Is Nasotracheal Intubation Safe in Surgery for Mandibular Cancer? Tarja Randell, MD, PhD; Anna-Lisa S\l=o"\derholm, MD, DDS, PhD; Christian Lindqvist, MD, DDS, PhD \s=b\ A retrospective study of problems of postoperative airway
maintenance after surgery for mandibular cancers was conducted. Twenty-seven patients treated in an intensive care unit after mandibular resection and primary reconstruction were included. The mean duration of nasotracheal intubation in 22 patients was 33.7 hours. Reintubation because of breathing difficulties was required in four cases. In one of these cases, failed intubation led to an emergency cricothyroidostomy. Failure to perform reintubation resulted in the death of one patient. One patient was tracheostomized after 5 days of nasotracheal intubation. Prolonged nasotracheal intubation after major surgery for oral malignant neoplasms may be an alternative to tracheostomy, provided that adequate monitoring is available after extubation. The safe duration of endotracheal intubation is difficult to determine. Primary reconstruction does not eliminate the need for an artificial airway after tumor surgery. (Arch Otolaryngol Head Neck Surg. 1992;118:725-728) of patent airway after oral orophaMaintenance ryngeal surgery is of the importance. Major which results is followed tissue a
or
utmost
tumor
surgery
by
edema,
in risk of a compromised airway. In cases of mandibular resection including the symphysis region, the suprahyoidal musculature loses its bony support, resulting in a pre¬
disposition to upper airway obstruction.1 Tracheostomy has been considered essential in surgery for oral malignant neoplasms,2 especially for tumors involving the mandible. However, tracheostomy can be
associated with various complications.2-3 It can also inter¬ fere with transposition of a tissue flap and can be a source of infection. Nasotracheal intubation is an alternative to tracheostomy.4 However, the disadvantages of prolonged nasotracheal intubation include a high incidence of sinusi¬ tis.5,6 In cases of accidental extubation, immediate reinser¬ tion of the tube can also prove difficult, even impossible, especially in patients with intermaxillary fixation or marked postoperative edema.
Accepted
for publication From the Departments of Anesthesia (Dr Randell), Maxillofacial Surgery (Drs S\l=o"\derholmand Lindqvist), Fourth Department of Surgery, Helsinki (Finland) University Central Hospital. Reprint requests to Department of Maxillofacial Surgery, Surgical Hospital, Helsinki University Central Hospital, Kasarmikatu 11-13, SF\x=req-\ 00130 Helsinki 13, Finland (Dr Lindqvist). October 17, 1991.
With modern reconstruction methods,
postoperative in¬
termaxillary fixation can be avoided.7 Various rigid plates also now allow reattachment of the suprahyoid muscula¬
ture, which supports the tongue. Primary reconstruction of the mandible in tumor surgery may therefore decrease the need for artificial airways during the immediate postoper¬ ative period. This retrospective study was carried out to determine whether or not nasotracheal intubation is safe in surgery for mandibular malignant neoplasms with primary recon¬ struction. Three case reports are presented.
