Does Elective Tracheostomy Reduce the Incidence of Airway Complications and Adverse Outcomes in Free Flap Reconstruction of Oral Cavity Malignancies?

Elective tracheostomy is commonly performed to secure the airway following major oncologic and reconstructive head and neck procedures, though it carries risks of additional morbidity and may not be necessary in all cases. The purpose of this study was to evaluate the association between elective tracheostomy and postoperative airway complications. This was a retrospective cohort study of all patients undergoing resection and free flap reconstruction of an oral cavity cancer from 2012 to 2022 in the American College of Surgeons National Surgical Quality Improvement Program databases. The primary predictor was elective tracheostomy. The primary outcome was the occurrence of any airway complication within 30 days of surgery. Secondary outcomes included adverse discharge disposition, extended length of hospital stay, 30-day mortality, and readmission. A total of 2722 subjects (mean age 62.4±13.1 y, 66.2% male) were included, with 195 experiencing an airway complication (7.16%). In adjusted analysis, longer operative time (P<0.001) and mandibular osteotomies (P=0.050) were the only independent predictors of airway complications. Elective tracheostomy was not associated with airway complications or secondary outcomes, but was independently associated with a 75% reduction in the odds of 30-day mortality (P=0.001). These findings suggest that while elective tracheostomy is not required in every case, it may confer a survival benefit in select patients. Decisions regarding tracheostomy should be individualized based on patient characteristics, anatomy, and surgical complexity.