Why is elective tracheostomy (elective creation of an airway in the trachea) done in midline tongue resection?

Elective Tracheostomy in Midline Tongue Resection

Elective tracheostomy is performed in midline tongue resection primarily to secure the airway and prevent potentially fatal airway obstruction due to postoperative edema, bleeding, or anatomical changes following surgery. 1

Indications for Elective Tracheostomy in Tongue Resection

Midline tongue resection, particularly for neoplastic diseases, presents significant risks to the airway that necessitate preventive measures:

1. Postoperative edema: Surgical manipulation of the tongue and surrounding tissues causes significant swelling that can compromise the airway
2. Risk of hemorrhage: Bleeding into the oral cavity can obstruct the airway
3. Anatomical changes: Resection of tongue tissue alters the normal airway anatomy
4. Prolonged intubation requirements: Many patients require extended ventilatory support

In maxillofacial surgery, tracheostomy is specifically indicated for oncologic conditions involving the tongue base, oral cavity, and pharyngeal regions 2. Among 198 patients who underwent tracheostomies in a retrospective study, 64.14% were performed for neoplastic diseases, including tongue tumors 2.

Benefits of Elective vs. Emergency Tracheostomy

Elective tracheostomy offers significant advantages over emergency procedures:

• Lower complication rates: A 10-year retrospective review showed significantly fewer complications in elective cases (46%) compared to emergency cases (54%) (p=0.0002) 3
• Better planning: Allows for proper patient preparation and optimal surgical conditions
• Reduced mortality: Overall mortality rate was only 2.2% in the studied population 3

Clinical Considerations for Tracheostomy Timing

The decision for tracheostomy should be made as soon as the need for prolonged airway access is identified, generally within 7-10 days 4. For midline tongue resection, this is typically planned preoperatively due to the predictable risk of airway compromise.

Benefits of early tracheostomy include:

• Patient comfort
• Improved safety
• Better ability to communicate
• Enhanced oral and airway care
• Potentially shorter ICU stays and mechanical ventilation duration 4

Potential Complications to Monitor

While necessary, tracheostomy carries risks that require vigilant management:

• Intraoperative complications: Bleeding (16.2%), pretracheal or paratracheal tube placement (1.51%) 2
• Postoperative complications: Subcutaneous emphysema (13.12%), tracheostomy dehiscence (2.52%) 2
• Infectious complications: Most common, representing 43% of all complications 3

Alternative Approaches

Recent evidence suggests that routine elective tracheostomy may not be necessary for all patients undergoing maxillofacial reconstruction. A 2022 study found that younger patients with fewer comorbidities may be safely managed with overnight intubation (delayed extubation) rather than elective tracheostomy 5.

However, for midline tongue resection specifically, the risk of airway compromise remains high, and elective tracheostomy continues to be the standard approach for most patients to ensure airway security.

Key Practice Points

• Multidisciplinary planning involving anesthesiologists, surgical specialists, and perioperative nurses is essential 1
• Patients requiring long-term tracheostomy must receive education on home care before discharge 3
• The surgical technique should follow anatomical markers to minimize risks 2
• Regular follow-up is crucial for patients with tracheostomy 3