Journal of Otology & RhinologyISSN: 2324-8785

All submissions of the EM system will be redirected to Online Manuscript Submission System. Authors are requested to submit articles directly to Online Manuscript Submission System of respective journal.
bahis siteleri bahis siteleri bahis siteleri casino siteleri

Research Article, J Otol Rhinol Vol: 5 Issue: 3

Outcome of Tracheostomy Closure in Oral Cancer Surgery Patients

Higashino M*, Kawata R, Omura S, Kikuoka Y, Suzuki N and Terada T
Department of Otolaryngology, Head and Neck Surgery, Osaka Medical College, Takatsuki, Japan
Corresponding author : Higashino M, MD
Department of Otolaryngology, Head and Neck Surgery, Osaka Medical College, 2-7 Daigakumachi, Takatsuki, Osaka 569-8686, Japan
Tel: +81-72-683-1221
Fax: +81-72-684-6539
E-mail: [email protected]
Received: March 14, 2016 Accepted: April 22, 2016 Published: April 27, 2016
Citation: Higashino M, Kawata R, Omura S, Kikuoka Y, Suzuki N, et al. (2016) Outcome of Tracheostomy Closure in Oral Cancer Surgery Patients. J Otol Rhinol 5:3.. doi:10.4172/2324-8785.1000278

Abstract

Objective: We investigated the outcome of tracheal fistula in patients with oral cancer who underwent tracheostomy at the time of initial surgery.

Study Design: retrospective study

Methods: We retrospectively investigated the outcome of tracheal fistula in 57 patients with oral cancer who underwent tracheostomy. The patients were classified into three groups, which were patients in whom the tracheal fistula closed spontaneously (Group A), patients in whom closure of the tracheal fistula did not occur spontaneously and surgical closure was required (Group B), and patients in whom closure of the tracheostomy could not be achieved (Group C). The following factors were examined for associations with failure of spontaneous closure: patient demographics, primary tumor site, T classification, N classification, stage classification, presence or absence of neck dissection, presence or absence of reconstructive surgery, presence or absence of postoperative (chemo)radiotherapy, presence or absence of postoperative aspiration pneumonia, and duration of tracheal cannula placement.

Results: Among the 57 subjects, Group A were 27 (47.4%), Group B were 23 (40.4%), and Group C were 7 (12.3%). In Group B, surgical closure with a hinge flap was performed in all 23 patients. We found that neck dissection and postoperative (chemo) radiotherapy were both factors that had an independent influence on whether closure of the tracheostomy could be achieved.

Conclusion: Although early removal of the tracheal cannula is advantageous for improving the QOL of the patient, long-term cannulation does not interfere with spontaneous closure. Accordingly, it is necessary to carefully consider the timing of decannulation.

Keywords: Tracheostomy closure; Oral cancer; Larynx; Trachea

Keywords

Tracheostomy closure; Oral cancer; Larynx; Trachea

Introduction

Advanced oral cancer often requires surgical treatment, and it is not uncommon for tracheotomy to be performed in patients requiring radical surgery. Tracheostomy and cannulation are also disadvantage for postoperative function for oral intake. However, prophylactic tracheotomy is indicated when there is concern about aspiration pneumonia due to postoperative impairment of swallowing, when laryngeal edema may cause airway constriction, or when there is a risk of postoperative bleeding from the wound in the oral cavity. Following tracheotomy, closure of the tracheostomy is considered when swallowing recovers and the surgical wound heals, but respiratory complications have been reported in 11 - 27.7% of patients undergoing head and neck cancer surgery [1-4].
While the tracheostomy usually closes spontaneously within one to two weeks after removal of the tracheal cannula, it fails to close in some patients. In such cases, the tracheal fistula has to be closed surgically using a technique that is selected according to the state of the tissues surrounding the tracheostomy and the size of the residual tracheal fistula. A hinge flap is often used in patients with incomplete tracheostomy closure, but a skin flap is sometimes required in order to close the tracheal fistula.
Thus, prophylactic tracheotomy and associated surgery to close the tracheostomy are often carried out following head and neck cancer surgery. Among patients with head and neck cancer, surgery is rarely performed on the tissues near the larynx and trachea in those undergoing resection of oral cancer. In the present study, we investigated the outcome of tracheal fistula in patients with oral cancer who underwent tracheostomy at the time of initial surgery.

