Oral and Maxillofacial Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Klaus-Dietrich Wolff
- Department of Oral and Maxillofacial Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Jochen Weitz
- Department of Oral and Maxillofacial Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
- Department of Oral and Maxillofacial Surgery, Josefinum, Augsburg and Private Practice Oral and Maxillofacial Surgery im Pferseepark, Augsburg, Germany
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Denholm KA, Steel BJ, Wilson A, Nugent M, Burns A. Factors Determining Post-Operative Length of Stay and Time to Resumption of Feeding Following Free Flap Reconstruction for Oral Cancer. Br J Oral Maxillofac Surg 2022; 60:1240-1245. [DOI: 10.1016/j.bjoms.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/17/2022] [Accepted: 07/11/2022] [Indexed: 11/16/2022]
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Gupta R, Gupta N, Kumar V, Garg R, Bharati SJ, Mishra S, Bhatnagar S. El-Ganzouri multivariate risk index based airway management in head and neck cancer patients: A retrospective analysis of 1000 patients in a tertiary care center. J Anaesthesiol Clin Pharmacol 2022; 38:97-103. [PMID: 35706626 PMCID: PMC9191799 DOI: 10.4103/joacp.joacp_176_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 05/02/2021] [Accepted: 05/19/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND AIMS Intubation in head and neck carcinoma (HNC) is difficult due to many reasons. Various guidelines recommend strategies for airway management in such anticipated difficult airway cases. However, literature is limited on airway management planning as per the level of difficulty based on airway assessment in these patients. EL-Ganzouri risk index (EGRI) has been proposed to aid in making airway management plan in HNC cases by some authors. This retrospective study was conducted to look at the data related to the pre-anesthetic airway assessment and the airway management plan executed by the anesthesiologists in 1000 patients of HNC in the previous nearly four years in order to determine how the choices made conformed to EGRI scores. MATERIAL AND METHODS Records of all the patients with oral cancer posted for surgery over four years from January 2014 to December 2017 were retrospectively analyzed for preoperative airway assessment using El Ganzouri risk index assessment (EGRI), the intraoperative technique for nasotracheal intubation, airway management plan, and any intraoperative complications. RESULTS The risk of predicted airway difficulty was low (EGRI <4) in 38 patients and was high in the rest. The EGRI score was higher in the FOB group [4-9] as compared to DL [2-3] and VL [1-6]. The patients with EGRI >7 were intubated awake and those with EGRI <7 were intubated under general anesthesia (79.8%). Overall, the technique of choice for intubation was fibreoptic bronchoscopy (54%) followed by video laryngoscopy (42.6%). CONCLUSION The airway management plan used in a tertiary care cancer center conformed to the approach suggested by the multivariate El Ganzouri risk index (EGRI). EGRI appears to be a useful means to ascertain the appropriate strategies for intubation in head and neck cancer patients.
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Affiliation(s)
- Raghav Gupta
- Department of Oncoanaesthesia and Palliative Medicine, Dr. BRAIRCH, AIIMS, New Delhi, India
| | - Nishkarsh Gupta
- Department of Oncoanaesthesia and Palliative Medicine, Dr. BRAIRCH, AIIMS, New Delhi, India
- Address for correspondence: Dr. Nishkarsh Gupta, Room no 139, First Floor, Department of Oncoanaesthesia and Palliative Medicine, Dr. BRAIRCH, AIIMS, New Delhi, India. E-mail:
| | - Vinod Kumar
- Department of Oncoanaesthesia and Palliative Medicine, Dr. BRAIRCH, AIIMS, New Delhi, India
| | - Rakesh Garg
- Department of Oncoanaesthesia and Palliative Medicine, Dr. BRAIRCH, AIIMS, New Delhi, India
| | - Sachidanand J. Bharati
- Department of Oncoanaesthesia and Palliative Medicine, Dr. BRAIRCH, AIIMS, New Delhi, India
| | - Seema Mishra
- Department of Oncoanaesthesia and Palliative Medicine, Dr. BRAIRCH, AIIMS, New Delhi, India
| | - Sushma Bhatnagar
- Department of Oncoanaesthesia and Palliative Medicine, Dr. BRAIRCH, AIIMS, New Delhi, India
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Abe A, Ito Y, Hayashi H, Furuta H, Ishihama T, Adachi M. The degree of agreement between score-based decision and clinician's discretion regarding the need for tracheotomy in oral cancer surgery: A retrospective analysis. Medicine (Baltimore) 2021; 100:e26712. [PMID: 34397703 PMCID: PMC8322477 DOI: 10.1097/md.0000000000026712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 06/24/2021] [Indexed: 01/04/2023] Open
Abstract
In oral cancer surgery, the decision to perform a tracheotomy is often determined by the surgeon. In this study, we investigated the competency of clinical scoring systems in identifying patients who require tracheotomy and examined the degree of agreement between the surgeon's decision and the indications of various scoring systems. We identified 110 patients who were surgically treated for oral cancer. Of these, 67 patients (44 men and 23 women) who underwent resection and reconstruction were retrospectively analyzed. To derive the score, we evaluated the endpoint of the airway management score using clinical records and images. We divided the patients into two groups based on the Cameron and Gupta scores (tracheotomy and no-tracheotomy groups) and evaluated the degree of agreement with the surgeon's decision by calculating the κ coefficient. The κ coefficients of the Gupta and Cameron scores were 0.61 (95% confidence interval [CI]: 0.40-0.82) and 0.60 (95% CI: 0.38-0.82), respectively. The clinical evaluation of the κ coefficient indicated that the Cameron and Gupta scores agreed fairly with the surgeon's decision. In this study, the Cameron and Gupta scores fairly agreed with the decision of experienced surgeons and were confirmed as acceptable guides for making clinical judgments.
