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; SCS-17-0843; Total nos of Pages: 3;
SCS-17-0843
BRIEF CLINICAL STUDIES
Role of Swallowing Function of
Tracheotomised Patients in
Major Head and Neck
Cancer Surgery
Alexander K. Bartella, MD, Mohammad Kamal, MD, DMD,
Sean Berman,y Timm Steiner, MD, PhD, Dirk Frölich, MD,z
Frank Hölzle, MD, PhD, and Bernd Lethaus, MD, PhD
Introduction: Tracheotomy is a frequent procedure in extended
head and neck cancer surgery and known to be a risk factor for
prolonged hospitalization. The authors hypothesized that the clini-
cal course and delayed decannulation of patients are not only
influenced by airway narrowing, but also by a compromised
postoperative swallowing function.
Material and Methods: The investigators implemented a retro-
spective cohort study. The sample was composed of a tertiary care
center patients who underwent major head and neck cancer surgery,
each receiving a tracheostomy. Data collected include general
clinical data as well as endoscopical evaluation of swallowing
function and aspiration rate. Descriptive and bivariate statistics
were computed and the P value was set at.05.
Results: The sample was composed of 96 patients with an average
age of 64.2 and sex ratio of 1.4:1 (m:f). There was a strong
statistically significant relation between swallowing function and
timing of decannulation (P < 0.001) and duration of hospitalization
(P < 0.001). Age (P ¼ 0.55), sex (P ¼ 0.54), tumor size (P ¼ 0.12),
general diseases (P ¼ 0.24), distant metastases (P ¼ 0.15), or extent
of neck dissection (P ¼ 0.15) were not significantly associated to
swallowing function. Permanent cannulation was significantly
correlated to a primary cancer of the soft palate or base of the
tonge (P < 0.001).
Conclusion: The results of this study confirm the importance of the
evaluation of swallowing function before the removal of the
tracheotomy cannula in head and neck cancer patients.
Key Words: oral squamous cell carcinoma, postoperative care,
swallowing function, tracheotomy
T racheotomy is a routine procedure in extended head and neck
cancer surgery owing to the vital role of airway security.
Although tracheotomies are frequently performed, optimal timing
for postoperative decannulation remains uncertain. In literature,
many factors influencing airway management are described. Large
From the Department of Oral, Maxillofacial and Plastic Facial Surgery;
ySchool of Biological Sciences, Louisiana Tech University, Ruston, LA;
and zDepartment of Phoniatry and Pedaudiology, University Hospital of
Aachen University, Aachen, Germany.
Received May 30, 2017.
Accepted for publication August 8, 2017.
Address correspondence and reprint requests to Alexander K. Bartella, MD,
Resident, Department of Oral, Maxillofacial and Plastic Facial Surgery,
University Hospital of Aachen University, Pauwelsstraße 30, 52074
Aachen, Germany; E-mail: abartella@ukaachen.de
The authors report no conflicts of interest.
Copyright # 2017 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000004099
The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2017
Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
tumor size, glossectomy, smoking, and reconstruction with an
anterior lateral thigh (ALT)-flap are known predictors for a failed
or delayed decannulation.1
However, not only narrowed upper airways have to be consid-
ered before decannulation. A frequently underestimated problem
appears to be (silent-) aspiration of saliva and food because of
impaired postoperative swallowing function. A cannula with a
blocked cuff is known to reduce the conduction of saliva or food
to the lower airways and thus participates in protection from
respiratory tract infections.2
Nevertheless, patients do not only benefit from tracheotomies.
There is a significant correlation between delayed decannulation
and higher nosocomial morbidity, delayed social integration, and a
prolonged hospitalization.3 –6
In postoperative care, potential benefits of early decannulation
on the one hand and increased risk of narrowed airways and
aspiration on the other hand have to be weighted out. Although
airway narrowing can be observed clinically by the removal of the
cannula and subsequent temporary taping of the tracheotomy site,
the presence of (silent-) aspirations is clinically hard to monitor.
Aim of the study is to evaluate the postoperative swallowing
function in patients with oral squamous cell carcinoma who had
undergone major head and neck cancer surgery. We focussed on
the influence of swallowing function on the clinical course and
risk factors that have to be considered before decannulation of
patients.
MATERIAL AND METHODS
In this retrospective study, 96 consecutive patients who underwent
extended head and neck cancer surgery (defined as oral cancer
resection, neck dissection of at least three levels, microvascular free
tissue transfer, and tracheotomy) because of primary head and neck
cancer were included. The study period ranged from January 2015
until July 2016.
Patients were screened for sex, age, general diseases, pathologi-
cal TNM formula and localization of tumor. Intra- and postopera-
tive parameters included the duration in intensive care unit (ICU)
and hospitalization, necessity of postoperative percutaneous endo-
scopic gastrostomy (PEG) for nutrition, timing of decannulation,
and operative tracheostomy closure.
Oral nutrition was rated according to Table 1. (Silent-) aspiration
was further valued by a specialty trained phoniatrist on 4th day in
standard care by the use of an endoscopic pharyngoscopy, examin-
ing the glottis closure during swallowing (Table 2).
Spearman rank correlation coefficient was calculated as a
measure of the association between 2 ordinal or metric variables
and Pearson x2 test was applied to sets of unpaired categorical data.
Independent sample t test was performed for the measure of
statistical differences between 2 metric variables. Statistical evalu-
ation was performed by the use of SPSS version 23.0 (SPSS Inc,
TABLE 1. Clinical Appearance of Swallowing Function
Grade Appearance
0 Swallowing function as preoperative. Patient is able to consume
liquid and solid food.