Subjects and Methods

Subjects
Among oral cancer patients treated at the Department of Otolaryngology and Head & Neck Surgery of Osaka Medical College, those undergoing tracheotomy were investigated. Between 2000 and 2013, 222 oral cancer patients were treated at our department, and 57 of them (25.7%) underwent tracheotomy at the time of initial surgery for tumor resection. They included 43 men and 14 women aged from 28 to 84 years (median age: 64 years). The site of the primary cancer was the tongue in 25 patients (43.9%), the mandibular gingiva in 13 patients (22.8%), the floor of the mouth in 9 patients (15.8%), the buccal mucosa in 6 patients (10.5%), the maxillary gingiva in 2 patients (3.5%), and the hard palate in 2 patients (3.5%).
Tracheotomy procedure
Tracheotomy involves making a median incision of the trachea and dividing the thyroid isthmus. An inverted U-shaped tracheal valve is created at the second and third or third and fourth tracheal rings, and this valve and the skin below it are sutured to place a cuffed cannula. If unilateral whole-neck dissection is performed, a Y-shaped incision is made in the lateral region of the neck and the level of the skin incision is different to that of the opening in the trachea. On the other hand, if bilateral neck dissection is performed, a transverse incision of the neck is connected to lateral Y-shaped skin incisions on both sides of the neck over the hyoid bone, and the skin incision is also at a different level to the tracheal opening. After tracheotomy has been performed, the tracheal cartilages and the skin are sutured using nylon threads (3 - 4 sutures) to close the lower 1/3 of the tracheal fistula. In the upper 2/3 of the tracheal fistula, the tracheal cartilages and the skin are not sutured to each other. Instead, the skin around the tracheal fistula is sutured to the corresponding deep tissues in order to make the tracheostomy airtight. The nylon sutures in the tracheal cartilages and skin around the fistula are removed after approximately one week. At the time of tracheostomy closure, the tracheal cartilages (which were incised in an inverted U shape) are not replaced in the original position.
Methods of tracheostomy closure
Ethical considerations: Before closing a tracheostomy, it is important to ascertain that there is no bleeding from the wound and no airway obstruction that causes difficulty with breathing. At the time when the patient becomes capable of swallowing saliva, the cuffed cannula is switched for a speech cannula. Then the patient starts oral intake, and it is confirmed that aspiration pneumonia does not develop and there are no issues with swallowing. Subsequently, the speech cannula is removed and the tracheostomy is covered with gauze to allow the opening to close spontaneously. In principle, we do not suture the tracheostomy and we wait for at least one month to allow it to close spontaneously. If the tracheostomy has not closed after that time, surgical closure is performed. We generally close the residual opening in the tracheal wall by using the so-called hinge flap reported by Lawson et al. [5], while the opening in the skin is closed by reefing with the surrounding skin. In cases where closure of the skin defect is difficult after creating the hinge flap, we use the technique reported by Murakami et al. [6], which involves adding an anterior chest wall flap such as a small deltopectoral flap.
Parameters investigated
We retrospectively investigated the 57 patients in whom tracheotomy was performed to determine the outcome of the tracheal fistula. The patients were classified into three groups, which were patients in whom the tracheal fistula closed spontaneously (Group A), patients in whom closure of the tracheal fistula did not occur spontaneously and surgical closure was required (Group B), and patients in whom closure of the tracheostomy could not be achieved (Group C). The following factors were examined for associations with failure of spontaneous closure: patient demographics, primary tumor site, T classification, N classification, stage classification, presence or absence of neck dissection, presence or absence of reconstructive surgery, presence or absence of postoperative (chemo)radiotherapy, presence or absence of postoperative aspiration pneumonia, and duration of tracheal cannula placement. Statistical analysis was performed by using the Chi-square test and the Mann-Whitney U-test, and p<0.05 was considered statistically significant.

