Without elective tracheostomy, 1 in 10 head and neck reconstructions had an airway event

Design

Systematic review and meta-analysis of observational studies

Population

5,987 patients having head and neck cancer reconstruction

Primary outcome

Adverse airway events without elective tracheostomy; outcomes with tracheostomy

Effect

AAE 10.3% (6.7-15.6%); floor of mouth OR 5.96; bilateral neck dissection OR 6.36

A systematic review and meta-analysis of 25 studies (5,987 patients) examined adverse airway events in head and neck cancer reconstruction managed without elective tracheostomy, and the harms of tracheostomy itself.

The pooled airway event rate without tracheostomy was 10.3% (95% CI 6.7-15.6%). Floor-of-mouth tumours (OR 5.96), oropharyngeal tumours (OR 2.60), bilateral neck dissection (OR 6.36) and higher ASA class (OR 1.51) raised the odds. Elective tracheostomy was associated with more flap complications (OR 2.15), more unplanned returns to theatre (OR 1.73) and oral feeding about 5.9 days later.

Blanket tracheostomy protects some airways at the cost of harm to many patients who did not need it. These predictors allow a selective policy.

The data are observational, and patients chosen for tracheostomy were likely higher risk, which could exaggerate its apparent harms.

• Plan the airway preoperatively with anaesthesia using tumour subsite and neck dissection extent.
• Favour tracheostomy for floor-of-mouth resection with bilateral neck dissection.
• For lower-risk patients without tracheostomy, plan delayed extubation in a monitored setting.
• Record the rationale so outcomes can be audited.

Why it matters

It gives surgeons named risk factors to replace routine tracheostomy with a selective, audited policy.

Don't overread it

The harms of tracheostomy come from observational comparisons, where sicker patients were more likely to receive one.

The statistics, in plain English

Odds ratios near 6 for floor-of-mouth tumours and bilateral neck dissection are large, but they come from pooled observational data with varying definitions of an airway event.

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