1 Patient is able to consume all types of food, but in small portions.
2 Patient is not able to consume liquids without coughing and aspiration.
3 Patient is not able to consume any food without coughing and aspiration.
For an objectivation of clinical appearance of swallowing function, patients were
rated according to Table 1. Patients with grade 2 and 3 were limited in daily nutritional
routines.
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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.
In 18 patients (18.8%), a decannulation on the 4th postoperative day
or sooner was conducted. Of them, 6 needed to be recannulated
during the clinical course because of an episode of dyspnea.
Eighteen patients (18.8%) became permanently cannulated and
further received a PEG tube for sufficient nutrition (Table 3).
Permanent cannulation was significantly associated (P < 0.001)
with a tumor resection at some part of the muscular sphincter
system involved in initiation of swallowing, namely base of the
tongue (n ¼ 5) and and the soft palate (n ¼ 7).
Timing of decannulation was significantly negatively correlated
with swallowing function (P < 0.001) and aspiration (P < 0.001),
meaning the worse the swallowing function the later the decannula-
tion. Furthermore, duration of cannulation was significantly related
with respiratory infections (P < 0.001) as well as length of hospi-
talization (P < 0.001) and stay in ICU (P < 0.001). Likewise,
permanent supply with a tracheostomy cannula was significantly
related to the duration of hospitalization (P ¼ 0.001), problems with
aspiration (P < 0.001), and swallowing (P < 0.001). Age
(P ¼ 0.55), sex (P ¼ 0.54), and stay on ICU (P ¼ 0.42) were not
significantly associated. The clinical course of decannulation is
summarized in Table 3.
There was no significant association of tumor size (P ¼ 0.12),
distant metastases, or extent of neck dissection (P ¼ 0.15) to timing
of postoperative decannulation. General diseases (P ¼ 0.24) other
than squamous cell carcinoma were also not significantly related to
duration of cannulation.
Emphysema after surgical closure of tracheostomy was seen in 7
cases (14.6%). Wound dehiscence was noticed at the site of
previously closed tracheotomy in 4 patients (8.3%). Dehiscences
were not closed again, but left to granulation.
Duration until decannulation related to primary cancer site can
be found in Table 4. Suiting our above-mentioned findings, patients
with primary cancer site at the soft palate were dependent on the
blocked cannula for the longest time (on average 12 days). Shortest
time of cannulation was seen in patients with primary cancer site at
the hard palate (5 days postoperatively) and buccal mucosa (5.5
days postoperatively).
DISCUSSION
Temporary tracheostomy is considered a routine procedure in
oncologic head and neck surgery to ensure a postoperative safe
airway and to prevent aspiration of food and saliva in the first days
after surgery. However, it is described by many patients as an
extraordinary burden in their therapeutic process and is known to
have consequences on the healing process and life quality.7– 9
Girod et al10 declare the presence of a tracheostomy as a
significant factor prolonging hospitalization. Likewise, we could
find a significant correlation (P < 0.001) between the timing of
decannulation and the duration of hospitalization, suggesting the
earlier patients were decannulated the sooner they were discharged.
However, similar to other authors, we could confirm that
postoperative timing of decannulation was neither associated with
the extent of TNM-formula, nor age (P ¼ 0.55), nor sex(p ¼ 0.54),
nor general diseases of patients (P ¼ 0.24); the question rises which
factors have to be taken into account before decannulation.11
Doubtless, the most vital problem is airway narrowing owing to
postoperative swelling. Guerlain et al12 describe a peak inspiratory
flow of 40ı̈mL/I as threshold for successful decannulation.
Another important factor is the swallowing function. We exam-
ined our patients endoscopically on the 4th day of normal care for
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)

2 # 2017 Mutaz B. Habal, MD

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The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2017
Either result was significantly (P < 0.001) negative correlated to
prolonged cannulation of patients. This is also reflected in patients
with a long-term gastrostomy tube placement and long-term can-
nulation owing to impaired swallowing function (n ¼ 18; 18.9%).
Those results endorse the importance of the swallowing function
for the clinical course, but raising the question for the therapeutical
consequence. We could show problems with swallowing in partic-
ular when the primary cancer was located at the base of the tongue
or soft palate. As those anatomical structures are crucial for
initiating the swallowing bolus, cancer resection at those distinct
sites seems to increase postoperative probability for severe pro-
blems with swallowing function and subsequent long-term cannu-
lation and PEG tube supply.13 These findings describe the necessity
of tracheotomies in patients with cancer resections at the tongue or
soft palate, not only because of airway narrowing, but also because
of potential aspiration pneumonia. Clinicians should be aware of
mentioned risk factors before early decannulation of patients with
primary cancer at those distinct anatomical sites.
A drawback of this study is that we did not examine all patients
on the same postoperative date in consideration of their general
condition. Instead, patients were examined on the 4th day of
standard care. Furthermore, in this study, only observations during
the hospitalization were considered. Especially in regard to swal-
lowing function, a long-term evaluation would be interesting.
Summarizing the findings of our study we can conclude:
(1) Location of primary cancer site appears to affect the
postoperative swallowing function more than tumor size.
(2) Swallowing function should be considered before decannula-
tion, especially in patients with primary cancer site at soft
palate or base of the tongue.
(3) Early decannulation and appropriate swallowing function
seem to have a significant impact on postoperative
rehabilitation process.
CONCLUSION
Patients with extended cancer surgery at the tongue or soft palate tend
to have severe problems with swallowing. In those patients, we
recommend endoscopical examination of swallowing function before
removal of the blocked cannula for the prevention of aspiration.
# 2017 Mutaz B. Habal, MD
Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Brief Clinical Studies
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