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Limited dissection and early primary closure of the tracheostomy stoma in head and neck oncology operations: a retrospective study of 158 cases

Limited dissection and early primary closure of the tracheostomy stoma in head and neck oncology operations: a retrospective study of 158 cases

International Journal of Oral & Maxillofacial Surgery, 2015-03-01, Volume 44, Issue 3, Pages 297-300, Copyright © 2014 International Association of Oral and Maxillofacial Surgeons


Tracheostomy is an efficient and widely used method to secure a patent airway in patients undergoing major oral and maxillofacial oncology operations. The inferiorly based Björk flap technique, through a limited incision, followed by early primary skin closure, has been the preferred method in our unit. Patients who underwent tracheostomy for major oral and maxillofacial oncology operations during the period June 2005 to December 2012 were reviewed. Age, gender, preoperative diagnosis, duration the tracheostomy tube was in situ , tracheostomy-associated complications, and long-term sequelae were evaluated. A total 158 tracheostomies were performed using the same surgical approach in patients aged 18–84 years (median 59, mean 58.2, standard deviation 14.24 years). The time the tracheostomy tube was in situ ranged from 3 to 40 days (median 7, mean 9.0, standard deviation 6.52 days). The complication rate was 5.06% (8/158 patients). A major concern highlighted in previous publications is the risk of surgical emphysema with early closure. In this study, no patients developed surgical emphysema, tracheal fistula, clinical tracheal stenosis, or cosmetically unacceptable scarring of the neck. No patient died of a tracheostomy-related cause. In summary, the Björk flap with early primary closure of the skin by simple sutures provides a safe and easily managed approach, causing minimal postoperative morbidity.

Essential in all major oral and maxillofacial oncology operations is a patent airway both intra- and postoperatively. A surgical airway (tracheostomy) is a common surgical procedure, which may be performed using various surgical techniques. Tracheostomy treatment has been used in oral and maxillofacial oncology surgery for a long time, and is considered to be a procedure with a relatively low frequency of adverse events. However, due to the risk of adverse events, such as surgical emphysema, tracheal stenosis, tracheostomy obstruction, bleeding, pneumothorax, and even death, there are those advocating that tracheostomy treatment should only be used in a few selected cases.

In this study, a Björk (inferiorly based) tracheal flap, as first described in 1960, was used in all cases. Tracheostomies were performed through a 2-cm horizontal skin incision using a modified limited vertical dissection with early primary closure of the cutaneous tracheostomy opening after removal of the tracheostomy, with no downsizing. The aim of this study was to review the short- and long-term complications, including the incidence of surgical emphysema and the cosmetic outcome of the skin incision, for elective tracheostomies used for supportive airway management in major oral and maxillofacial oncology operations, performed in the unit. A detailed description of the surgical technique is presented.

Materials and surgical technique


Patient data from consecutive subjects who required an elective tracheostomy for major oral and maxillofacial oncology surgery at our unit, were collected during the period 1 June 2005 to 31 December 2012 (91 months). A dedicated tracheostomy nurse supports all patients with a tracheostomy for the head and neck teams in the hospital. The nurse collects all patient information with regards to their tracheostomy and enters this into a database. Patient age, gender, indications, operative details, time the tracheostomy tube was in situ , and complications associated with the tracheostomy treatment were analyzed. The statistical analysis was performed using GraphPad Prism version 5.0a software (GraphPad Software Inc., San Diego, CA, USA).

Surgical technique

Tracheostomies were performed under general anaesthesia at the beginning of each oncology operation. A 2-cm horizontal midline incision equidistant to the suprasternal notch and the hyoid bone (level of the lower border of the cricoid cartilage) was made to gain access. The skin incision was kept to the minimum (2 cm). A vertical incision through the cervical fascia and deep fascia to the infrahyoid muscles was made. The infrahyoid muscles, i.e., the strap muscles, were separated in the midline vertically by blunt dissection with scissors to the pretracheal fascia. This dissection was kept to the anterior of the trachea to ensure the neck dissection could be performed without breaching the fascial support of the tracheostomy.

The cricoid was identified and a transverse incision made, just below the cricoid, to release the pretracheal fascia and allow blunt exposure of tracheal rings 1–4. When encountered, the thyroid isthmus was mobilized off the trachea and gently retracted downwards. In no case was the thyroid isthmus divided. Subsequently an inverted U-shaped incision with an inferior base was made through tracheal rings 3 and 4. The flap was secured with a 3-0 Vicryl suture, placed between the third and fourth tracheal ring, and attached to the inferior deep cervical fascial edge. A tracheostomy tube (Shiley size 6 (female) or size 8 (male); Covidien plc, Dublin, Ireland) was then inserted into the trachea as the anaesthetist slowly withdrew the endotracheal tube. The low-pressure tracheal cuff was inflated immediately after insertion of the tube. The tracheostomy tube used was a fenestrated outside tube with an inner non-fenestrated tube to allow ventilation and prevent aspiration. The tracheostomy tube was then coupled to the anaesthetic equipment, CO 2 return confirmed, and held in place, while the tracheostomy wings were secured with four 2-0 silk sutures to the skin. Postoperatively, when safe (usually at 24–48 h), the cuff was deflated and when tolerated by the patient, the inner tube was converted to a fenestrated tube, enabling the patient to speak. When the airway was safe, usually at days 5–7, local anaesthetic was given (2% lidocaine with 1:80,000 adrenaline), the tracheostomy tube was removed, a 3-0 Vicryl suture was placed to hold the soft tissues gently together, and the skin closed using three or four simple Ethilon 5-0 sutures to the skin. An antibiotic ointment was applied to the area. If for some reason the patient could not be decannulated at days 5–7, the tracheostomy was downsized to the next size Shiley (in men from a size 8 to a 6, and in women from a size 6 to a 4) and when removed the closure was done as above.


