Limited dissection and early primary closure of the tracheostomy stoma in head and neck oncology operations: a retrospective study of 158 cases

Abstract

Tracheostomy is an efficient and widely used method to secure a patent airway in patients undergoing major oral and maxillofacial oncology operations. The inferiorly based Björk flap technique, through a limited incision, followed by early primary skin closure, has been the preferred method in our unit. Patients who underwent tracheostomy for major oral and maxillofacial oncology operations during the period June 2005 to December 2012 were reviewed. Age, gender, preoperative diagnosis, duration the tracheostomy tube was in situ , tracheostomy-associated complications, and long-term sequelae were evaluated. A total 158 tracheostomies were performed using the same surgical approach in patients aged 18–84 years (median 59, mean 58.2, standard deviation 14.24 years). The time the tracheostomy tube was in situ ranged from 3 to 40 days (median 7, mean 9.0, standard deviation 6.52 days). The complication rate was 5.06% (8/158 patients). A major concern highlighted in previous publications is the risk of surgical emphysema with early closure. In this study, no patients developed surgical emphysema, tracheal fistula, clinical tracheal stenosis, or cosmetically unacceptable scarring of the neck. No patient died of a tracheostomy-related cause. In summary, the Björk flap with early primary closure of the skin by simple sutures provides a safe and easily managed approach, causing minimal postoperative morbidity.

Essential in all major oral and maxillofacial oncology operations is a patent airway both intra- and postoperatively. A surgical airway (tracheostomy) is a common surgical procedure, which may be performed using various surgical techniques. Tracheostomy treatment has been used in oral and maxillofacial oncology surgery for a long time, and is considered to be a procedure with a relatively low frequency of adverse events. However, due to the risk of adverse events, such as surgical emphysema, tracheal stenosis, tracheostomy obstruction, bleeding, pneumothorax, and even death, there are those advocating that tracheostomy treatment should only be used in a few selected cases.

In this study, a Björk (inferiorly based) tracheal flap, as first described in 1960, was used in all cases. Tracheostomies were performed through a 2-cm horizontal skin incision using a modified limited vertical dissection with early primary closure of the cutaneous tracheostomy opening after removal of the tracheostomy, with no downsizing. The aim of this study was to review the short- and long-term complications, including the incidence of surgical emphysema and the cosmetic outcome of the skin incision, for elective tracheostomies used for supportive airway management in major oral and maxillofacial oncology operations, performed in the unit. A detailed description of the surgical technique is presented.

Materials and surgical technique

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.

Results

During the period of the study (91 months), elective tracheostomies were performed on 158 patients who underwent major oral and maxillofacial oncology surgery. Patients ranged in age from 18 to 84 years (median 59, mean 58.2, standard deviation 14.24 years) ( Fig. 1 ); 107 were males and 51 were females. The indication in all patients was to secure a patent airway intra- and postoperatively for major head and neck oncology surgery. The duration that the tracheostomy tube was left in situ ranged from 3 to 40 days (median 7, mean 9.0, standard deviation 6.52 days), with removal for the majority at days 5–7 ( Fig. 2 ).

Fig. 1
Age when treated with a tracheostomy.

Fig. 2
Number of days the tracheostomy tube was in situ .

Complications associated with the tracheostomy treatment occurred in eight of the 158 patients, resulting in a complication rate of 5.06% ( Table 1 ). All complications were minor in character. Patients were assessed daily from all aspects including a respiratory point of view. A chest X-ray was taken if any respiratory symptoms were noted. After decannulation and discharge from hospital, all patients were followed-up as outpatients and aesthetic outcome complications of the tracheostomy site were assessed.

Table 1
Complications associated with tracheostomies.
Patient Age, years Gender Days tubes in situ Complication
1 63 M 4 Desaturation due to mucous plug. Airway suctioned.
2 65 F 14 Fistula. Managed with occlusive dressing.
3 62 M 26 Desaturation on decannulation. New tube inserted.
4 59 M 8 Minor bleeding from site. Managed on the ward.
5 52 M 32 Patient pulled balloon from tube. New tube inserted.
6 82 F 6 Minor bleeding from site. Managed on the ward.
7 68 M 14 Minor bleeding from site. Managed on the ward.
8 66 M 13 Aspiration pneumonia. Resolved with antibiotics.
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Jan 17, 2018 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Limited dissection and early primary closure of the tracheostomy stoma in head and neck oncology operations: a retrospective study of 158 cases
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