Evolution Over Time of Ventilatory Management and Outcome of Patients With Neurologic Disease.

OBJECTIVES: To describe the changes in ventilator management over time in patients with neurologic disease at ICU admission and to estimate factors associated with 28-day hospital mortality. DESIGN: Secondary analysis of three prospective, observational, multicenter studies. SETTING: Cohort studies conducted in 2004, 2010, and 2016. PATIENTS: Adult patients who received mechanical ventilation for more than 12 hours. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among the 20,929 patients enrolled, we included 4,152 (20%) mechanically ventilated patients due to different neurologic diseases. Hemorrhagic stroke and brain trauma were the most common pathologies associated with the need for mechanical ventilation. Although volume-cycled ventilation remained the preferred ventilation mode, there was a significant (p < 0.001) increment in the use of pressure support ventilation. The proportion of patients receiving a protective lung ventilation strategy was increased over time: 47% in 2004, 63% in 2010, and 65% in 2016 (p < 0.001), as well as the duration of protective ventilation strategies: 406 days per 1,000 mechanical ventilation days in 2004, 523 days per 1,000 mechanical ventilation days in 2010, and 585 days per 1,000 mechanical ventilation days in 2016 (p < 0.001). There were no differences in the length of stay in the ICU, mortality in the ICU, and mortality in hospital from 2004 to 2016. Independent risk factors for 28-day mortality were age greater than 75 years, Simplified Acute Physiology Score II greater than 50, the occurrence of organ dysfunction within first 48 hours after brain injury, and specific neurologic diseases such as hemorrhagic stroke, ischemic stroke, and brain trauma. CONCLUSIONS: More lung-protective ventilatory strategies have been implemented over years in neurologic patients with no effect on pulmonary complications or on survival. We found several prognostic factors on mortality such as advanced age, the severity of the disease, organ dysfunctions, and the etiology of neurologic disease.

Early versus late tracheotomy in ICU patients: A meta-analysis of randomized controlled trials.

BACKGROUND: This study aimed to quantitatively analyze the available randomized controlled trials (RCTs) and investigate whether early tracheotomy can improve clinical endpoints compared with late tracheotomy in critically ill patients undergoing mechanical ventilation. METHODS: The electronic databases of PubMed, Embase, and the Cochrane library were systematically searched in August 2019. The investigated outcomes were calculated using relative risks (RRs) and standardized mean differences (SMDs) with corresponding 95% confidence intervals (CIs) through the random-effects model for categories and continuous data, respectively. RESULTS: The electronic searches yielded 2289 records, including 15 RCTs comprising a total of 3003 patients and found to be relevant for the final quantitative analysis. The summary RRs that indicated early versus late tracheotomy were not associated with the risk of short-term mortality (RR: 0.87; 95% CI: 0.74-1.03; P = .114) and ventilator-associated pneumonia (RR: 0.90; 95% CI: 0.78-1.04; P = .156). Moreover, early tracheotomy was associated with shorter intensive care unit (ICU) stay (SMD: -1.81; 95% CI: -2.64 to -0.99; P < .001) and mechanical ventilation duration (SMD: -1.17; 95% CI: -2.10 to -0.24; P = .014). Finally, no significant difference was observed between early and late tracheotomy for hospital stay (SMD: -0.42; 95% CI: -1.36-0.52; P = .377). CONCLUSIONS: The present meta-analysis suggests that early tracheotomy can reduce the length of ICU stay and mechanical ventilation duration, but the timing of the tracheotomy was not associated with the short-term clinical endpoints in critically ill patients undergoing mechanical ventilation.

Traqueotomía en enfermos con ELA: pro / Tracheotomy in Amyotrophic Lateral Sclerosis: The Argument in Favor

No disponible

Controversias en la retirada de la ventilación mecánica y extubación en el paciente neurocrítico / Controversies in weaning from mechanical ventilation and extubation in the neurocritical patient

No disponible

Decannulation of tracheotomized patients after long-term mechanical ventilation - results of a prospective multicentric study in German neurological early rehabilitation hospitals.