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Affiliation(s)
- Atsushi Abe
- Department of Oral and Maxillofacial Surgery, Nagoya Ekisaikai Hospital, Nagoya, Japan
| | - Yu Ito
- Department of Oral and Maxillofacial Surgery, Nagoya Ekisaikai Hospital, Nagoya, Japan
| | - Hiroki Hayashi
- Department of Oral and Maxillofacial Surgery, Nagoya Ekisaikai Hospital, Nagoya, Japan
| | - Hiroshi Furuta
- Department of Oral and Maxillofacial Surgery, Nagoya Ekisaikai Hospital, Nagoya, Japan
| | - Takanori Ishihama
- Department of Oral and Maxillofacial Surgery, Nagoya Ekisaikai Hospital, Nagoya, Japan
| | - Moriyasu Adachi
- Department of Oral and Maxillofacial Surgery, Shizuoka General Hospital, Shizuoka, Japan
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Abe A, Umemura E, Hayashi H, Ito Y, Adachi M. Evaluation of Scoring Systems for Airway Management After Oral Cancer Surgery: A Retrospective Study. Ann Otol Rhinol Laryngol 2021; 130:873-880. [PMID: 33403865 DOI: 10.1177/0003489420984353] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Postoperative airway obstruction following oral cancer surgery is difficult to predict. Scoring systems used to assess the need for tracheotomy use risk factors as criteria. We aimed to examine whether these clinical scoring systems can predict airway obstruction following oral cancer surgery. METHODS We assessed 95 patients who underwent oral cancer surgery without tracheotomy under general anesthesia between January 2007 and April 2019. We reviewed multiple factors from the patients' medical records, including age, sex, tumor site, body mass index, tumor stage, type of surgery, airway management method, Cameron and Gupta scores, and postoperative airway complications. RESULTS Tumors were located in the maxilla (n = 14), buccal mucosa (n = 13), mandible (n = 14), floor of the mouth (n = 6), and tongue (n = 48). Twenty-seven patients (28.4%) were graded as Stage 1, 37 patients (38.9%) as Stage 2, 9 patients (9.5%) as Stage 3, and 3 (3.2%) patients as Stage 4. Nine patients (9.5%) had local recurrences, and ten patients (10.5%) had neck metastases. Postoperative oxygen administration alone failed to improve dyspnea in 4 patients (4.2%). The median Cameron scores between patients with and without airway trouble were not significantly different (P = 0.226). However, a significant difference was observed in median Gupta scores between patients with and without airway trouble (P = 0.01). We created a receiver operating characteristic curve to predict postoperative airway trouble based on the preoperative Gupta score; the area under the curve was 0.856 (95% confidence interval: 0.61-1). A Gupta score cutoff value of 3.0 had a sensitivity of 92.3% and specificity of 75.0%. CONCLUSIONS Screening based on the Gupta score appears to be effective in predicting postoperative airway obstruction. We propose that this screening tool can be used to better plan tracheotomy and other airway management strategies during preoperative patient assessment.
