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Oncological Tracheostomy
CarlosEduardoSantaRittaBarreira,
MarinaAzziQuintanilha, TerencePiresde Farias,
JoseGabrielMirandada Paixão, JulianaFernandes
de Oliveira, FernandoLuizDias, andPauloJose
de CavalcantiSiebra
Introduction
The prevalent reasons why tracheostomy is performed depends on each institution’s
policies. In general hospitals, most tracheostomies are performed due to prolonged intubation in intensive care units; in cancer centers they are performed mostly to manage the
symptoms of growing head and neck cancers or in preparation for major surgeries to
treat these tumors. Patients with tumors of the oral cavity, pharynx, or larynx, or other
neck masses, may suffer airway narrowing, swallowing disorders, decreased mouth
opening, dysphagia, and aspiration during disease progression. Airway intervention
may occur before, during, or after the proposed treatment, and the timing to perform it
has a profound impact on the patient’s life. Although tracheostomy performance is part
of head and neck surgical routine, literature regarding this theme is scarce, especially
with regard to the indications and head and neck patient management (Figs.1 and 2).
C.E.S.R. Barreira, M.D., Ph.D. (*) • M.A. Quintanilha, M.D.
Department of Head and Neck Surgery, Santa Luzia Hospital, Brasília, DF, Brazil
e-mail: csantaritta@yahoo.com.br
T.P. de Farias, M.D., Ph.D., M.Sc., Researcher.
Department of Head and Neck Surgery, Brazilian National Cancer Institute—INCA,
Rio de Janeiro, RJ, Brazil
Department of Head and Neck Surgery, Pontical Catholic University of Rio de Janeiro,
Rio de Janeiro, RJ, Brazil
F.L. Dias, M.D., Ph.D., M.Sc., F.A.C.S.
Head and Neck Surgery Department, Brazilian National Cancer Institute—INCA,
Rio de Janeiro, RJ, Brazil
Head and Neck Department, Pontical Catholic University of Rio de Janeiro, Rio de Janeiro,
RJ, Brazil
J.G.M. da Paixão, M.D. • J.F. de Oliveira, M.D. • P.J. de CavalcantiSiebra
Department of Head and Neck Surgery, Brazilian National Cancer Institute– INCA,
Rio de Janeiro, RJ, Brazil
© Springer International Publishing AG 2018
T.P. de Farias (ed.), Tracheostomy, https://doi.org/10.1007/978-3-319-67867-2_10
169
170
Fig. 1 Patient with
decreased mouth opening
and swallowing disorder
Fig. 2 Growing neck mass
and narrowing airways
C.E.S.R. Barreira et al.
Indications inOncological Patients
The management of airways in patients with head and neck tumors needs special
attention by medical staff. In those cases, most tracheostomies are indicated to
ensure optimal breathing conditions by preventing the growing tumor from
Oncological Tracheostomy
Fig. 3 Tracheostomy
indication due to risk of
airway blockage
171
blocking the airway, providing clearance of upper respiratory tract secretions, or
protecting against or minimizing the risk of bronchoaspiration. The risk of airway
blockage is a life-threatening condition and should be considered the most important indication to perform an elective tracheostomy in patients with head and neck
tumors. This risk may be identied by any of the following respiratory signs and
symptoms: inadequate ventilation; uncomfortable breathing; dyspnea; or nocturnal
dyspnea, orthopnea, or stridor. Stridor [1] and these other signs are not common
until an obstruction of greater than 50% occurs. Patients with compromised airways
should undergo tracheostomy as soon as possible, in order to prevent the need for an
emergency approach (Fig.3).