BACKGROUND: In the course of neurological early rehabilitation, decannulation is attempted in tracheotomized patients after weaning due to its considerable prognostic significance. We aimed to identify predictors of a successful tracheostomy decannulation. METHODS: From 09/2014 to 03/2016, 831 tracheotomized and weaned patients (65.4 ± 12.9 years, 68% male) were included consecutively in a prospective multicentric observation study. At admission, sociodemographic and clinical data (e.g. relevant neurological and internistic diseases, duration of mechanical ventilation, tracheotomy technique, and nutrition) as well as functional assessments (Coma Recovery Scale-Revised (CRS-R), Early Rehabilitation Barthel Index, Bogenhausener Dysphagia Score) were collected. Complications and the success of the decannulation procedure were documented at discharge. RESULTS: Four hundred seventy patients (57%) were decannulated. The probability of decannulation was significantly negatively associated with increasing age (OR 0.68 per SD = 12.9 years, p < 0.001), prolonged duration of mechanical ventilation (OR 0.57 per 33.2 days, p < 0.001) and complications. An oral diet (OR 3.80; p < 0.001) and a higher alertness at admission (OR 3.07 per 7.18 CRS-R points; p < 0.001) were positively associated. CONCLUSIONS: This study identified practically measurable predictors of decannulation, which in the future can be used for a decannulation prognosis and supply optimization at admission in the neurological early rehabilitation clinic.

National changes in pediatric tracheotomy epidemiology during 36 years.

BACKGROUND: Information on the incidence, indications and morbidity of pediatric tracheotomy from a nationwide setting is sparse. METHODS: From the nationwide Danish National Patient Registry, we identified all cases: 0-15-year-old children registered with a first-time tracheotomy from 1979 to 2014. We extracted the date of surgery, admission, discharge, age, gender, hospital, department, hospitalization length, hospital contacts, and diagnosis-code related to the surgery. We estimated age-adjusted incidence rates (AAIR) and annual (APC) and average annual percentage change (AAPC) of tracheotomy incidence. RESULTS: A total of 510 children (328 boys, 63%) underwent tracheotomy. The median age at surgery was 8 years. The AAIR was 1.4/100,000 person-years (range 1.0-1.8) from 1980 to 2014. During 1979-2014, the AAPC decreased - 0.9% (95% confidential interval - 2.4; 0.8, p < 0.3). From 1979 to 2003 the APC decreased - 4.1% (95% CI - 5.4; - 2.8, p < 0.001) and from 2003 to 2014 the APC increased 6.6% (95% CI 2.0; 11.5, p < 0.001). Infants had the highest incidence (4.0/100,000 years) compared with the 12-15-year-olds (AAIR: 0.4/100,000 years). From 1979 to 2014 the most common indication for tracheotomy among children aged 0-2 years was congenital malformations (n = 48, 30%) and among children aged 3-11 and 12-15 years the most common indication was trauma (respectively n = 67, 36% and n = 85, 52%). During 2006-2014 the most common indications for all ages was neurological impairment (n = 25, 21%) and neoplasms (n = 20, 17%). CONCLUSIONS: Pediatric tracheotomy was a rare surgical procedure with decreasing incidence rates from 1980-89 to 1990-99 and increasing incidence rates from 2000-2009 to 2010-2014. Indications and postoperative morbidity have changed adjunct to the treatment of chronic disorders.

Is tracheotomy on the decline in otolaryngology? A single institutional analysis.

OBJECTIVE: A recent study reported decreasing trends in tracheotomy procedures by its otolaryngology service. We set out to determine whether the previously reported decrease in otolaryngology performed tracheotomies by one institution is a local or generalizable phenomenon. DESIGN: Retrospective cohort study from 2010 to 2015. SETTING: Tertiary care hospital and affiliated regional hospitals. SUBJECT AND METHODS: All patients who received tracheotomy during the period of analysis were included. Performing specialty, surgical technique, and procedure location were recorded. Procedures were stratified by year and specialty to generate incidence rate ratios for otolaryngologists and non-otolaryngologists. Incidence rate ratios were estimated with negative binomial regression across services. RESULTS: The otolaryngology service demonstrated a yearly decrease of 3.4% in the total number of tracheotomies (95% CI -7.9% to +1.4, P=0.17). While the thoracic service remained constant (+0.3%, 95% CI -2.6% to +3.3%, p=0.83), general surgery demonstrated the greatest increase in procedures (+4.4%, 95% CI -6.0% to +15.8%, P=0.42). Thoracic and general surgery both dramatically increased the number of percutaneous tracheotomies performed, with general surgery also performing a greater number of bedside procedures. CONCLUSIONS AND RELEVANCE: We observed a similar decline in the number of tracheotomies otolaryngology over six years. Our trend is likely due to changes in consultations patterns, increasing use of the percutaneous method, and an increase in adjunctive gastrostomy tube placements. Investigations on the impact of a greater number of non-otolaryngology performed tracheotomies on follow up care is warranted.