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Affiliation(s)
- Atsushi Abe
- Department of Oral and Maxillofacial Surgery, Nagoya Ekisaikai Hospital, Nagoya, Japan
| | - Eri Umemura
- Department of Oral and Maxillofacial Surgery, Nagoya Saisyukan Hospital, Kita Nagoya, Japan
| | - Hiroki Hayashi
- Department of Oral and Maxillofacial Surgery, Nagoya Ekisaikai Hospital, Nagoya, Japan
| | - Yu Ito
- Department of Oral and Maxillofacial Surgery, Nagoya Ekisaikai Hospital, Nagoya, Japan
| | - Moriyasu Adachi
- Department of Oral and Maxillofacial Surgery, Shizuoka General Hospital, Shizuoka, Japan
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11
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Goetz C, Burian NM, Weitz J, Wolff KD, Bissinger O. Temporary tracheotomy in microvascular reconstruction in maxillofacial surgery: Benefit or threat? J Craniomaxillofac Surg 2019; 47:642-646. [DOI: 10.1016/j.jcms.2019.01.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 01/11/2019] [Indexed: 01/18/2023] Open
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Badr H, Sobrero M, Chen J, Kotz T, Genden E, Sikora AG, Miles B. Associations between pre-, post-, and peri-operative variables and health resource use following surgery for head and neck cancer. Oral Oncol 2019; 90:102-108. [PMID: 30846167 DOI: 10.1016/j.oraloncology.2019.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 01/31/2019] [Accepted: 02/04/2019] [Indexed: 01/01/2023]
Abstract
OBJECTIVE We examined associations between pre-, post-, and peri-operative variables and health resource use in head and neck cancer patients. METHODS Patients (N = 183) who were seen for a pre-surgical consult between January 2012 and December 2014 completed surveys that assessed medical history, a patient-reported outcome measure (PROM) of dysphagia, and quality of life (QOL). After surgery, peri-operative (e.g., tracheostomy, feeding tube) and post-operative (e.g., complications) variables were abstracted from patients' medical records. RESULTS Multivariate regression models using backward elimination showed that pre-surgical University of Washington Quality of Life (UW-QOL) Inventory and M.D. Anderson Dysphagia Inventory (MDADI) composite scores, documented surgical complications, and having a tracheostomy, were all significant predictors of hospital length of stay, explaining 57% of the total variance (F(5, 160) = 18.71, p < .001). Male gender, psychiatric history, and lower pre-surgical MDADI scores significantly predicted thirty-day unplanned readmissions (30dUR). Pre-surgical MDADI composite scores also significantly predicted emergencey department (ED) visits within 30 days of initial hospital discharge (p = .02). CONCLUSIONS Assessment of PROMs and QOL in the pre-surgical setting may assist providers in identifying patients at risk for prolonged LOS and increased health resource use after hospital discharge.
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Affiliation(s)
- Hoda Badr
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, TX, USA.
| | | | - Joshua Chen
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, TX, USA; Department of Psychology, University of St Thomas, Houston, TX, USA
| | - Tamar Kotz
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Eric Genden
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Andrew G Sikora
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Brett Miles
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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13
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Dong PV, ter Horst L, Krage R. Emergency percutaneous transtracheal jet ventilation in a hypoxic cardiopulmonary resuscitation setting: a life-saving rescue technique. BMJ Case Rep 2018; 2018:bcr-2017-222283. [DOI: 10.1136/bcr-2017-222283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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14
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Eskander A, Kang SY, Tweel B, Sitapara J, Old M, Ozer E, Agrawal A, Carrau R, Rocco J, Teknos TN. Quality Indicators: Measurement and Predictors in Head and Neck Cancer Free Flap Patients. Otolaryngol Head Neck Surg 2018; 158:265-272. [DOI: 10.1177/0194599817742373] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Objective To determine the predictors of length of stay (LOS), readmission within 30 days, and unplanned return to the operating room (OR) within 30 days in head and neck free flap patients. Study Design Case series with chart review. Setting Tertiary academic cancer hospital. Subjects and Methods All head and neck free flap patients at The Ohio State University (OSU, 2006-2012) were assessed. Multivariable logistic regression to assess the impact of patient factors, flap and wound factors, and intraoperative factors on the aforementioned quality metric outcomes. Results In total, 515 patients were identified, of whom 66% had oral cavity cancers, 33% had recurrent tumors, and 28% underwent primary radiotherapy. Of the patients, 31.5% had a LOS greater than 9 days, predicted by longer operative time, oral cavity and pharyngeal tumor sites, blood transfusion, diabetes mellitus, and any complication. A total of 12.6% of patients were readmitted within 30 days predicted by absent OSU preoperative assessment clinic attendance and any complication, and 14.8% of patients had an unplanned OR return predicted by advanced age. Conclusions When assessing quality metrics, adjustment for the complexity involved in managing patients with head and neck cancer with a high comorbidity index, clean contaminated wounds, and a high degree of primary radiotherapy is important. Patients seen in a preoperative assessment clinic had a lower risk of readmission postoperatively, and this should be recommended for all head and neck free flap patients. Quality improvement projects should focus on predictors and prevention of complications as this was the number one predictor of both increased length of stay and readmission.