During preparation for major surgery, patients may need denitive airway protection until complete recovery. Tracheostomies should be indicated when surgical
conditions may lead to severe edema, risk of respiratory tract structure collapse, or
bronchoaspiration. The risk of narrowing of the airway by edema should be considered in oral or laryngopharyngeal cancer resections. Although it is not easy to predict or measure the severity of edema and its consequences for respiratory conditions,
two factors that play pivotal roles in determining airway protection are tumor localization and stage. Mandibulectomies, partial laryngectomies, and large reconstructions of the aerodigestive tract may lead to abnormal function and airway obstruction
postoperatively. Swallowing disorders due to these surgeries may cause bronchoaspiration by secretion or bleeding. If there is a possibility of a postoperatively
compromised airway, elective tracheostomy should be considered as a safe course
of treatment [2]. In the UK, a national survey showed that 69% of maxillofacial
surgical units perform elective tracheostomy routinely in patients with free ap
reconstruction following ablative head and neck surgery [3] (Figs.4 and 5).
172
Fig. 4 Preparation for
major surgery
C.E.S.R. Barreira et al.
Craniofacial surgeries are other major procedures that need respiratory attention
in postoperative care. In addition to the aforementioned indications to protect airways and assist patient recovery, tracheostomy is indicated to avoid pneumocephalus [4]. It can occur as a complication due to positive air pressure in upper airways,
collecting air or gas in the intracranial cavity. Fliss etal. reported a tension pneumocephalus incidence of 5.6% in skull base reconstructions after anterior subcranial
tumor resection [5] (Figs.6 and 7).
Emergency Tracheostomy inOncological Patients
Patients with a delayed diagnosis and/or receiving treatment for head and neck
tumors can suffer acute obstruction of the upper airways, and urgent tracheostomy
can be frequently indicated in these situations [6, 7]. Urgent surgical airway intervention occurs with high stress levels and critical conditions, exposing patients to a
higher risk of hypoxia and cardiopulmonary arrest. Research shows that the occurrence of complications is increased 2- to 5-fold in urgent situations [8–10] (Fig.8).
Oncological Tracheostomy
Fig. 5 After
mandibulectomy and
detachment of tongue
muscles, leading to
superior airway collapse
173
Fig. 6 Craniofacial
surgery, showing potential
communication between
the central nervous system
and the upper aerodigestive
tract
174
Fig. 7 After craniofacial
surgery, with tracheostomy
indicated to avoid positive
air pressure in upper
airways
C.E.S.R. Barreira et al.
Fig. 8 Severe edema due
to oropharyngeal tumor;
tracheostomy was
performed to secure the
airway
Oncological Tracheostomy
Table 1 Tracheostomy indications in patients with head and neck tumors
Context Signs and symptoms
Elective tracheostomy Progressive airway narrowing
Swallowing disorder
Decreased mouth opening
Aspiration
Preparation for major surgery
Emergency tracheostomy Acute airway obstruction
Inadequate ventilation
Uncomfortable breathing
Dyspnea
Nocturnal dyspnea, orthopnea, or stridor
175
Due to obstruction caused by tumor growth, orotracheal intubation—even for
bronchoscopy—can be very difcult to execute, and a cricothyrotomy procedure
should be avoided because of the possibility of tumor violation and contamination
of surrounding tissues. Due to these peculiarities, emergency tracheostomy in
patients with head and neck cancer is frequently performed on awake patients under
local anesthesia. This procedure should be considered a safe and effective method
to ensure airway patency in these patients [6, 11, 12] (Table1).
Tracheostomy inOral andOropharyngeal Cancer
Patients with oral cancer may be eligible for tracheostomy at any stage of treatment,
due to either the risk of airway blockage or a critical emergency of acute obstruction. Whether or not to perform tracheostomy may be a thorny decision for medical
staff, as there are many factors inuencing the difculty of predicting airway maintenance, and because it has a profound impact on the patient’s life—not only because
of psychological aspects or nursing care, but also because it may increase the complication rate. Chest infection rates in patients undergoing major head and neck
surgery may increase from 11% to 20% in tracheostomized patients [13].
Surgeons should evaluate surgical defects, resected structures, and functional
loss and its consequences. The patient’s clinical condition and pathological ndings
are important in making a decision. As a consensus, elective tracheostomy is considered the most effective and denitive method to ensure airway safety, and it is
recommended for patients with a high risk of airway obstruction [2, 14, 15]
(Figs.9, 10, and 11).
