Whether to perform elective tracheostomy after head and neck cancer reconstruction is among the more consequential perioperative decisions in this specialty, and it has been made largely on individual judgement. This meta-analysis of 25 studies and 5,987 patients quantified both sides of it.
In patients managed without elective tracheostomy, adverse airway events occurred in 10.3% (95% CI 6.7-15.6). Risk was concentrated: floor-of-mouth tumours carried an odds ratio of 5.96 against other oral cavity subsites, oropharyngeal tumours 2.60, bilateral neck dissection 6.36 and higher ASA class 1.51. But tracheostomy carried its own cost — flap complications (odds ratio 2.15), unplanned return to theatre (1.73) and 5.86 days longer to oral feeding.
The analysis therefore supports selectivity rather than a policy in either direction, which is a more useful conclusion than it sounds. A patient with a floor-of-mouth tumour undergoing bilateral neck dissection has multiplicative risk factors and is the patient for whom the airway risk plausibly outweighs the tracheostomy morbidity. A patient with neither is one in whom a routine tracheostomy is likely to cause more harm than it prevents. Converting these odds ratios into a documented preoperative airway plan is the practical step.
- Adverse airway events in 10.3% managed without elective tracheostomy
- Floor-of-mouth (OR 5.96) and bilateral neck dissection (OR 6.36) predict events
- Tracheostomy: more flap complications, more returns to theatre, later oral feeding
- Use the predictors to make a documented, selective airway plan
The statistics, in plain English
These odds ratios come from pooled observational data, so they describe association rather than causation — surgeons already choose tracheostomy for patients they judge higher risk, which means the tracheostomy harms may partly reflect that those patients were sicker to begin with. The airway-event predictors are less vulnerable to this, because they describe patients who did not receive a tracheostomy. Note also the wide interval on the 10.3% incidence, 6.7% to 15.6%, reflecting genuine variation between centres.
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