Materials

Patient data from consecutive subjects who required an elective tracheostomy for major oral and maxillofacial oncology surgery at our unit, were collected during the period 1 June 2005 to 31 December 2012 (91 months). A dedicated tracheostomy nurse supports all patients with a tracheostomy for the head and neck teams in the hospital. The nurse collects all patient information with regards to their tracheostomy and enters this into a database. Patient age, gender, indications, operative details, time the tracheostomy tube was in situ , and complications associated with the tracheostomy treatment were analyzed. The statistical analysis was performed using GraphPad Prism version 5.0a software (GraphPad Software Inc., San Diego, CA, USA).

Surgical technique

Tracheostomies were performed under general anaesthesia at the beginning of each oncology operation. A 2-cm horizontal midline incision equidistant to the suprasternal notch and the hyoid bone (level of the lower border of the cricoid cartilage) was made to gain access. The skin incision was kept to the minimum (2 cm). A vertical incision through the cervical fascia and deep fascia to the infrahyoid muscles was made. The infrahyoid muscles, i.e., the strap muscles, were separated in the midline vertically by blunt dissection with scissors to the pretracheal fascia. This dissection was kept to the anterior of the trachea to ensure the neck dissection could be performed without breaching the fascial support of the tracheostomy.

The cricoid was identified and a transverse incision made, just below the cricoid, to release the pretracheal fascia and allow blunt exposure of tracheal rings 1–4. When encountered, the thyroid isthmus was mobilized off the trachea and gently retracted downwards. In no case was the thyroid isthmus divided. Subsequently an inverted U-shaped incision with an inferior base was made through tracheal rings 3 and 4. The flap was secured with a 3-0 Vicryl suture, placed between the third and fourth tracheal ring, and attached to the inferior deep cervical fascial edge. A tracheostomy tube (Shiley size 6 (female) or size 8 (male); Covidien plc, Dublin, Ireland) was then inserted into the trachea as the anaesthetist slowly withdrew the endotracheal tube. The low-pressure tracheal cuff was inflated immediately after insertion of the tube. The tracheostomy tube used was a fenestrated outside tube with an inner non-fenestrated tube to allow ventilation and prevent aspiration. The tracheostomy tube was then coupled to the anaesthetic equipment, CO ₂ return confirmed, and held in place, while the tracheostomy wings were secured with four 2-0 silk sutures to the skin. Postoperatively, when safe (usually at 24–48 h), the cuff was deflated and when tolerated by the patient, the inner tube was converted to a fenestrated tube, enabling the patient to speak. When the airway was safe, usually at days 5–7, local anaesthetic was given (2% lidocaine with 1:80,000 adrenaline), the tracheostomy tube was removed, a 3-0 Vicryl suture was placed to hold the soft tissues gently together, and the skin closed using three or four simple Ethilon 5-0 sutures to the skin. An antibiotic ointment was applied to the area. If for some reason the patient could not be decannulated at days 5–7, the tracheostomy was downsized to the next size Shiley (in men from a size 8 to a 6, and in women from a size 6 to a 4) and when removed the closure was done as above.