In an attempt to clarify and provide criteria for indication for elective tracheostomy
in patients with oral and oropharyngeal tumors, some authors have developed scoring
systems based on multiple ndings. Kruse-Lösler etal. [16] developed a system that
predicts the likelihood of postoperative respiratory failure. They identied the following signicant parameters for indication for tracheostomy: tumor size, tumor localization, multimorbidity, alcohol consumption, and pathologic chest X-ray ndings.
Kruse-Lösler considered the size and the localization to be the main signicant factors
176
Fig. 9 Recurrent oral
cavity tumor; tracheostomy
was performed to prepare
for the procedure
C.E.S.R. Barreira et al.
inuencing the indication for tracheostomy. The patient’s general medical condition,
which includes cardiorespiratory disease and the level of alcohol consumption, were
also considered important parameters. Based on different score values (Table2), KruseLösler recommended elective tracheostomy in patients with seven or more points [16].
However, the scoring system devised by Kruse-Lösler etal. lacked consideration
in regard to surgical factors [15]. Indeed, there were no considerations for technical
surgical details or the reconstructive methods adopted. Cameron etal. described the
development of a surgical scoring system based on tumor localization, mandibulectomy, neck dissection, and reconstruction [14]. Thus, Cameron et al. evaluated
important surgical aspects to predict the need for tracheostomy, the decision to perform mandibulectomy and neck dissections, and the use of bulky reconstructive
aps. Cameron describes that a threshold score of 5 gives acceptable sensitivity and
specicity, and good positive predictive value (PPV) and negative predictive value
(NPV). Cameron’s complete scoring system is shown in Table 3. The authors
pointed out that this scoring system has the potential to assist clinicians in the decision regarding airway management; it is not intended to replace clinical judgment.
Lee etal. proposed a retrospective study to investigate the usefulness of a tracheostomy scoring system in decision making for postoperative airway management in oral
Oncological Tracheostomy
Fig. 10 After resection,
showing a major
tridimensional defect of
the upper aerodigestive
tract
177
cancer patients, and concluded that both Cameron’s and Kruse-Lösler’s systems cannot be absolute guidelines in all cases. Using these scoring systems was not sufcient
to make a decision on whether to perform an elective tracheostomy after oral cancer
surgery, but it could be helpful in predicting the severity of the airway obstruction
after surgery [2] (Fig.12).
Kim etal. [15] noted the insufciency of Cameron’s considerations about tumor
size and the patient’s systemic health condition, and suggested a new scoring system for elective tracheostomy, covering both surgical and systemic factors. This
scoring system considers a score of 5 as a relevant cutoff to determine that an elective tracheostomy is indicated [15] (Table4).
Kruse-Lösler etal. published, for the rst time, a scoring system to assist in
establishing the indications for elective tracheostomy; they described an easily
performed scoring system, enabling comparison of different patients and using
well- dened criteria. Since this publication, some authors have tried to develop
new scoring systems to solve limitations. These systems are aimed at better prediction of airway safety regarding patients undergoing oral and oropharyngeal
resections. At present, there are no scoring systems able to replace clinical experience regarding whether or not to perform a tracheostomy.
178
Fig. 11 After free ap
reconstruction, requiring
tracheostomy due to
important functional loss
C.E.S.R. Barreira et al.
Table 2 Scoring system devised by Kruse-Lösler etal. for elective tracheostomy in oral cancer
0
Parameter
Tumor
localization
Tumor size - T1 T2 T3 T4 1–4
Chest X-ray
ndings
Multimorbidity No Ye s - - - 0–1
Alcohol use No <100g/day >100g/day Hard
Total 2–11
Acta Anaesthesiol Scand
points 1 point 2 points 3 points4 points
- Anterior second
premolar
Normal Pathological
ndings
Posterior
second
premolar
- - - 0–1
- - 1–2
- 0-3
drinks
[16]
Points
value
Tracheostomy inLaryngeal andPharyngeal Cancer
Tracheostomy inOrgan Preservation
Transglottic carcinoma—a term designated to clarify tumor growth patterns
(involvement of both true and false vocal cords), created by McGavran and associates—can be treated by total laryngectomy. Mittal et al. do not consider