A contemporaneous study of 140 consecutive Head & Neck cancer patients requiring Free Flap surgery: To establish the need for routine peri operative Tracheostomy

Introduction Tracheostomy has traditionally been the standard of care in major oral and oropharyngeal ablative surgery. Emerging evidence suggests immediate extubation(IE) is safe in wide surgical cohorts. This study challenges the routine use of tracheostomy and presents a 5-year experience from a unit where immediate extubation has become the standard practice. Methods A review of 140 consecutive patients undergoing resection and free-flap reconstruction (2020–2025) was performed. Outcomes included airway management success, complications, and postoperative recovery. Results Of 140 patients, 112 (80%) were immediately extubated, 22 (15.7%) had delayed extubation, and only 6 (4.3%) underwent elective tracheostomy. Immediate extubation was safely achieved in patients considered high risk (posterior oral/oropharyngeal resections, bilateral neck dissections) Airway complications were low (4.46% in the immediate extubation group). Two patients required short-term re-intubation (1.78%). One patient required delayed tracheostomy. IE group had shorter length of stay (mean 12.1 days) and earlier return to oral intake (average 5.1 days). Conclusions IE is a safe airway strategy following major head and neck free-flap surgery. Re-intubation was consistently successful, facilitated by modern airway adjuncts. These findings challenge routine tracheostomy and support IE as a primary airway strategy.