[Tracheotomy].

The number of tracheotomies in Denmark has roughly tripled over the past 15 years. During this period, percutaneous dilatational tracheotomy has become still more common because of its easier accessibility, and it accounted for 66% of all tracheotomies in 2015 vs. 9% in 2000. However, due to the risk of fatal complications the method is only applicable when anatomical and medical conditions are favourable. Surgical tracheotomy is a safer method in some patients, and it is preferred if the patient has had a tracheostomy previously or presents with a difficult anatomy, coagulopathy or previous neck irradiation.

Indications of pediatric tracheostomy over the last 30 years: Has anything changed?

IMPORTANCE: Recent reports have shown that the indications for pediatric tracheostomy have evolved over time. OBJECTIVE: To review the indications for pediatric tracheostomy over the last 30 years. DESIGN: Retrospective chart review. SETTING: Tertiary referral children's hospital. PARTICIPANTS: Patients who underwent tracheostomy. INTERVENTION: Surgical tracheostomy placement. MAIN OUTCOMES AND MEASURES: Medical records for patients who underwent surgical tracheostomy over the 30-year study period (1984-2014) were reviewed. Patient characteristics including age, gender, birth-weight, gestational age and death were collected and compared with the primary indication for tracheostomy using bivariable analysis. RESULTS: Five hundred and one patients met inclusion criteria. The most common primary indications for tracheostomy were cardiopulmonary disease (34%) and neurological impairment (32%), followed by airway obstruction (19%), craniofacial (11%), and traumatic injury (4%). Over the last five years (2010-14) cardiopulmonary disease became the most common indication for tracheostomy. CONCLUSIONS: and RELEVANCE: The indications for pediatric tracheostomy have evolved over the past 30 years. Infectious causes of airway obstruction and tracheostomy have almost disappeared. Tracheostomy is now most commonly performed in very premature patients with cardiopulmonary or neurological impairment who require prolonged ventilator support.

Traqueotomías abiertas a pie de cama / No disponible

Introducción: La traqueotomía como procedimiento para asegurar la vía aérea, se puede realizar de dos formas; mediante cirugía abierta, llamada también traqueotomía estándar. Y de forma percutánea, con el método de Seldinger, popularizado por Ciaglia. Se plantea un análisis descriptivo de una serie de pacientes a los que se les realizó traqueotomía abierta a pie de cama por un servicio de cirugía torácica, en los que se desestimó la técnica percutánea por el equipo medico de cuidados intensivos. Metodología: Se trata de un estudio descriptivo y retrospectivo, de todas las traqueotomías abiertas a pie de cama realizadas por el servicio de Cirugía torácica en las diferentes unidades de cuidados intensivos de un Hospital de tercer nivel, entre junio de 2009 y diciembre de 2013. Los criterios de inclusión para este estudio, fueron todos los pacientes que requerían una traqueotomía en la unidad de reanimación (en esta unidad no se realizan traqueotomías percutáneas) y todos aquellos pacientes que por cualquier tipo de anormalidades; anatómicas y/o funcionales, fueron desestimados para la realización de la traqueotomía percutánea por parte del personal medico de la UCI. Resultados: En total se realizaron 166 traqueotomías abiertas durante el periodo de estudio, de ellas se excluyeron 10 por ser realizadas en quirófano o de forma percutánea. Se realizaron 156 traqueotomías a pie de cama, a 94 varones y 62 mujeres con una edad media de 60,15 años (rango 16-84). La principal indicación para el procedimiento fue la intubación orotraqueal prolongada por dificultad para el destete en pacientes con cirugía cardiaca y pulmonar, seguido del distrés respiratorio en 29 casos. La contraindicación más frecuente para realizar el procedimiento por la vía percutánea fueron las alteraciones de la coagulación en 60 casos, seguida de la dificultad para extender el cuello en 26 casos. No existía contraindicación para realizar el procedimiento de manera percutánea en 26 casos. La principal complicación del procedimiento fue el sangrado en 8 casos, que se solucionó durante el procedimiento y que no requirieron transfusiones. Conclusión: La traqueotomía abierta a pie de cama puede ser realizada de forma segura en todos los pacientes, independientemente de las desventajas anatómicas o funcionales del paciente

