Documente Academic
Documente Profesional
Documente Cultură
From the Department of Oral, Maxillofacial and Plastic Facial Surgery; TABLE 1. Clinical Appearance of Swallowing Function
ySchool of Biological Sciences, Louisiana Tech University, Ruston, LA;
and zDepartment of Phoniatry and Pedaudiology, University Hospital of Grade Appearance
Aachen University, Aachen, Germany.
Received May 30, 2017. 0 Swallowing function as preoperative. Patient is able to consume
Accepted for publication August 8, 2017. liquid and solid food.
Address correspondence and reprint requests to Alexander K. Bartella, MD, 1 Patient is able to consume all types of food, but in small portions.
Resident, Department of Oral, Maxillofacial and Plastic Facial Surgery, 2 Patient is not able to consume liquids without coughing and aspiration.
University Hospital of Aachen University, Pauwelsstraße 30, 52074 3 Patient is not able to consume any food without coughing and aspiration.
Aachen, Germany; E-mail: abartella@ukaachen.de
The authors report no conflicts of interest. For an objectivation of clinical appearance of swallowing function, patients were
Copyright # 2017 by Mutaz B. Habal, MD rated according to Table 1. Patients with grade 2 and 3 were limited in daily nutritional
ISSN: 1049-2275 routines.
DOI: 10.1097/SCS.0000000000004099
The Journal of Craniofacial Surgery Volume 00, Number 00, Month 2017 1
Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
CE: R.R.; SCS-17-0843; Total nos of Pages: 3;
SCS-17-0843
Brief Clinical Studies The Journal of Craniofacial Surgery Volume 00, Number 00, Month 2017
TABLE 2. Endoscopical Evaluation of Aspiration TABLE 3. Patients With Permanent Tracheotomy Tube and PEG Tube Compared
to Patients With Temporary Tracheotomy
Grade Swallowing Function
Permanent Tracheotomy Temporary
0 No aspiration. Sufficient glottic closure during swallowing. and PEG Tracheotomy P
1 Minor aspiration of liquid food, otherwise sufficient glottic
closure during resting state and swallowing. Number 6 42
2 Aspiration in case of larger jelly bolus and major aspiration of Age 64 65 0.55
liquid foods. No sufficient glottic closure during swallowing food. General diseases 0.7 0.9 0.66
3 Aspiration of small portions of jelly. Insufficient glottis closure even T-stagey 2.1 2.2 0.83
in resting state. N-stagey 1.4 0.8 0.26
M-stagey 0 0 —
Patients were examined on the 4th day on normal ward by a trained phoniatrist. First
glottis closure in resting state was examined for sufficiency, followed by the closure Hospitalization, days 21.6 16.3 <0.001
during oral jelly intake, if which did not lead to aspiration, the ability to drink water was Swallowing function 1.9 0.3 <0.001
rated instead. Aspiration 2.3 0.5 <0.001
This table emphasizes the role of swallowing for the clinical outcome regarding
long-term cannulation and PEG tube supply. PEG indicates percutaneous endoscopic
Chicago, IL). Values with a P < 0.05 were considered to gastrostomy.
be significant. Significant general diseases were each rated with 1 point and summed up.
y
Grading according to TNM formula.
RESULTS
Patients were on average 64.2 years’ old, sex ratio (m:f) was 1.4:1. Duration until decannulation related to primary cancer site can
In 18 patients (18.8%), a decannulation on the 4th postoperative day be found in Table 4. Suiting our above-mentioned findings, patients
or sooner was conducted. Of them, 6 needed to be recannulated with primary cancer site at the soft palate were dependent on the
during the clinical course because of an episode of dyspnea. blocked cannula for the longest time (on average 12 days). Shortest
Eighteen patients (18.8%) became permanently cannulated and time of cannulation was seen in patients with primary cancer site at
further received a PEG tube for sufficient nutrition (Table 3). the hard palate (5 days postoperatively) and buccal mucosa (5.5
Permanent cannulation was significantly associated (P < 0.001) days postoperatively).
