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Complex head and neck cancer cases with reconstruction can be challenging due to the risk of loss of airway. Temporary tracheostomies are often used to protect the airway following complex oral and maxillofacial ablative surgery and reconstruction. However, while this is common and its use is widespread, tracheostomy itself can cause severe life-threatening complications, such as bleeding, loss of the airway with obstruction or displacement of the tube, surgical emphysema, pneumothorax, infection pulmonary complications, tracheal complications e.g. scarring and failure to decannulate. Studies that confirm patients with the tracheostomies have longer hospital stay and greater complications have been published in peer-reviewed journals. In order to avoid this, some units practice overnight intubation with sedation. This is a retrospective study from Germany that looks at their experience with tracheostomy and complications in 150 consecutive patients from March 2017 to August 2018; 150 patients that underwent surgery are included in the study. Patients underwent resection of oral cancer and reconstruction with appropriate free flap and neck dissection. All patients had an elective tracheostomy and free flap reconstruction, the commonest free flap was the radial forearm free flap with 92, 37 fibula flaps and 14 anterolateral thigh free flaps.

All patients spent the first night under sedation with a further 10.8% staying an extra day and 18 patients returned to the ICU, seven as a result of pneumonia, six with postoperative delirium, three with pulmonary embolism, one for sepsis, and one cardiac failure. Following a return to the ward 76% of patients were decannulated within the first six days, the total range 2-56 days. In seven cases (4.7%) a cannula had to be re-inserted for various reasons. The total length of hospitalisation range is from 8 to 72 days with a significant difference depending on what the complication linked to. Patients with complications linked to postoperative tracheostomy stayed much longer with the total complication rate recorded at 20%. The most common complication was pneumonia and the authors identified significant risk factors for this: chronic bronchitis, alcohol abuse, and an ASA grade 3. This is a good study that looks at tracheostomy associated complications and reminds the reader to assess the need for tracheostomies on an individual basis. Clearly, there are cases where it is not always necessary and can lead to longer hospitalisation with higher patient and financial costs.

The study suggests extra approaches for the reconstruction of the mandible with minimal intra-oral disruption or tumours of the palate and buccal regions with no encroachment of the airway, tracheostomy may not be necessary.
It is excellent in reminding the reader of the various complications that can occur in tracheostomies.

Temporary tracheotomy in microvascular reconstruction in maxillofacial surgery: Benefit or threat?
Goetz C, Burian N, Weitz J, et al
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Sunil K Bhatia

Royal Shrewsbury Hospital, Shrewsbury, UK.

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