Introduction: As an airway stabilizing surgical procedure, tracheotomy can be performed in two ways, by an open surgery as a standard tracheotomy, and by a percutaneous method using the Seldinger technique, popularized by Ciaglia. This paper expose a descriptive analysis of a patient series dismissed for a percutaneous tracheotomy by Intensive Care Unit (ICU) specialists, and then operated by thoracic surgeons with a bedside open tracheotomy. Methods: Descriptive retrospective study of all bedside open tracheotomy performed by the Thoracic Surgery Department in a tertiary Hospital, between June 2009 and December 2013. Inclusion criteria were: 1) patients with a bedside open tracheotomy done in the Post Anesthesia Care Unit (PACU), where no percutaneous tracheotomies are usually performed in this Hospital, and 2) patients who for any anatomic or functional reasons were dismissed for a percutaneous procedure by ICU specialists, and in consequence a bedside open tracheotomy was performed by thoracic surgeons. Results: In the period of the study, a total number of 166 open tracheotomies were performed, and 10 of these were done in a operating room (OR) or percutaneously; these were excluded. A total of 156 bedside open tracheotomies were performed, 94 patients were male and 62 female, with a media age of 60.15 years (range 16-84 years old). Principal indication for the procedure was a prolonged orotracheal intubation due to a difficult weaning, 29 of them due to respiratory distress syndrome. Principal contraindication of the percutaneous procedure were coagulopathies in 60 cases, followed by difficulties in spine extensión in 26 cases. There were no absolute contraindications for the percutaneous tracheotomy in 26 cases. The most frequent complication of the open bedside tracheotomy was bleeding in 8 cases, but it was resolved during the procedure and did not required blood transfusion in any case. Conclusion: Open bedside tracheotomy can be a safe and secure procedure in all patients, nevertheless the tracheal and spine anatomic or functional characteristics of the patient

Tracheostomy and invasive mechanical ventilation in amyotrophic lateral sclerosis: decision-making factors and survival analysis.

BACKGROUND: Invasive and/or non-invasive mechanical ventilation are most important options of respiratory management in amyotrophic lateral sclerosis. METHODS: We evaluated the frequency, clinical characteristics, decision-making factors about ventilation and survival analysis of 190 people with amyotrophic lateral sclerosis patients from 1990 until 2013. RESULTS: Thirty-one percentage of patients underwent tracheostomy invasive ventilation with the rate increasing more than the past 20 years. The ratio of tracheostomy invasive ventilation in patients >65 years old was significantly increased after 2000 (25%) as compared to before (10%). After 2010, the standard use of non-invasive ventilation showed a tendency to reduce the frequency of tracheostomy invasive ventilation. Mechanical ventilation prolonged median survival (75 months in tracheostomy invasive ventilation, 43 months in non-invasive ventilation vs natural course, 32 months). The life-extending effects by tracheostomy invasive ventilation were longer in younger patients ≤65 years old at the time of ventilation support than in older patients. Presence of partners and care at home were associated with better survival. Following factors related to the decision to perform tracheostomy invasive ventilation: patients ≤65 years old: greater use of non-invasive ventilation: presence of a spouse: faster tracheostomy: higher progression rate; and preserved motor functions. No patients who underwent tracheostomy invasive ventilation died from a decision to withdraw mechanical ventilation. CONCLUSION: The present study provides factors related to decision-making process and survival after tracheostomy and help clinicians and family members to expand the knowledge about ventilation.

