In Response to Predictive Nomogram for the Necessity of Tracheotomy During Oral and Oropharyngeal Cancer Surgery

Abstract

We would like to thank Suresh Mani et al. for their interest in our publication “Predictive Nomogram for the Necessity of Tracheotomy During Oral and Oropharyngeal Cancer Surgery” and insightful comments regarding additional factors that should be considered in the analysis. We agree that decision-making of performing elective tracheotomy or not for patients with oral and oropharyngeal cancer needs comprehensive evaluation of multiple factors. In fact, the factors analyzed in our study included patient characteristics (age, sex, body mass index, weight loss, smoking, and drinking history), tumor condition (tumor site, tumor size, midline crossing, and preoperative radiation), surgery information (operative time, mandibulectomy, and neck dissection), and reconstructive choices (type of flap reconstruction). And the seven factors appeared in the final nomogram were selected by univariate and multivariate analyses, which were significantly associated with the result event. There have been several scoring systems for evaluating upper airway including the abovementioned scoring for predicting difficult intubation. However, the situations are different. Difficult intubation generally occurs when patients are under anesthesia induction and passive ventilation while elective tracheotomy is considered to avoid postoperative airway obstruction. Some risk factors relating to difficult intubation may have slight effect on ventilation when a patient is awake, that is why elective tracheostomy is unnecessary for most patients undergoing surgery outside head and neck, even if difficult intubation is expected. We quite agree that to prevent aspiration, pneumonia is another important consideration of elective tracheostomy, especially for patients with a major tongue or oropharyngeal resection, then cardiopulmonary factors are also generally taken into consideration. In our study, considering it is difficult to define golden standard of elective tracheotomy, we took potential airway obstruction as the only consideration because patients who required tracheotomy for aspiration is hard to define under that circumstance. Decision-making of elective tracheotomy is indeed common for head and neck surgeon but always hard to quantify, both surgeon’s experience and risk predictive model play essential role in clinical practice.