Results

Among the 57 subjects, there were 27 (47.4%) in whom the tracheal fistula closed spontaneously (Group A), 23 (40.4%) in whom surgical closure of the tracheal fistula was performed (Group B), and 7 (12.3%) in whom closure of the tracheal fistula could not be achieved (Group C). In Group B, surgical closure with a hinge flap was performed in all 23 patients. Among them, two patients had partial wound dehiscence postoperatively, but this subsequently healed and closure was achieved. Surgery using an anterior chest wall flap was not performed in any of these 23 patients. Surgical closure was performed from 3 to 20 months (median: 7 months) after tracheotomy. In Group C, closure of the tracheostomy could not be achieved in three patients due to early recurrence of cancer, while three patients could not undergo decannulation due to prolonged dysphagia and one patient required laryngectomy due to dysphagia.
Gender, age, and body mass index (BMI) (Table 1)
Group A comprised 18 men and 9 women, Group B had 19 men and 4 women, and Group C contained 6 men and 1 woman. The age range was 28 - 77 years (median: 64 years) in Group A, 41 - 81 years (median: 65 years) in Group B, and 59 - 84 years (median: 70 years) in Group C. BMI was 12.5 - 28.1 (median: 21.3) in Group A, 18.0 - 26.2 (median: 21.5) in Group B, and 17.1 - 24.6 (median: 19.6) in Group C.
Table 1: Profile of the three groups.
Primary tumor site and stage
In Group A, the site of the primary tumor was the tongue (12 patients), mandibular gingiva (9 patients), floor of the mouth (2 patients), buccal mucosa (3 patients), and hard palate (1 patient). In Group B, primary tumors were located on the tongue (7 patients), mandibular gingiva (4 patients), floor of the mouth (6 patients), buccal mucosa (3 patients), maxillary gingiva (2 patients), and hard palate (1 patient). All 7 patients in Group C had primary tumors of the tongue. The T classification data were as follows: Group A [T1: 1 patient, T2: 6 patients, T3: 9 patients, and T4: 11 patients]; Group B [T2: 9 patients, T3: 7 patients, and T4: 7 patients]; and Group C [T2: 1 patient, T3: 3 patients, and T4: 4 patients]. In addition, the N classifications were as follows: Group A [N0: 14 patients, N1: 4 patients, and N2b: 9 patients]; Group B [N0: 11 patients, N1: 7 patients, N2b: 1 patient, and N2c: 4 patients]; and Group C [N0: 3 patients, N1: 1 patient, N2b: 2 patients, and N2c: 1 patient]. Furthermore, tumor staging was as follows: Group A [Stage II: 3 patients, Stage III: 8 patients, and Stage IV: 16 patients]; Group B [Stage II: 3 patients, Stage III: 10 patients, and Stage IV: 10 patients]; and Group C [Stage III: 2 patients, and Stage IV: 5 patients]. Most of the patients who underwent tracheotomy had advanced cancer, with 51 patients (89.5%) being in Stages III or IV.
Among the 50 patients in whom closure of the tracheostomy was achieved, we compared 27 patients in Group A with 23 patients in Group B by assessing the following factors.
Differences of management and outcomes (Table 2)
Neck dissection: Two patients (one in Group A and one in Group B) did not undergo neck dissection. Thirty-nine patients had unilateral neck dissection, including 24 patients in Group A and 15 patients in Group B. Nine patients underwent bilateral neck dissection, including two patients in Group A and seven patients in Group B. These results suggested that surgical closure of the tracheal fistula was significantly more likely to be required (p=0.03) when bilateral neck dissection was performed.