SUBJECTS AND METHODS The records of all patients requiring surgery for malignant oral tumors between 1986 and 1990 at Helsinki (Finland) University Central Hospital were reviewed. Fifty-three of these patients were treated in the intensive care unit (ICÜ). A detailed analysis of post¬ operative airway maintenance was conducted in 27 patients who had undergone mandibular resection and primary reconstruction (Table 1). Eighteen patients underwent hemimandibulectomy. In seven cases, exarticulation was also performed. In 10 cases, the symphysis region was resected. Seven of the resections of the symphysis were combined with removal of either body area. In two of them, the mandibular condyle was also included in the resection (Figure). One patient underwent two resections of the mandible. Rigid plates were used for primary hard-tissue reconstruction in each case. Different composite flaps were raised for soft-tissue re¬ construction in 23 cases. The length of the operation was 9.4±2.8 hours (mean±SD) (range, 4 to 15 hours). All patients had an artificial airway postoperatively. The trachea was not extubated until the surgeon had examined the operative field and oropharynx. Marked edema was considered a contraindi¬ cation to extubation. The length of operation and administration of corticosteroids were recorded. The route of intubation, the length of intubation, and the duration of stay in the ICU were also recorded. Airway complications were analyzed in detail. The results are presented as mean±8D and range. Analysis of variance for factorial measures was used for comparisons of parametric data between different groups. We considered val¬ ues of less than .05 to indicate statistical significance. RESULTS Five patients were tracheostomized before surgery. The patients were decannulated after 10±5 days (range, 5 to 14 days). None of these patients were decannulated in the ICU. In two of these patients, minor airway problems were encountered (Table 2). Twenty-two patients were intubated nasotracheally using an endotracheal tube with a
Downloaded From: http://archotol.jamanetwork.com/ by a Monash University Library User on 06/04/2015
Table 1.—Characteristics of 27 Patients With
Mandibular
Malignant Neoplasms
Value
Characteristic
Sex, No. M/F Mean (±SD) age, y (range) Mean (±SD) weight, kg Stage lll-IV, % Mean (±SD) length of operation, h Extent of mandibular resection, cm (range) No. with nasotracheal intubation/
Major
16/11 62±16
(25-89)
69±16 93 9.4±2.8 11 (5-19)
22/5
tracheostomy
low-pressure cuff. In one case, a rubber tube was used. The
duration of nasotracheal intubation was 33.7±30.3 hours (range, 12 to 120 hours). Extubation was performed in the ICU. In four of 22 patients, major airway problems occurred on average 12 hours after extuba tion. One patient required reintubation 20 hours after extubation. One patient died after failure to reintubate 14 hours after extu¬ bation. In one case, an emergency cricothyroidostomy was performed 10 hours after extubation (Tables 2 and 3). In one case, reintubation was needed 2.5 hours after extuba¬ tion, because of acute airway obstruction caused by clot¬ ted blood. One patient was tracheostomized on the fifth day after operation (Table 2). One patient suffered cardiac infarction and needed reintubation and mechanical venti¬ lation. The mean duration of stay in the ICU was 6 days (range, 2 to 22 days) in patients with airway problems (Ta¬ ble 2) and 2 days (range, 1 to 7 days) in patients without mean
airway complications (P
maintenance after surgery for mandibular cancers was conducted. Twenty-seven patients treated in an intensive care unit after mandibular resection and primary reconstruction were included. The mean duration of nasotracheal intubation in 22 patients was 33.7 hours. Reintubation because of breathing difficulties was required in four cases. In one of these cases, failed intubation led to an emergency cricothyroidostomy. Failure to perform reintubation resulted in the death of one patient. One patient was tracheostomized after 5 days of nasotracheal intubation. Prolonged nasotracheal intubation after major surgery for oral malignant neoplasms may be an alternative to tracheostomy, provided that adequate monitoring is available after extubation. The safe duration of endotracheal intubation is difficult to determine. Primary reconstruction does not eliminate the need for an artificial airway after tumor surgery. (Arch Otolaryngol Head Neck Surg. 1992;118:725-728) of patent airway after oral orophaMaintenance ryngeal surgery is of the importance. Major which results is followed tissue a
or
utmost
tumor
surgery
by
edema,
in risk of a compromised airway. In cases of mandibular resection including the symphysis region, the suprahyoidal musculature loses its bony support, resulting in a pre¬
disposition to upper airway obstruction.1 Tracheostomy has been considered essential in surgery for oral malignant neoplasms,2 especially for tumors involving the mandible. However, tracheostomy can be
associated with various complications.2-3 It can also inter¬ fere with transposition of a tissue flap and can be a source of infection. Nasotracheal intubation is an alternative to tracheostomy.4 However, the disadvantages of prolonged nasotracheal intubation include a high incidence of sinusi¬ tis.5,6 In cases of accidental extubation, immediate reinser¬ tion of the tube can also prove difficult, even impossible, especially in patients with intermaxillary fixation or marked postoperative edema.