Angina de Ludwig. Reporte de 2 casos / Ludwig's angina: a report of two cases

La angina de Ludwig (AL) es una entidad patológica, odontogénica e infecciosa que representa una situación de emergencia en la Cirugía Bucal y Maxilofacial por comprometer la vida del paciente debido a una progresiva oclusión de la vía aérea, producto del avance de la infección hacia los espacios submandibulares, sublinguales y submental, lo que trae como consecuencia el colapso de la misma. En el presente trabajo se hace una revisión de la literatura actualizada acerca de dicha entidad, origen, vías de diseminación, manejo terapéutico y posibles complicaciones. Se reportan 2 casos que acuden a Emergencias del Hospital General del Oeste «Dr. José Gregorio Hernández» (HGO) en Los Magallanes de Catia (Caracas, Venezuela) con diagnóstico de AL. Se presenta el manejo clínico y la relevancia del rol que adquiere el cirujano maxilofacial en el diagnóstico en aras de la preservación de la vida del paciente (AU)

Ludwig's angina (LA) is an odontogenic infection, a pathological condition that represents an emergency in Oral and Maxillofacial Surgery as it threatens the life of the patient, as it progressively obstructs the airway, due to the advance of the infection in the submandibular, sublingual and submental spaces. An updated review of the literature is presented here, including the management, treatment, origin, its transmission routes, the possible complications, as well as a report of two cases seen in the West General Hospital "Dr. José Gregorio Hernández" (HGO) in Los Magallanes de Catia (Caracas, Venezuela). The diagnosis of LA, clinical handling, and the relevance of the role played by the oral and maxillofacial surgeon in the diagnosis, in order to save the life of the patient, is also discussed (AU)

A randomized clinical trial for the timing of tracheotomy in critically ill patients: factors precluding inclusion in a single center study.

INTRODUCTION: We investigated the potential benefits of early tracheotomy performed before day eight of mechanical ventilation (MV) compared with late tracheotomy (from day 14 if it still indicated) in reducing mortality, days of MV, days of sedation and ICU length of stay (LOS). METHODS: Randomized controlled trial (RCT) including all-consecutive ICU admitted patients requiring seven or more days of MV. Between days five to seven of MV, before randomization, the attending physician (AP) was consulted about the expected duration of MV and acceptance of tracheotomy according to randomization. Only accepted patients received tracheotomy as result of randomization. An intention to treat analysis was performed including patients accepted for the AP and those rejected without exclusion criteria. RESULTS: A total of 489 patients were included in the RCT. Of 245 patients randomized to the early group, the procedure was performed for 167 patients (68.2%) whereas in the 244 patients randomized to the late group was performed for 135 patients (55.3%) (P <0.004). Mortality at day 90 was similar in both groups (25.7% versus 29.9%), but duration of sedation was shorter in the early tracheotomy group median 11 days (range 2 to 92) days compared to 14 days (range 0 to 79) in the late group (P <0.02). The AP accepted the protocol of randomization in 205 cases (42%), 101 were included in early group and 104 in the late group. In these subgroup of patients (per-protocol analysis) no differences existed in mortality at day 90 between the two groups, but the early group had more ventilator-free days, less duration of sedation and less LOS, than the late group. CONCLUSIONS: This study shows that early tracheotomy reduces the days of sedation in patients undergoing MV, but was underpowered to prove any other benefit. In those patients selected by their attending physicians as potential candidates for a tracheotomy, an early procedure can lessen the days of MV, the days of sedation and LOS. However, the imprecision of physicians to select patients who will require prolonged MV challenges the potential benefits of early tracheotomy. TRIAL REGISTRATION: Controlled-Trials.com ISRCTN22208087 . Registered 27 March 2014.

Neumotórax bilateral y neumomediastino tras microcirugía transoral con láser y traqueotomía / Bilateral and pneumomediastinal pneumothorax after transoral laser microsurgery and tracheotomy

La microcirugía transoral con láser CO2 se ha convertido en una alternativa cada vez más empleada para el tratamiento del cáncer de laringe y faringe. Entre las ventajas que aporta frente a la cirugía abierta y la radioterapia, se encuentran su menor invasividad, mayor precisión, mejor preservación funcional del órgano y menor morbilidad asociada al procedimiento. No obstante, esta técnica quirúrgica no está exenta de complicaciones, algunas hasta ahora poco frecuentes, pero de gran trascendencia clínica. Presentamos el caso de una paciente que en el contexto de una microcirugía con traqueotomía por cáncer de laringe sufrió un enfisema subcutáneo, neumomediastino y neumotórax bilateral precisando de las medidas pertinentes para su control y estabilización, que se describen. Además, se realiza una revisión actual en la literatura, sobre las consideraciones anestésicas y las principales complicaciones perioperatorias de la microcirugía con láser(AU)

Transoral laser CO2 microsurgery is becoming an increasing used treatment option for cancer of the larynx and the pharynx. Amongst the advantages it has compared to open surgery and radiotherapy are, it less invasiveness, greater precision, better functional preservation of the organ, and less procedure-associated morbidity. However, this surgical technique is not without its complication, some being rare up until now, but with great clinical importance. We present the case of a patient subjected to microsurgery with a tracheotomy due to cancer of the larynx, who suffered a subcutaneous emphysema, and a bilateral and pneumomediastinal pneumothorax, requiring the appropriate measures for its control and stabilisation, which are described. A review was also performed of the current literature as regards anaesthetic considerations and the main peri-operative complications of laser microsurgery(AU)

Pediatric tracheotomy: are the indications changing?