Table 2: Management and outcomes in Groups A and B.
Reconstructive surgery: Reconstructive surgery was performed in 33 of the 50 patients using the following methods: free rectus abdominis flap in 20 patients, forearm flap in 4 patients, scapular muscle flap in 4 patients; fibular flap in 2 patients, latissimus dorsi flap in 2 patients, and buccal mucosa valve in 1 patient. Among the patients who underwent reconstructive surgery, 18 were from Group A and 15 were from Group B. On the other hand, nine patients in Group A and eight patients in Group B did not undergo reconstructive surgery. There was no significant difference in the rate of spontaneous closure of the tracheostomy in relation to the presence or absence of reconstructive surgery (p=0.91).
Postoperative (chemo) radiotherapy: Postoperative chemoradiotherapy received to the patients with positive resection margins and/or extracapsula nodal disease. Among the 50 patients, 22 patients received postoperative (chemo) radiotherapy, with the radiation dose being 50 – 70 Gy. Our policy was to perform closure of the tracheal fistula at the time where decannulation became possible, regardless of whether or not the patient had postoperative (chemo) radiotherapy. Of the 22 patients who received postoperative (chemo) radiotherapy, eight were from Group A and 14 were from Group B. On the other hand, among the 28 patients who did not undergo postoperative (chemo) radiotherapy, 19 were from Group A and nine were from Group B. These results suggest that surgical closure of the tracheal fistula was significantly more likely to be required (p=0.03) when postoperative (chemo) radiotherapy was performed.
Postoperative aspiration pneumonia: Twelve of the 50 patients (24%) developed aspiration pneumonia after surgery. The duration of tracheal cannulation was 7 - 94 days (median: 37 days) in the patients with pneumonia, while it was 4 - 42 days (median: 18 days) in the 38 patients who did not develop pneumonia. Accordingly, development of pneumonia was significantly associated with a longer duration of tracheal cannulation (p=0.02). Among the 12 patients who developed pneumonia, five were from Group A and seven were from Group B, whereas 22 of the 38 patients who did not develop pneumonia were from Group A and 16 were from Group B. These results indicate that there was no significant difference in the rate of spontaneous closure of the tracheostomy in relation to the presence or absence of postoperative aspiration pneumonia (p=0.16).
Duration of tracheal cannulation (Figure 1): The two groups were compared with respect to the duration of tracheal cannulation, which was defined as the period from when a cuffed cannula was placed after tracheotomy until decannulation was performed. The median duration was 21 days (range: 4 - 94 days) in Group A and 20 days (range: 7 - 90 days) in Group B. There was no significant difference in the rate of spontaneous closure of the tracheostomy in relation to the duration of cannulation (p=0.54).
Figure 1: Comparison of the duration of tracheal cannulation.