Accepted
for publication From the Departments of Anesthesia (Dr Randell), Maxillofacial Surgery (Drs S\l=o"\derholmand Lindqvist), Fourth Department of Surgery, Helsinki (Finland) University Central Hospital. Reprint requests to Department of Maxillofacial Surgery, Surgical Hospital, Helsinki University Central Hospital, Kasarmikatu 11-13, SF\x=req-\ 00130 Helsinki 13, Finland (Dr Lindqvist). October 17, 1991.
With modern reconstruction methods,
postoperative in¬
termaxillary fixation can be avoided.7 Various rigid plates also now allow reattachment of the suprahyoid muscula¬
ture, which supports the tongue. Primary reconstruction of the mandible in tumor surgery may therefore decrease the need for artificial airways during the immediate postoper¬ ative period. This retrospective study was carried out to determine whether or not nasotracheal intubation is safe in surgery for mandibular malignant neoplasms with primary recon¬ struction. Three case reports are presented.
SUBJECTS AND METHODS The records of all patients requiring surgery for malignant oral tumors between 1986 and 1990 at Helsinki (Finland) University Central Hospital were reviewed. Fifty-three of these patients were treated in the intensive care unit (ICÜ). A detailed analysis of post¬ operative airway maintenance was conducted in 27 patients who had undergone mandibular resection and primary reconstruction (Table 1). Eighteen patients underwent hemimandibulectomy. In seven cases, exarticulation was also performed. In 10 cases, the symphysis region was resected. Seven of the resections of the symphysis were combined with removal of either body area. In two of them, the mandibular condyle was also included in the resection (Figure). One patient underwent two resections of the mandible. Rigid plates were used for primary hard-tissue reconstruction in each case. Different composite flaps were raised for soft-tissue re¬ construction in 23 cases. The length of the operation was 9.4±2.8 hours (mean±SD) (range, 4 to 15 hours). All patients had an artificial airway postoperatively. The trachea was not extubated until the surgeon had examined the operative field and oropharynx. Marked edema was considered a contraindi¬ cation to extubation. The length of operation and administration of corticosteroids were recorded. The route of intubation, the length of intubation, and the duration of stay in the ICU were also recorded. Airway complications were analyzed in detail. The results are presented as mean±8D and range. Analysis of variance for factorial measures was used for comparisons of parametric data between different groups. We considered val¬ ues of less than .05 to indicate statistical significance. RESULTS Five patients were tracheostomized before surgery. The patients were decannulated after 10±5 days (range, 5 to 14 days). None of these patients were decannulated in the ICU. In two of these patients, minor airway problems were encountered (Table 2). Twenty-two patients were intubated nasotracheally using an endotracheal tube with a
Downloaded From: http://archotol.jamanetwork.com/ by a Monash University Library User on 06/04/2015
Table 1.—Characteristics of 27 Patients With
Mandibular
Malignant Neoplasms
Value
Characteristic
Sex, No. M/F Mean (±SD) age, y (range) Mean (±SD) weight, kg Stage lll-IV, % Mean (±SD) length of operation, h Extent of mandibular resection, cm (range) No. with nasotracheal intubation/
Major
16/11 62±16
(25-89)
69±16 93 9.4±2.8 11 (5-19)
22/5
tracheostomy
low-pressure cuff. In one case, a rubber tube was used. The
duration of nasotracheal intubation was 33.7±30.3 hours (range, 12 to 120 hours). Extubation was performed in the ICU. In four of 22 patients, major airway problems occurred on average 12 hours after extuba tion. One patient required reintubation 20 hours after extubation. One patient died after failure to reintubate 14 hours after extu¬ bation. In one case, an emergency cricothyroidostomy was performed 10 hours after extubation (Tables 2 and 3). In one case, reintubation was needed 2.5 hours after extuba¬ tion, because of acute airway obstruction caused by clot¬ ted blood. One patient was tracheostomized on the fifth day after operation (Table 2). One patient suffered cardiac infarction and needed reintubation and mechanical venti¬ lation. The mean duration of stay in the ICU was 6 days (range, 2 to 22 days) in patients with airway problems (Ta¬ ble 2) and 2 days (range, 1 to 7 days) in patients without mean
airway complications (P