with a tumor resection at some part of the muscular sphincter
system involved in initiation of swallowing, namely base of the DISCUSSION
tongue (n ¼ 5) and and the soft palate (n ¼ 7). Temporary tracheostomy is considered a routine procedure in
Timing of decannulation was significantly negatively correlated oncologic head and neck surgery to ensure a postoperative safe
with swallowing function (P < 0.001) and aspiration (P < 0.001), airway and to prevent aspiration of food and saliva in the first days
meaning the worse the swallowing function the later the decannula- after surgery. However, it is described by many patients as an
tion. Furthermore, duration of cannulation was significantly related extraordinary burden in their therapeutic process and is known to
with respiratory infections (P < 0.001) as well as length of hospi- have consequences on the healing process and life quality.7– 9
talization (P < 0.001) and stay in ICU (P < 0.001). Likewise, Girod et al10 declare the presence of a tracheostomy as a
permanent supply with a tracheostomy cannula was significantly significant factor prolonging hospitalization. Likewise, we could
related to the duration of hospitalization (P ¼ 0.001), problems with find a significant correlation (P < 0.001) between the timing of
aspiration (P < 0.001), and swallowing (P < 0.001). Age decannulation and the duration of hospitalization, suggesting the
(P ¼ 0.55), sex (P ¼ 0.54), and stay on ICU (P ¼ 0.42) were not earlier patients were decannulated the sooner they were discharged.
significantly associated. The clinical course of decannulation is However, similar to other authors, we could confirm that
summarized in Table 3. postoperative timing of decannulation was neither associated with
There was no significant association of tumor size (P ¼ 0.12), the extent of TNM-formula, nor age (P ¼ 0.55), nor sex(p ¼ 0.54),
distant metastases, or extent of neck dissection (P ¼ 0.15) to timing nor general diseases of patients (P ¼ 0.24); the question rises which
of postoperative decannulation. General diseases (P ¼ 0.24) other factors have to be taken into account before decannulation.11
than squamous cell carcinoma were also not significantly related to Doubtless, the most vital problem is airway narrowing owing to
duration of cannulation. postoperative swelling. Guerlain et al12 describe a peak inspiratory
Emphysema after surgical closure of tracheostomy was seen in 7 flow of 40ı̈mL/I as threshold for successful decannulation.
cases (14.6%). Wound dehiscence was noticed at the site of Another important factor is the swallowing function. We exam-
previously closed tracheotomy in 4 patients (8.3%). Dehiscences ined our patients endoscopically on the 4th day of normal care for
were not closed again, but left to granulation. swallowing function and clinical eating abilities (Tables 1 and 2).
TABLE 4. Localization of Primary Cancer and Day of Postoperative Decannulation. Majority of Patients With the Soft Palate or the Base of the Tongue as a Primary
Cancer Site Had to be Cannulated Permanently
Buccal Alveolar Crest of Anterior Floor of the Lateral Tongue Base of the Hard Palate Soft Palate
Localization Mucosa the Mandible (n ¼ 6) Mouth (n ¼ 14) (n ¼ 9) Tongue (n ¼ 4) (n ¼ 3) (n ¼ 5)
Number of patients 4 6 14 9 4 3 5
Postoperative day of decannulation 5.5 9.16 8.7 6.6 7 5 12
Permanent cannulation 0% (n ¼ 0) 17% (n ¼ 1) 14% (n ¼ 2) 0% (n ¼ 0) 75% (n ¼ 3) 0% (n ¼ 0) 60% (n ¼ 3)
Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
CE: R.R.; SCS-17-0843; Total nos of Pages: 3;
SCS-17-0843
The Journal of Craniofacial Surgery Volume 00, Number 00, Month 2017 Brief Clinical Studies