OBJECTIVE: The most common indications for tracheotomy in pediatric patients include upper airway obstruction, prolonged ventilator dependence, and hypotonia secondary to neurologic impairment. In this study we review the indications for tracheotomy within our patient population over the last 11 years. METHODS: We conducted a retrospective chart review of consecutive patients undergoing tracheotomy at a tertiary care pediatric hospital from January 2000 to April 2011. We evaluated patient age, sex, pre-operative and post-operative diagnosis, and direct laryngoscopic and bronchoscopic findings. Patients were divided into six groups based on their indication for tracheotomy. In order to assess changing indications for tracheotomy over time, we compared an early (2000-2005) and a late (2006-2011) patient group. RESULTS: We had complete data available on 158/165 patients (95.8%) who underwent tracheotomy from 2000 to 2011. There was no significant difference in mean age between the early and late groups (4.73 ± 6.0 years vs. 3.6 ± 5.5 years, p=0.26). There was a change in the most common indication for tracheotomy between the early and late groups, with upper airway obstruction becoming more common in the late group and significantly fewer patients undergoing tracheotomy for prolonged ventilation in the late group (33/76 (43%) vs. 23/82 (28%), p=0.05). More patients underwent bronchoscopy at the time of tracheotomy in the late group (52/82 (63%) vs. 28/76 (37%), p=<0.01). CONCLUSION: A review of our pediatric tracheotomy experience demonstrated a change in the most common indication for tracheotomy between 2000 and 2011. In our patient population, there was a significant decline in the number of tracheotomies performed for prolonged intubation and an increasing number of patients who required tracheotomy for upper airway obstruction.

[Pediatric tracheotomy]. / Tracheotomie bei Kindern.

Tracheotomies are increasingly performed in the pediatric population in the context of long-term treatment. There are specific pediatric aspects that require attention: differences in the pediatric compared to adult anatomy, the necessity for later reconstruction and the negative impact on oral feeding and speech development. Caring for pediatric tracheostomy patients is more challenging compared to adult patients. This needs to be addressed by a dedicated team during both in- and outpatient treatment.

Changing patterns of tracheotomy use in anterior skull base surgery with free tissue reconstruction.

OBJECTIVE: To evaluate how changing patterns of tracheotomy use with free tissue reconstruction of the anterior skull base affect postoperative complications. DESIGN: Retrospective comparison of clinical cohort to historic control group. SETTING: Tertiary care medical center. PATIENTS: We reviewed 201 patients with a diagnosis of malignant or locally aggressive benign neoplasms of the nasal cavity and paranasal sinuses between January 1993 and December 2006. Of these, we studied 33 consecutive patients that underwent ablative anterior skull base surgery reconstructed with free tissue transfers. We divided the study group into two cohorts: Group 1, patients treated from 1993-2000, and Group 2, patients treated from 2000-2006. MAIN OUTCOME MEASURES: Tracheotomy use and postoperative complications. RESULTS: There were 16 patients in Group 1 and 17 patients in Group 2. There were 11 patients who received a tracheotomy in Group 1, and only 5 in Group 2 (P = .038). Five patients in either group experienced complications (P = 1.000). There was one case of meningitis in Group 1 and no cases in Group 2 (P = .485). There were two cases of pneumocephalus in Group 2 and none in Group 1 (P = .485) and no cases of tension pneumocephalus. Six patients in each group had recurrent disease (P = 1.000). There was no statistically significant difference in survival (P = .675). CONCLUSIONS: The decreased use of tracheotomy in patients undergoing free tissue transfer reconstruction of anterior skull base defects did not lead to an increase in complications. Routine use of tracheotomy in these patients is unnecessary and should be reserved for selected cases. Laryngoscope, 2009.