efficacy of overnight intubation in oral oncological surgeries a retrospective study

objective. In the post-operative period of maxillofacial oncological operations, tracheostomy is the most commonly used method for securing the airway. These untoward complications made practitioners choose 67 СИБИРСКИЙ ОНКОЛОГИЧЕСКИЙ ЖУРНАЛ. 2018; 17(5): 67–71 souvick sarkar, maxfacssouvick@gmail.com


INTRODUCTION
In the postoperative period of maxillofacial oncological surgeries, tracheostomy has been the mainstay for securing the airway. 1,23][4][5] As reported by Morton et al., 45% of patients who undergo head and neck surgery requiring tracheostomy, suffer pulmonary complications. 6Rao et al. 7 adjudicate tracheostomy as one of the major risk element for pulmonary complications.Ong et al. 8 observed 47 patients who underwent head and neck surgery with tracheostomy, 37 reported complications, though they were administered prophylactic antibiotics.Recently, as a part of the enhanced recovery after surgery (ERAS) programs, restricting the use of tracheostomy to selected cases have been emphasized. 9Therefore, the practitioners choose alternative modalities like submental intubation to prevent the untoward complications.However, literature support on an alternative to tracheostomy for oral oncologic cases is limited. 10In this study, an alternative regime to tracheostomy was employed, by overnight intubation of patients postoperatively, with a subsequent review for swelling the next morning, which may result in airway compromise, in the absence of which, extubation was performed.Therefore, the aim of this observational study is to ascertain whether the use of overnight intubation is a safer and cost-effective practice and if it can be considered an alternative to tracheostomy.

MATERIALS AND METHODS
Thirty patients, 23 males and 7 females in the age group of 34-80 years who underwent treatment for head and neck cancer with major intraoral resection and a unilateral or bilateral neck dissection were included in the study.The endotracheal tube was retained in situ and the patient was observed overnight in the intensive care unit (ICU) without a tracheostomy.The following variables were recorded: age, sex, site of a tumor, type of neck dissection, use of mandibulotomy/mandibulectomy, type of reconstruction, duration of stay in ICU, mean hospital stay and Mallampati classification. 11Postoperative complications, associated with the airway, if any, were recorded simultaneously.Patients with a mean duration of hospital stay of 10 days(range 8-15 days), were considered.

RESULTS
Thirty head and neck surgery cases, (23 males and 7 females) belonging to the age groups of 34-80 a mean duration of hospital stay of 10 days(range 8-15 days) were taken into consideration.Table 1 shows the site of a tumor; Table 2 shows Mallampati score; Tables 3 and 4 show surgical intervention and neck dissection, respectively; and Table 5 shows reconstruction technique used.
All the patients were intubated overnight nasotracheally.Nasal intubation using fibreoptic bronchoscopy was done for the patients with Mallampati classes 3 and 4. Post-surgery, the patients were kept intubated on fentanyl infusion for the first postoperative night.Dexamethasone 8 mg was administered intravenously at induction and two doses postoperatively, to all the patients.The next morning, a thorough examination of the site of resection, flap and the airway was done.The patients were extubated of the trachea.Thereafter, the patients were shifted to the oral and maxillofacial surgery ward, 4 hours after extubation when considered stable.None of the patients required reintubation nor did they develop any respiratory distress.The patients also received saline nebulization 6th hourly for subsequent 2-3 days as well as chest physiotherapy, to avoid the clogging of the upper and lower respiratory tract.

