The Laryngoscope | 2021
In reference to Predictive Nomogram for the Necessity of Tracheotomy During Oral and Oropharyngeal Cancer Surgery
Abstract
The predictive nomogram developed by Siyuan Xu et al. is novel. However, this nomogram has included only a few factors such as primary tumor site, tumor size, midline crossing, preoperative radiation, mandibulectomy, flap reconstruction, and neck dissection. We feel these factors are inadequate and would not predict the need for tracheostomy in all cases. The decision to perform elective tracheostomy to prevent postoperative airway obstruction depends on multiple other factors such as patient factors, tumor characteristics, surgery-related factors, and reconstructive factors. Scoring systems are available for preoperative clinical predictors of difficult intubation. Laryngoscore is a good predictor of difficult cases and assists in selecting the ideal candidates. The score includes inter-incisors gap, thyromental distance, upper jaw dental status, trismus, mandibular prognathism, macroglossia, micrognathia, degree of neck flexion-extension, history of previous open-neck surgery and/or radiotherapy, Mallampati’s modified score, and body mass index. Trismus should be included in this checklist as most of the patients with oral and oropharyngeal cancer will trismus due to either oral submucous fibrosis or disease extension into the masticator space. In our experience, postoperative mouth-opening assessment at the end of surgery should also be considered in the risk assessment. Elective postoperative intubation in patients with moderate risk reduces the risk of airway compromise. But those patients who fail extubation on third postoperative day should undergo an elective tracheostomy. Aspiration can occur when the patient has a major tongue or oropharyngeal resection and even after reconstruction without compromising airway. Tracheostomy can be considered for pulmonary toileting to prevent pneumonia in patient with poor pulmonary function. Cardiopulmonary factors are integral for deciding whether a tracheostomy should be done. Surgeon’s expertise and availability of the intensive care unit for monitoring also plays a significant role. The scoring system should therefore be a reliable screening method and appropriately predict the patients who do not require tracheostomy. Although none of the factors independently predicts the obstruction in the postoperative period, all the abovementioned factors should be considered for forming a robust risk assessment system.