During the period of the study (91 months), elective tracheostomies were performed on 158 patients who underwent major oral and maxillofacial oncology surgery. Patients ranged in age from 18 to 84 years (median 59, mean 58.2, standard deviation 14.24 years) ( Fig. 1 ); 107 were males and 51 were females. The indication in all patients was to secure a patent airway intra- and postoperatively for major head and neck oncology surgery. The duration that the tracheostomy tube was left in situ ranged from 3 to 40 days (median 7, mean 9.0, standard deviation 6.52 days), with removal for the majority at days 5–7 ( Fig. 2 ).

Age when treated with a tracheostomy.
Fig. 1
Age when treated with a tracheostomy.

Number of days the tracheostomy tube was in situ .
Fig. 2
Number of days the tracheostomy tube was in situ .

Complications associated with the tracheostomy treatment occurred in eight of the 158 patients, resulting in a complication rate of 5.06% ( Table 1 ). All complications were minor in character. Patients were assessed daily from all aspects including a respiratory point of view. A chest X-ray was taken if any respiratory symptoms were noted. After decannulation and discharge from hospital, all patients were followed-up as outpatients and aesthetic outcome complications of the tracheostomy site were assessed.

Table 1
Complications associated with tracheostomies.
Patient Age, years Gender Days tubes in situ Complication
1 63 M 4 Desaturation due to mucous plug. Airway suctioned.
2 65 F 14 Fistula. Managed with occlusive dressing.
3 62 M 26 Desaturation on decannulation. New tube inserted.
4 59 M 8 Minor bleeding from site. Managed on the ward.
5 52 M 32 Patient pulled balloon from tube. New tube inserted.
6 82 F 6 Minor bleeding from site. Managed on the ward.
7 68 M 14 Minor bleeding from site. Managed on the ward.
8 66 M 13 Aspiration pneumonia. Resolved with antibiotics.
M, male; F, female.


In this retrospective study of tracheostomy treatments, a modified version of the Björk flap technique is presented. The treatment outcomes of this technique in terms of complications, the complication rate, and long-term sequelae were investigated. Previous studies have shown that the complication rate associated with elective tracheostomies for oral and maxillofacial oncology surgery is in the range of 4.1–11%, which is similar to the data presented here.

Few complications were found in this study (5%); these were relatively minor in nature, and all were managed on the ward or in the intensive care unit without surgical intervention. All complications seen in our patient cohort occurred when the tracheostomy tube was in situ , or during the first days after tube removal. Interestingly, none of the patients developed surgical emphysema. We speculate that the paucity of surgical emphysema is a result of the limited dissection, which preserves the fascial support, i.e., no communication between the tracheostomy dissection and the field of the neck dissection. Only one case of pneumonia was identified. The infrequency of respiratory complications in this study, we believe, may reflect the extensive tracheostomy nursing care programme in place, with theatre, ward, and patient education provided. Longstanding complications including clinically evident tracheal stenosis were not seen in any of the patients. Since no clinical signs of tracheal stenosis were found, no patients were evaluated for tracheal stenosis using endoscopy. We cannot exclude that minor or subclinical tracheal stenosis occurred. In cases where the tracheostomy was left in situ for a longer than average time, the tracheostomy was downsized to a non-cuffed tube as soon as possible. We believe that the initial low-pressure tube and the downsizing procedure contributed to the paucity of clinically evident tracheal stenosis seen in our patient cohort. The skin incision used in this technique is significantly shorter than the standard approach, enabling a more local dissection, resulting in a smaller scar. No patient demonstrated skin–tracheal adhesions leading to unsightly skin tethering on swallowing. Furthermore, no patient died or had any life-threatening complication associated with the tracheostomy.

Our data confirm that the Björk flap tracheostomy treatment (inferiorly hinged) to secure a patent airway intra- and postoperatively in major oral and maxillofacial oncology surgery is a safe and efficient method. These results are in line with those of a recent study by Coyle et al. performed in 2013 that also showed no long-term complications associated with tracheostomies. Coyle et al. suggested that tracheostomies should not be used as a routine procedure if a less invasive alternative is possible, e.g., overnight intubation, since the use of tracheostomies in their study prolonged the hospital stay and therefore costs. Although a tracheostomy is a relatively safe procedure, we also believe that its use should be limited to cases where there is a significant risk to the airway and if extubation may not be possible for the first 3 days postoperatively. The hospital time was not prolonged in our patients due to the use of tracheostomy, and the patients were discharged early from the intensive care unit or high dependency unit to the ward with the tracheostomy in place.

The modifications to the Björk flap dissection technique described here have the advantage of enabling easy early closure of the skin wound, leaving minimal scarring, and no skin–tracheal adhesions. This technique was used in 158 cases and we saw no case of surgical emphysema despite early skin closure. Because of the comparatively small incision, limited vertical dissection, bloodless field and access made in this approach, the surgery is easier once competence is obtained, but initially higher demand on surgical experience is needed in comparison to other techniques. In summary, although tracheostomies are associated with complications, we would argue, that if performed with caution and for selected cases, by experienced/competent surgeons, the overall risk of any complications, even minor, is small.



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