Adverse Airway Events Following Head and Neck Cancer Reconstruction Without Elective Tracheostomy

OBJECTIVE: Prior literature has examined characteristics associated with the decision to perform elective tracheostomy (ET); however, the risk of adverse airway events (AAEs) in patients managed without ET remains unclear. We aimed to identify predictors of AAEs in patients managed without ET and to evaluate postoperative outcomes associated with ET. DATA SOURCES: Embase, PubMed, Web of Science, Scopus, and Ovid MEDLINE (January 1, 2009-January 6, 2026). REVIEW METHODS: A systematic review and meta-analysis were conducted following PRISMA guidelines. Risk of bias was assessed for included studies. AAE predictors were analyzed using pooled odds ratios (ORs). Postoperative outcomes associated with ET were evaluated by converting pooled ORs into number needed to harm. RESULTS: Overall, 25 studies (N = 5987) were included. The pooled AAE incidence in patients managed without ET was 10.3% (95% CI, 6.7%-15.6%). Compared with other oral cavity subsites, tumors of the floor-of-mouth (OR, 5.96) and oropharynx (OR, 2.60) were associated with higher AAE odds. Similarly, AAE risk was higher in patients with bilateral neck dissection (OR, 6.36) and higher American Society of Anesthesiologists class (OR, 1.51). ET was associated with increased risk of flap complications (OR, 2.15), unplanned return to the operating room (OR, 1.73), and prolonged time to oral feeding (mean difference, 5.86 days). CONCLUSION: Key predictors of AAEs were identified, supporting early risk recognition to guide selective ET in vulnerable patients. However, ET was also associated with increased postoperative morbidity and should be used selectively in perioperative airway planning.