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Background <p>Airway management following head and neck (H&amp;N) oncologic surgery is critical, and several scoring systems have been proposed to guide prophylactic tracheostomy. The Clinical Assessment Scoring System for Tracheostomy (CASST) is one such tool, but its external validity remains uncertain. This study evaluates the accuracy of the CASST criterion in predicting the need for tracheostomy in a high-volume tertiary cancer center.</p> Methods <p>A retrospective cohort study was conducted on patients who underwent H&amp;N cancer surgery at Shaukat Khanum Memorial Cancer Hospital and Research Centre between 2010 and 2018. Patients were assessed using the CASST scoring system, and those with scores ≥7 were identified as high-risk for requiring tracheostomy. Demographic characteristics, surgical details, postoperative complications, airway events, and actual tracheostomy requirements were analyzed. Diagnostic accuracy parameters of CASST were calculated.</p> Results <p>Among 2100 oral and oropharyngeal cancer surgeries, 34 patients (1.6%) had a CASST score ≥7. Despite the score’s recommendation for prophylactic tracheostomy, 31 patients (91.2%) did not undergo upfront tracheostomy and had no postoperative airway compromise. Only 3 patients (8.8%) required tracheostomy—2 preoperatively due to surgical complexity and 1 postoperatively due to failed intubation. The CASST score demonstrated 60% sensitivity, 98.5% specificity, 8.8% positive predictive value, and 100% negative predictive value for predicting tracheostomy need.</p> Conclusion <p>The CASST scoring system overestimates the need for tracheostomy in H&amp;N cancer surgery and shows poor sensitivity in identifying patients who truly require a surgical airway. While its high negative predictive value suggests reliability in ruling out airway concerns, its low positive predictive value may lead to unnecessary tracheostomies. Clinical judgment should therefore remain central to airway planning in H&amp;N oncologic surgery.</p>

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Evaluating the Validity of CASST Score: Clinical Judgment vs. Score-Guided Tracheostomy Decisions in Head and Neck Cancer Surgery Patients

  • 期刊论文

  • 发表日期：

    2026年3月14日

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  • Alishba Mubashar,
  • Muhammad Ali Majeed,
  • Muhammad Faisal,
  • Raza Hussain,
  • Abu Bakar,
  • Samiullah Khan,
  • Shayan Khalid Ghaloo

摘要

Background

Airway management following head and neck (H&N) oncologic surgery is critical, and several scoring systems have been proposed to guide prophylactic tracheostomy. The Clinical Assessment Scoring System for Tracheostomy (CASST) is one such tool, but its external validity remains uncertain. This study evaluates the accuracy of the CASST criterion in predicting the need for tracheostomy in a high-volume tertiary cancer center.

Methods

A retrospective cohort study was conducted on patients who underwent H&N cancer surgery at Shaukat Khanum Memorial Cancer Hospital and Research Centre between 2010 and 2018. Patients were assessed using the CASST scoring system, and those with scores ≥7 were identified as high-risk for requiring tracheostomy. Demographic characteristics, surgical details, postoperative complications, airway events, and actual tracheostomy requirements were analyzed. Diagnostic accuracy parameters of CASST were calculated.

Results

Among 2100 oral and oropharyngeal cancer surgeries, 34 patients (1.6%) had a CASST score ≥7. Despite the score’s recommendation for prophylactic tracheostomy, 31 patients (91.2%) did not undergo upfront tracheostomy and had no postoperative airway compromise. Only 3 patients (8.8%) required tracheostomy—2 preoperatively due to surgical complexity and 1 postoperatively due to failed intubation. The CASST score demonstrated 60% sensitivity, 98.5% specificity, 8.8% positive predictive value, and 100% negative predictive value for predicting tracheostomy need.

Conclusion

The CASST scoring system overestimates the need for tracheostomy in H&N cancer surgery and shows poor sensitivity in identifying patients who truly require a surgical airway. While its high negative predictive value suggests reliability in ruling out airway concerns, its low positive predictive value may lead to unnecessary tracheostomies. Clinical judgment should therefore remain central to airway planning in H&N oncologic surgery.