Discussion

Prophylactic tracheotomy is often performed in patients undergoing surgery for advanced head and neck cancer. In patients with pharyngeal cancer, laryngeal cancer, or thyroid cancer, the region around the larynx and trachea or the trachea itself may be affected by surgery, and closure of the tracheal fistula after prophylactic tracheotomy is not indicated in such cases. On the other hand, surgery for tumor resection rarely involves areas around the larynx and trachea in patients with oral cancer. Therefore, we examined the outcome of tracheostomy closure in oral cancer patients in the present study.
While various methods have been reported for closing a tracheostomy [7-11], closure was achieved using only a hinge flap in all patients who underwent tracheostomy closure in the present study. Although postoperative wound dehiscence occurred in two patients, spontaneous closure of the residual defect was subsequently achieved in both cases and there was no re-rupture. As factors potentially related to spontaneous closure of the tracheal fistula, we can consider whether neck dissection or reconstructive surgery has an influence, as well as considering the potential influence of postoperative (chemo) radiotherapy, the duration of tracheal cannulation, the presence or absence of thyroidectomy, a history of prior tracheotomy, and postoperative respiratory complications. In the present series, none of the subjects underwent thyroidectomy or had a history of prior tracheotomy, so we investigated the potential influence of neck dissection, reconstructive surgery, postoperative radiotherapy, and postoperative aspiration pneumonia. As a result, we found that neck dissection and postoperative (chemo)radiotherapy were both factors that had an independent influence on whether closure of the tracheostomy could be achieved. With respect to neck dissection, significantly more patients who underwent bilateral neck dissection did not achieve spontaneous closure when compared with patients undergoing unilateral neck dissection. In patients undergoing bilateral neck dissection, it is possible that blood flow in the region around the trachea will be worse than after unilateral dissection, because the skin incision is longer, skin separation is wider, and deep tissue dissection is more extensive. Although there was no significant difference of the postoperative radiotherapy rate between patients who underwent bilateral neck dissection and those receiving unilateral dissection, the radiation field is larger in patients with bilateral dissection and the dose of radiation could have been higher in the region around the trachea. Patients who received postoperative radiotherapy had a significantly lower rate of spontaneous closure of the tracheostomy compared with patients who did not receive radiotherapy. It is well known that postoperative wound healing is delayed by radiation [12], and this is consistent with our results regarding tracheostomy closure.
When a tracheal cannula remains in situ over a long period, it has been suggested that tissue between the tracheal cartilages and the skin of the tracheostomy becomes thicker and stronger. As a result, long-term tracheal cannulation is considered to be unfavorable for spontaneous closure of a tracheostomy. However, the present study revealed no significant relationship between long-term cannulation and spontaneous tracheostomy closure. A study of reconstructive surgery in oral cancer patients revealed that the reconstructed tissue volume was correlated with the duration of cannulation [13]. In the present study, 17 out of 26 patients with tongue cancer underwent reconstructive surgery and nine patients did not. When the duration of tracheal cannulation was compared between these two groups, it was 18 - 90 days (median: 35 days) for the group with reconstructive surgery and 9 - 94 days (median: 17 days) for the group without reconstruction, being significantly longer in the former group (p=0.0087). Thus, although it may require a longer time until decannulation can be performed after reconstructive surgery, we found no evidence that the tracheal cannula should be removed at an early stage in anticipation of promoting spontaneous closure of the tracheal fistula.
In Group C, closure of the tracheostomy could not be achieved. All the patients in Group C, were advanced tongue cancer who were needed reconstruction surgery. This was because 3 of the 7 patients developed recurrence at 2 - 3 months postoperatively (local recurrence in 1 patient and metastasis to the cervical lymph nodes in 2 patients), and closure of the tracheostomy was not indicated. The other four patients were because of postoperative dysphagia. 1 patient who took the operation of esophageal cancer previously, 1 patient who was recurrence after postchemoradiation for T4 tongue cancer, 1 patient who took radical surgery with elevation of larynx and CP myotomy who expected severe dysphagia postoperatively. Three of these patients had a speech cannula placed or became cannula-free. Although they were temporarily able to speak and initiate oral intake, they all subsequently developed aspiration pneumonia and died at 1.5 months, 3 months, and 5 months after surgery, respectively. The other patient was no sign of improvement in dysphagia and could not be switched to a speech cannula, so we underwent total laryngectomy at three months postoperatively. Although this procedure resulted in the loss of vocal function, the patient is currently alive and free of cancer at seven and a half years postoperatively. Two patients were treated by subtotal glossectomy, while the remaining two patients (both were elderly, being aged 81 years) received hemiglossectomy to maintain the range of tongue motion. Although early removal of the tracheal cannula is advantageous for improving the QOL of the patient, long-term cannulation does not interfere with spontaneous closure, as described above. Accordingly, it is necessary to carefully consider the timing of decannulation in older patients and patients who have undergone extensive dissection.

References

Track Your Manuscript

Media Partners

Associations