Efficacy of overnight intubation in oral oncological surgeries a retrospective study

In the post‑operative period of maxillofacial oncological surgeries, tracheostomy has been the mainstay for securing the airway [1, 2]. However, tracheostomy has reported 8–45 % complications, such as bleeding, surgical emphysema, pneumothorax, tracheo‑esophageal fistula, failure to decannulate, among others [2, 3–5]. As reported by Mortan et al, 45 % patients who undergo head and neck surgery requiring tracheostomy, suffer pulmonary complications [6]. Rao et al. [7] adjudicate tracheostomy as one of the major risk element for pulmonary complications. Ong et al. [8] observed 47 patients who underwent head and neck surgery with tracheostomy, 37 reported complications, though they were administered prophylactic antibiotics. Recently, as a part of the ERAS (enhanced recovery after surgery) programs, restricting the use of tracheostomy to selected cases has been emphasized [9]. Therefore, the practitioners choose alternative modalities like submental intubation to prevent the untoward complications. However, literature support on alternative to tracheostomy for oral oncologic cases is limited [10]. In this study, an alternate regime to tracheostomy was employed, by overnight intubation of patients postoperatively, with subsequent review for swelling the next morning, which may result in airway compromise, in the absence of which, an extubation was performed. Therefore, the aim of this observational study is to ascertain whether the use of overnight intubation is a safer and cost‑effective practice and if it can be considered an alternative to tracheostomy.

Material and methods

30 patients, 23 males and 7 females in the age group of 34–80 years who underwent treatment for head and neck cancer with major intraoral resection and a unilateral or bilateral neck dissection were included in the study. The endotracheal tube was retained in situ and the patient was observed overnight in the Intensive Care Unit (ICU) without a tracheostomy. The following variables were recorded: age, sex, site of tumour, type of neck dissection, use of mandibulotomy/ mandibulectomy, type of reconstruction, duration of stay in ICU, mean hospital stay and Mallampati classification. Postoperative complications, associated with the airway, if any, were recorded simultaneously. Patients with a mean duration of hospital stay of 10 days (range 815 days), were considered.

Results

Thirty head and neck surgery cases, (23 males and 7 females) belonging to the age groups of 34–80 years with mean duration of hospital stay of 10 days (range 8–15 days) were taken into consideration. Table 1 shows the site of the tumour, table 2 shows Mallampati score, table 3 and 4 shows surgical intervention and neck dissection respectively and table 5 shows reconstruction technique used.

All the patients were intubated overnight nasotracheally. Nasal intubation using fibreoptic bronchoscopy wa s done for the patients with Mallampati Class 3 and 4. Post‑surgery, the patients were kept intubated on fentanyl infusion for the first postoperative night. Dexamethasone 8 mg was administered intravenously at induction and 2 doses postoperatively, to all the patients. The next morning, a thorough examination of the site of resection, flap and the airway was done. The patients were extubated of the trachea. Thereafter, the patients were shifted to the Oral and Maxillofacial surgery ward, 4 hours after extubation when considered stable. None of the patients required re‑intubation nor did they develop any respiratory distress. The patients also received saline nebulization 6th hourly for subsequent 2–3 days as well as chest physiotherapy, to avoid the clogging of upper and lower respiratory tract.

Discussion

Ensuing major intraoral resection and reconstruction, is the development of edema around the airway requisitioning the need for tracheostomy. Over the years, with the improvisation of surgical techniques and advances in anesthesia, surgeons started believing that tracheostomy could be replaced by overnight intubation with good patient compliance. Tracheostomy related complications are not uncommon [2, 5–10]. Chest infections being the most common among all [11]. It is a source of anxiety to patients and agony to their

depicts the site of the tumours table 1 Site Number of cases Anterior tongue 4 Floor of the mouth 3 Mandible/ Alveolus 10 Buccal Mucosa 10 Maxilla 3 table 2 depicts Mallampati score Mallampati score Number of cases ^^м Class 0 0 Class 1 4 Class 2 11 Class 3 12 Class 4 3 table 3 depicts surgical technique used Surgical Method Number of cases ^^м Composite Resection 15 Hemiglossectomy 4 Hemimandibulectomy with Wide Local excision 5 Segmental Resection 3 Subtotal maxillectomy 3 table 4 depicts neck dissection done Neck Dissection Number of cases ^^м Functional Neck dissection (FND) 5 Radical Neck dissection (RND) 10 Supraomohyiod Neck dissection (SOHND) 15 table 5 depicts reconstruction done Reconstruction Number of cases Primary closure 2 PMMC 20 Nasolabial flap 6 Buccal pad flap and tongue flap 2 relatives or bystanders, and stands to be potentially life threatening, as well. It is noted that patients having tracheostomy‑related complication spend a longer time in the ICU for recovery and thus have longer total hospital stay. Castling et al [2] reported that the patients who underwent tracheostomy spent a mean of 4 days in the ICU compared to other patients who spent a mean of 2 days. And the mean hospital stay was 25 days and 14 days for tracheostomy patients and other patients respectively. The mean duration of hospital stay for the patients included in this study was 11.5 days.

The routine use of tracheostomy remains undeterred even with the high complication rate. As per literature, considering the category of patients that were chosen for this study (neck dissection, major intraoral resection, reconstruction with a free flap) a surgeon would have chosen the mundane method of tracheostomy as a treatment choice. Results from this study have shown that the management of airway can be safely carried out by leaving the endotracheal tube overnight in the immediate postoperative period, as an alternative to tracheostomy. Additionally, not performing a tracheostomy has benefits of a minimized operation time and hospital stay, making it conducive for a quick recovery. Patients find it easier to cough, communicate and clear secretions sooner, evading any untoward risks and 8–45 % morbidity connected to tracheostomy [12].

In view of the cost effectiveness, with the economic benefits of not using intensive care unit following surgery, the additional cost of prolonged time in the operating room, tracheostomy kit, extended hospital stay and if complications occur, the associated expenditure with a multitude of antibiotics can be reconsidered [2]. The occurrence of a complication further, increases the demand of the allied health science professionals. Certainly, if overnight intubation is given preference over routine tracheostomy, the opportunities for trainees will be narrowed. However, continuing the practice with an elaborate and invasive procedure (such as tracheostomy) while a less morbid alternative (overnight intubation) is available, would at the same time be unethical. Concurrently, it is undebatable that tracheostomy will still be needed for patients who require prolonged intubation for major head and neck cancer and some other major surgical procedures.

The data was collected retrospectively for this study, which could be regarded as a foible, but the quality of data handling was refined. No control group was designated as overnight intubation offered a safe alternative making tracheostomy unjustified at least in cases which did not require periods of long intubation postoperatively. A future study could be pursued with direct comparison between two groups, who have undergone routine tracheostomy and those who have not, thus generating more data and numbers to facilitate the study.