Utilization of tracheostomy in craniomaxillofacial trauma at a level-1 trauma center

Eric P Holmgren, Shahrokh Bagheri, R Bryan Bell, Sam Bobek, Eric J Dierks
Journal of Oral and Maxillofacial Surgery 2007, 65 (10): 2005-10

PURPOSE: The decision to perform a tracheostomy on patients with maxillofacial trauma is complex. There is little data exploring the role of tracheostomy in facial fracture management. We sought to profile the utilization of tracheostomy in the context of maxillofacial trauma at our institution by comparing patients who required tracheostomy with and without facial fractures versus those with facial fractures not requiring tracheostomy.

MATERIALS AND METHODS: All patients admitted to the Trauma Service at Legacy Emanuel Hospital and Health Center (LEHHC), Portland, OR, from 1993 to 2003 that sustained facial fractures or underwent tracheostomy were identified and data were retrospectively reviewed using patient charts and the trauma registry. Variables such as age, gender, death, injury severity score (ISS), facial injury severity score (FISS), Glasgow coma score (GCS), intensive care days (ICU), hospital length of stay (LOS), facial fracture profile, and oral and maxillofacial surgery (OMFS) operative intervention were tabulated and analyzed. Data were divided into 3 groups for comparison: group 1 (ffxT) consisted of patients who underwent a tracheostomy procedure and repair of their facial fracture during the SAME operation by the OMFS department (N = 125); group 2 (ffxNT) were those patients who had repair of their facial fractures by OMFS and did not require a tracheostomy (N = 224); and group 3 (NffxT) were patients who did not have facial fractures but received a tracheostomy during their hospitalization (N = 259). Ten-year data were used to analyze the ffxT and 5-year data were used to analyze the ffxNT and NffxT. Analysis of variance and chi2 testing was used for statistical analysis.

RESULTS: A total of 18,187 patients were admitted to the trauma LEHHC Trauma Service during the study period, of which 1,079 (5.9%) patients sustained facial fractures and 788 (4.3%) required a tracheostomy. One hundred twenty-five patients (0.69% of total; 11.6% of facial fracture) received a tracheostomy at the same time as the facial fracture repair. All patients had their facial fractures successfully managed, regardless of the type of method used to stabilize the airway. There were no known cases of tracheal stenosis, severe bleeding requiring a return to the operating room, airway obstruction, or loss of secured airway. Males were the predominate gender in all 3 groups. The NffxT group (mean, 44.9 years) was much older compared with the ffxT (mean, 36.2 years) and ffxNT (mean, 30.9 years) groups. The incidence of death was higher in the tracheostomy groups compared with 0% with the non-tracheostomy group. The ffxNT group had a statistically significant higher GCS with an average of 12.4 when compared with the tracheostomy groups (ffxT = 6.8; NffxT = 6.7). ISS was nearly the same in the tracheostomy group (ffxT = 28.45; NffxT = 30.04), but higher when compared with the ffxNT (ISS = 17.33). All 3 groups were much different in terms of LOS and ICU days, in which the NffxT group had an average hospital LOS and ICU days of 34.4 and 16.56, respectively. This was higher when compared with the ffxT (LOS = 19.71 days; ICU = 7.21 days) and ffxNT (LOS = 6.82 days; ICU = 1.33 days) groups. The FISS averaged 6.22 in the ffxT group and was higher compared with an FISS of 3.16 in the ffxNT group. Overall, the fracture profile was different between the tracheostomy and non-tracheostomy groups. There was a higher prevalence of mandibular fractures, multiple mandibular fractures, and Le Fort III fractures in the ffxT group compared with the ffxNT group.

CONCLUSION: Tracheostomy is commonly performed in the context of multisystem trauma and is a safe method for airway stabilization in patients with craniomaxillofacial trauma. Multi-institutional collaboration and a prospective, randomized trial measuring outcome, resource utilization, and length of ICU stay is necessary to determine if tracheostomy is indeed of measurable benefit to patients with complex injuries.

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