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Affiliation(s)
- Antoine Eskander
- Department of Otolaryngology–Head & Neck Surgery, Division of Head & Neck Oncology, University of Toronto, Sunnybrook Health Sciences Centre and Michael Garron Hospital, Toronto, Ontario, Canada
| | - Stephen Y. Kang
- Department of Otolaryngology–Head & Neck Surgery, Division of Head & Neck Oncology, Ohio State University, James Cancer Centre and Solove Research Institute, Columbus, Ohio, USA
| | - Benjamin Tweel
- Department of Otolaryngology–Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jigar Sitapara
- Department of Otolaryngology–Head & Neck Surgery, Division of Head & Neck Oncology, Ohio State University, James Cancer Centre and Solove Research Institute, Columbus, Ohio, USA
| | - Matthew Old
- Department of Otolaryngology–Head & Neck Surgery, Division of Head & Neck Oncology, Ohio State University, James Cancer Centre and Solove Research Institute, Columbus, Ohio, USA
| | - Enver Ozer
- Department of Otolaryngology–Head & Neck Surgery, Division of Head & Neck Oncology, Ohio State University, James Cancer Centre and Solove Research Institute, Columbus, Ohio, USA
| | - Amit Agrawal
- Department of Otolaryngology–Head & Neck Surgery, Division of Head & Neck Oncology, Ohio State University, James Cancer Centre and Solove Research Institute, Columbus, Ohio, USA
| | - Ricardo Carrau
- Department of Otolaryngology–Head & Neck Surgery, Division of Head & Neck Oncology, Ohio State University, James Cancer Centre and Solove Research Institute, Columbus, Ohio, USA
| | - James Rocco
- Department of Otolaryngology–Head & Neck Surgery, Division of Head & Neck Oncology, Ohio State University, James Cancer Centre and Solove Research Institute, Columbus, Ohio, USA
| | - Theodoros N. Teknos
- Department of Otolaryngology–Head & Neck Surgery, Division of Head & Neck Oncology, Ohio State University, James Cancer Centre and Solove Research Institute, Columbus, Ohio, USA
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15
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Nikhar SA, Sharma A, Ramdaspally M, Gopinath R. Airway Management of Patients Undergoing Oral Cancer Surgery: A Retrospective Analysis of 156 Patients. Turk J Anaesthesiol Reanim 2017; 45:108-111. [PMID: 28439444 DOI: 10.5152/tjar.2017.67365] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 01/02/2017] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Oral cancer patients have a potentially difficult airway, but if managed properly during the perioperative period, morbidity and mortality can be reduced or avoided. METHODS The medical records of 156 patients who were operated for oral cancers were reviewed for airway management during the perioperative period. RESULTS The surgical procedures ranged from excisions, wide local excisions with split skin graftings, hemiglossectomies and radical neck nodes dissections to pectoralis major myocutaneous or free fibular flaps. Intubation was assessed as difficult in 14.7% of patients because of tumour- or radiation fibrosis-related trismus, restricted neck mobility and prior similar surgeries. Twenty patients had undergone surgery for oral cancer previously and were scheduled for flap reconstruction. Nasotracheal intubation was a preferred route, and 62.8% of patients could be intubated nasotracheally after neuromuscular blockade. Tracheostomy (elective or existing) was utilised for airway control in 19.2% cases. Patients who had undergone prior radiotherapy were more likely to be tracheostomised. McCoy laryngoscopes (13.4%), gum elastic bougies (23.6%), Airtraq devices (0.006%) and fibreoptic bronchoscopes (FOBs) (0.03%) were the additional airway techniques employed. In total, 64 patients (50.7%) could be extubated immediately after surgery. CONCLUSION Proper preoperative evaluation and planning help manage difficult airways effectively with minimal need of advanced airway gadgets. Gum elastic bougies and Magill forceps are very useful in airway management and decrease the need of elective tracheostomy in oral cancer patients.
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Affiliation(s)
- Sapna Annaji Nikhar
- Department of Anaesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Ashima Sharma
- Department of Anaesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Mahesh Ramdaspally
- Department of Anaesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Ramachandran Gopinath
- Department of Anaesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, India
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