DISCUSSION
Ensuring major intraoral resection and reconstruction is the development of edema around the airway requisitioning the need for tracheostomy.Over the years, with the improvisation of surgical techniques and advances in anesthesia, surgeons started believing that tracheostomy could be replaced by overnight incubation with good patient compliance.][7][8][9][10] Chest infections being the most common among all. 12It is a source of anxiety to patients and agony to their relatives or bystanders and stands to be potentially life-threatening, as well.It is noted that patients having tracheostomy-related complication spend a long time in the ICU for recovery and thus have a longer total hospital stay.Castling et al. 2 reported that the patients who underwent tracheostomy spent a mean of 4 days in the ICU compared to other patients who spent a mean of 2 days.And the mean hospital stay was 25 days and 14 days for tracheostomy patients and other patients respectively.The mean duration of hospital stay for the patients included in this study was 11.5 days.
The routine use of tracheostomy remains undeterred even with the high complication rate.As per literature, considering the category of patients that were chosen for this study (neck dissection, major intraoral resection, reconstruction with a free flap) a surgeon would have chosen the mundane method of tracheostomy as a treatment choice.Rogers et al. 12 in his paper mentioned about temporary tracheostomy after microvascular reconstruction for cancer of head and neck.He also mentioned that not all patients who have free flap reconstruction will require a tracheostomy.Coyle et al. 13 countered his opinion stating that no patients require tracheostomy after free flap reconstruction.Results from our study have also shown that the management of airway can be safely carried out by leaving the endotracheal tube overnight in the immediate postoperative period, as an alternative to tracheostomy.
Additionally, not performing a tracheostomy has benefits of a minimized operation time and hospital stay, making it conducive for a quick recovery.Patients find it easier to cough, communicate and clear secretions sooner, evading any untoward risks and 8-45% morbidity connected to tracheostomy. 14In view of the cost-effectiveness, with the economic benefits of not using intensive care unit following surgery, the additional cost of prolonged time in the operating room, tracheostomy kit, extended hospital stay and if complications occur, the associated expenditure with a multitude of antibiotics can be reconsidered. 2The reluctance to keep the patient in the intensive care unit rather than transferring them to the head and neck ward in the tracheostomy patients was another reason for the prolonged hospital stay and in turn high hospital bills.Although there are many confounding factors like lack of staffing behind patients' prolonged hospital stay, the fact can not be denied that overnight intubated patients recover earlier. 15here are numerous studies highlighting the disadvantages of tracheostomy.The advantages of overnight intubation are also undebated making it one of the most sought after methods in anesthesia.
Along with the shorter duration of hospital stay patients can also speak early and swallow early which makes it more popular among the patients. 16he occurrence of a complication further, increases the demand of the allied health science professionals.Certainly, if overnight intubation is given preference over routine tracheostomy, the opportunities for trainees will be narrowed.However, continuing the practice with an elaborate and invasive procedure (such as tracheostomy) while a less morbid alternative (overnight intubation) is available, would at the same time be unethical.Concurrently, it is undebatable that tracheostomy will still be needed for patients who require prolonged intubation for major head and neck cancer and some other major surgical procedures.
The data were collected retrospectively for this study, which could be regarded as a foible, but the quality of data handling was refined.No control group was designated as overnight intubation offered a safe alternative making tracheostomy unjustified at least in cases which did not require periods of long intubation postoperatively.A future study could be pursued with a direct comparison between two groups, who have undergone routine tracheostomy and those who have not, thus generating more data and numbers to facilitate the study.

CONCLUSION
As surgeons, we should always contemplate over the routine procedures that we blindly follow while a less elaborate and less damaging alternative is available.Assessing the necessity of a surgical procedure should be a constant thought on the mind of a progressive surgeon with the highest precedence given to the wellbeing of the patient.Any procedure carried out should be clearly beneficial and the least invasive for the patient.At the end of this study, we strongly consider it wiser to carry out overnight intubation over tracheostomy.
The purpose of this study is to raise the conscience of every surgeon to cogitate his/her choice of procedure for his/her patients and advocate the use of overnight intubation, as it is a virtuous alternative to tracheostomy.We also suggest an assessment of each case individually for its requirement, rather than considering tracheostomy an automatic part of a patient's treatment plan.To conclude, mandatory unquestioned the use of tracheostomy in every head and neck oncological case should be avoided and its use should be limited to the situations where overnight intubation is not feasible, prolonged duration of postoperative intubation is required, or it is anticipated that return visits will be made by the patient.

CLINICAL SIGNIFICANCE
The clinical significance of this study is to show that the mortality and morbidity associated with a tracheostomy can be avoided.Overnight intubation is the modality to replace tracheostomy and can be considered as the gold standard.

Table 1 :
Site of the tumor

Table 3 :
Surgical technique used

Table 4 :
Neck dissection done

Table 5 :
Depicts Reconstruction done