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Original Investigation |

Association of Airway Complications With Free Tissue Transfer to the Upper Aerodigestive Tract With or Without Tracheotomy ONLINE FIRST

John D. Cramer, MD1; Sandeep Samant, MD1; Evan Greenbaum, MD2; Urjeet A. Patel, MD1,2
[+] Author Affiliations
1Department of Otolaryngology–Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
2Division of Otolaryngology–Head and Neck Surgery, John H. Stroger Hospital of Cook County, Chicago, Illinois
JAMA Otolaryngol Head Neck Surg. Published online July 20, 2016. doi:10.1001/jamaoto.2016.2002
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Importance  Airway management during microvascular reconstruction of the upper aerodigestive tract is of utmost importance; however, there is considerable debate about optimal management of the airway.

Objective  To examine if free tissue transfer to the upper aerodigestive tract without tracheotomy was associated with an increased rate of airway complications or death.

Design, Setting, and Participants  Cohort study of 861 patients undergoing microvascular reconstruction to sites in the oral cavity, oropharynx (excluding the base of tongue), and nasal and/or sinus cavity using data from the American College of Surgeons National Surgical Quality Improvement Program from 2005 to 2013. We compared the rate of airway-specific complications of patients who underwent simultaneous tracheotomy vs those who did not undergo tracheotomy.

Exposure  Tracheotomy.

Main Outcomes and Measures  The 30-day rate of airway-specific complications, including unplanned intubation, prolonged mechanical ventilation, or death.

Results  Among the 861 patients included in this study (mean age 61 years and 63.3% male), 551 underwent tracheotomy and 310 did not undergo tracheotomy. The rate of tracheotomy based on anatomic site was 66.1% for oral cavity (n = 728), 40.5% for nasal/sinus cavity (n = 85), and 70.3% for oropharynx (n = 48). The difference in the overall rate of airway complications between patients in the no-tracheotomy (10.3%) and tracheotomy (8.3%) groups was 2.0% (95% CI, 1.9%-6.4%). There were no significant differences in the rate of airway complications in the no-tracheotomy and tracheotomy groups for death (0.3% vs 0.7%, respectively; difference, 0.3%; 95% CI, −2.0% to 3.2%), unplanned intubation (3.2% vs 2.9%, respectively; difference, 0.3%; 95% CI, −2.0% to 3.2%) or for prolonged mechanical ventilation (8.1% vs 7.3%; difference, 0.8%; 95% CI, −2.7% to 4.8%). On multivariate analysis tracheotomy was not associated with the primary outcome (odds ratio [OR], 0.8; 95% CI, 0.5-1.3); however, preoperative bleeding disorder (OR, 9.0; 95% CI, 3.3-24.4), preoperative dyspnea (OR, 2.9; 95% CI, 1.5-5.5), and resection of the floor of mouth (OR, 2.1; 95% CI, 1.1-3.9) were associated with airway complications or death.

Conclusions and Relevance  Free tissue transfer to the upper aerodigestive tract is frequently performed without tracheotomy, and this is not associated with a significantly increased rate of airway complications. Routine tracheotomy may be safely avoided in a subset of patients undergoing microvascular reconstruction of the upper aerodigestive tract.

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