Introduction: Head and neck cancer patients undergoing oral or oromandibular reconstruction using free flaps are often managed with tracheostomy for maintenance of the post operative airway. Complications related to tracheostomy such as soft tissue infection, tracheal stenosis, scar formation and patient anxiety have been reported. In addition postoperative decannulation and stoma care can be cumbersome for patients and physicians. We report 15 consecutive cases of head and neck free flap reconstruction without tracheostomy.

Patients and methods: Records of 15 consecutive head and neck cancer patients undergoing free flap reconstruction of the oral cavity or mandible were reviewed. Six patients underwent mandibular reconstruction. Five were reconstructed with a free fibula flap and one using a free rectus flap. Five patients requiring hemi-glossectomy were reconstructed with a free radial forearm flap. One patient required total glossectomy and was reconstructed with an anterolateral thigh flap. Other head and neck patients included one maxillary reconstruction using a radial forearm flap and bone graft, a chronic massive oral cutaneous fistula with free rectus flap and right ear reconstruction using an anterolateral thigh flap. All but two patients underwent prolonged nasal tracheal intubation. Post operatively patients were admitted to the intensive care unit and monitored under sedation.

Results: Patients remained intubated an average of 4.3 days after reconstruction. None of the patients required tracheostomy or reintubation. None of the patients developed pneumonia. There were no fistulas. Two patients developed a pressure sore at the nasal ala but no permanent alar notching occurred. Partial free flap loss occurred in one patient requiring local revision.

Conclusions: Prolonged nasal or oral postoperative intubation is a safe alternative to tracheostomy after oral or oromandibular reconstruction using free flaps. It eliminates tracheostomy scars, and complications and difficulties with decanulation. Prolonged patient sedation reduces active tongue and mandibular movement and may contribute to decreased fistula formation.