A tracheostomy is the most secure method to prevent an airway obstruction after the surgical treatment of head and neck cancer. A national survey in UK showed 69 % of clinical units (39/57) electively performed a tracheostomy ‘usually’ or ‘almost always’ after free flap head and neck reconstructive surgery [7]. A postoperative compromised airway is very difficult to manage. If there are some emergency situations, emergency intubation is difficult due to edema and bleeding in the oral cavity and neck. Usually in that situation, the patient is not under sedation or there is not enough time for sedation or to bring the patient to an operation room. Even a tracheostomy is difficult in these emergency situations. It is generally known that complications are more frequent in tracheostomies performed under emergency conditions [8]. If a patient has a possibility of compromised airway postoperatively, elective tracheostomy can be considered as a secure choice of treatment.
However, tracheostomy is also a traumatic procedure to the patients, which needs careful postoperative management. Tracheostomy-related complications are common and sometimes are life-threatening. Complications occurring from tracheostomy can be from 4.1 to 45 % [9–11]. Chest infections are common and those patients have a longer hospital stay [12]. The total hospital stay can be longer in patients because of the tracheostomy itself. Castling showed that patients with a tracheostomy-related complication had a mean total hospital stay of 25 days compared with 14 days for all patients [3]. Most tracheostomy related complications occur on the ward rather than in the ICU [13]. An increased length of hospital stay after tracheostomy is another factor to consider. The cost of the intensive care unit and the hospital stay can increase because of a tracheostomy. If complications occur, the cost will increase even more. In this study, the length of the hospital stay showed a significant positive correlation with the tracheostomy score. The extubated group had significantly shorter hospital stays compared with the other groups for hospital stay in this study. The tracheostomy scores include the aggressiveness of the operation such as reconstruction surgery and bilateral neck dissection as factors. The more aggressive the surgery was, the higher the tracheostomy scores were. The extubated group underwent relatively less aggressive surgery and had shorter hospital stays. The tracheostomy score can be used as a grading system for the severity of the oral cancer surgery for a clinical study.
Maintaining the intubation overnight after surgery can be one of the safe alternatives to a tracheostomy in oral cancer patients [14]. It can reduce the potential risk associated with a tracheostomy and result in a shorter recovery. However, the use of overnight intubation also has risks and needs careful postoperative management. The nurses (ICU or wards) should be experienced in the care of oral and maxillofacial surgery patients [15] because the nasotracheal tube can become obstructed easily from bleeding and mucous secretion and sometimes the patients have maxillomandibular fixation.
The period for maintaining endotracheal intubation is usually short (one or two days). If a longer period of intubation is expected, then a tracheostomy is recommended. Coyle reported that their 55 oral cancer patients were returned to the ICU being intubated without a tracheostomy and the intubation was maintained for the first postoperative night. Twenty-four patients (44 %) of the 55 patients had a score of 5 or more, which was considered to be the score at which an elective tracheostomy should be considered for the management of the airway. In this study, 8 patients (7.7 %) had a tracheostomy, and 22 patients (22/104, 21.2 %) had scores of more than 5 points. However many patients with high scores (17/22, 77.3 %) did not receive a tracheostomy. Five patients (5/8, 62.5 %) in the tracheostomy group had more than 5 points. The patient No. 6 had emergency problems during postoperative care. Other two patients (patients 7,8) had less than 5 points, but the operator considered the operation time and intraoperative bleeding and decided elective tracheostomy based on the clinical experience of the operator.
Cameron’s scoring system classified the factors that influence the decision for performing a tracheostomy in 4 key domains: tumor site, mandibulectomy, neck dissection, and reconstruction6). They used a threshold score of 5 from the data of 143 patients (grouped into extubated at the end of the operation, overnight ventilation via an endotracheal tube, and elective tracheostomy) using Receiver operation characteristic (ROC) curve analysis. However, the results of this report showed that the scores of the patients in our clinic were not much in agreement with their report. Only 5 patients (22.7 %) among the 22 patients with more than 5 points for a Cameron score had a tracheostomy. The airway management was possible by maintaining overnight the intubation in the other patients. The tracheostomy score for the patient who had the nasotracheal tube on the second postoperative day and underwent an emergency tracheostomy was 3. From the result of this study, if we perform the elective tracheostomy with Cameron’s scoring system, there is possibility that more patients need tracheostomy unnecessarily. The differences of the results in this study can be explained with the limitation of the scoring system. Tumor size and location are important factors. Tumor size was not considered as a main factor in the Cameron’s scoring system. Tumor location such as anterior or posterior, buccal or lingual is also considered important in postoperative airway obstruction. Usually posterior and lingual side cancers have more complicated postoperative airway management. However, the airways of patients with cancer on the anterior mandible can be compromised despite its anterior location. Detachment of the genioglossus muscle, geniohyoid muscle, and mylohyoid muscle can be an aggravating factor in anterior midline cases. Bilateral neck dissection is also considered as one of the main factors for making an operator consider elective tracheostomy.
Another scoring system was introduced by Kruse-Losler [16]. They used the following 5 parameters: tumor localization (anterior and posterior to second premolars), tumor size (T1-4), Chest X-ray (with or without pathologic findings), multi morbidity (No or Yes), and alcohol consumption (No, <100g/day, >100g/day, hard drinks). An elective tracheostomy was recommended to a patient with more than 7 points. Their report showed that general medical condition and the level of alcohol consumption influenced significantly the decision for or against an elective tracheostomy. In this study, the Kruse-Losler’s scoring system could not be applied because the alcohol consumption data were not based on their criteria.
Predicting the postoperative airway state is difficult but it is one of the most important decisions for a safe and early recovery after oral cancer surgery. The airway was managed by maintaining the endotracheal intubation for 1 or 2 postoperative days in most cases in this study. Both Cameron’s score and Kruse’s score cannot be absolute guidelines in all cases. Using the scoring system was not sufficient to make a decision on whether to perform an elective tracheostomy after oral cancer surgery, but it can be helpful in predicting the severity of the airway obstruction after surgery.
The limitation of this study is that the decision whether to perform an elective tracheostomy or maintain the intubation in the patients of this study was not based on the scoring system, and only a retrospective study was done to review airway management according to the tracheostomy scoring system. Prospective studies are necessary to evaluate the predictive value of the scoring system.