Townsend Courtney M.Jr., Evers B. Mark. Atlas of General Surgical Techniques: Expert Consult

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CHAPTER 5 • Tracheotomy 75

◆ Bleeding: cut edge of thyroid or trachea (early); tracheo–innominate artery ﬁ stula (late)

◆ Infection: tracheitis

◆ Mucous plug

◆ Accidental decannulation (may result in death)

◆ Aspiration

◆ In morbidly obese patients, pretracheal fat is excised to decrease the amount of subcutane-

ous tissue lying between the cervical skin incision and the tracheotomy. In rare patients,

submental skin and fat must be excised before the tracheotomy to prevent obstruction of

the tracheotomy tube postoperatively by soft tissue.

◆ A saline-ﬁ lled syringe with a small-gauge needle can be used to localize the trachea in a

badly scarred neck (previous surgery, infection, radiation therapy, or a combination).

The needle is placed in the presumed tracheal lumen and the plunger is withdrawn. The

presence of air bubbles in the syringe conﬁ rms the location of the tracheal lumen.

◆ If there is difﬁ culty placing the tracheotomy tube, the anesthesiologist is instructed to

advance the ETT and resume ventilation. The cuff of the ETT should be past the trache-

otomy incision so that air does not escape from the wound.

◆ If it is difﬁ cult to place the tracheotomy tube and the ETT cannot be advanced distal to the

tracheotomy site, a small ETT (size 4 or 5) can be placed through the tracheotomy incision

to ventilate the patient. Troubleshooting can then commence with the patient under stable

conditions.

◆ When a local awake tracheotomy is performed, the patient’s face is left undraped (a towel is

placed over the chin) to allow the anesthesiologist access for mask ventilation and emergent

intubation.

SELECTED REFERENCES

1. Myers EN: Tracheostomy. In Myers EN (ed): Operative Otolaryngology: Head and Neck Surgery.

Philadelphia, Saunders, 1997, pp 575-585.

2. Morris WM: Cricothyroidotomy. In Lore JM, Medina J (eds): An Atlas of Head and Neck Surgery, 4th ed.

Philadelphia, Elsevier, 2005, pp 82-83.

3. Tracheostomy. In Lore JM, Medina J (eds): An Atlas of Head and Neck Surgery, 4th ed. Philadelphia,

Elsevier, 2005, pp 1015-1023.

4. McWhorter AJ: Tracheotomy: Timing and techniques. Curr Opin Otolaryngol Head Neck Surg

2003;11:473-479.

STEP 1: SURGICAL ANATOMY

◆ The following landmarks are useful in performing a tracheotomy or cricothyroidotomy

(Figure 6-1):

◆ Hyoid bone

◆ Thyroid notch

◆ Cricoid cartilage

◆ Sternal notch

◆ The thyroid isthmus overlies the anterior trachea at the level of the ﬁ rst tracheal ring.

◆ The relationship of the trachea to the thyroid gland, esophagus, and great vessels in the

neck are demonstrated in Figure 1-2.

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ Indications:

◆ Acute airway obstruction above the level of the cricoid cartilage (glottis, supraglottis)

◆ Elective procedure following median sternotomy

◆ The surgeon must be prepared to perform this procedure with the patient in a semirecum-

bent or sitting position.

◆ Because of the emergent nature of this procedure, the surgeon must maintain calm and

remain in charge. This rarely takes place in the operating room.

◆ Necessary instruments include good lighting.

◆ Small endotracheal tubes (ETTs) should be available. A small ETT is placed to prevent

fracture of the cricoid cartilage.

◆ See tracheotomy procedure (Chapter 5).

CHAPTER

Cricothyroidotomy

Anna M. Pou

CHAPTER 6 • Cricothyroidotomy 77

Hyoid bone

Anterior jugular vein

Cricoid cartilage

Trachea

Thyroid isthmus

Omohyoid muscle

Thyroid cartilage

Thyroid notch

Sternocleidomastoid

muscle

Thyroid gland

Sternohyoid muscle

Sternal notch

FIGURE 6 –1

78 Section I • Head and Neck and Endocrine Procedures

STEP 3: OPERATIVE STEPS

1. INCISION

◆ The patient is placed supine. The neck is extended using a shoulder roll, and the head is

stabilized using a doughnut-shaped cushion.

◆ The anesthesiologist is positioned at the head of the table.

◆ The patient’s neck is cleaned with betadine and draped in sterile fashion if patient is stable.

◆ The landmarks in the neck are palpated and the skin overlying the cricothyroid (CT)

membrane is marked using a sterile marking pen.

◆ The skin and subcutaneous tissue is anesthetized with 1% lidocaine with 1:100,000 epi-

nephrine.

◆ The skin overlying the CT membrane is “put on stretch,” with the surgeon using the

nondominant hand, and a horizontal skin incision is made using a no. 15 scalpel blade

(Figure 6-2, A). A vertical, rather than horizontal skin incision, is useful in patients whose

landmarks are not easily palpated due to trauma, hematoma, or obesity (Figure 6-2, B).

2. DISSECTION

◆ Using an index ﬁ nger, the surgeon palpates the CT membrane in the wound (Figure 6-2, C).

CHAPTER 6 • Cricothyroidotomy 79

FIGURE 6 –2

Incision

Thyroid cartilage

Finger placed on

Cricothyroid membrane

Cricothyroid

muscle

Cricoid cartilage

80 Section I • Head and Neck and Endocrine Procedures

◆ The CT membrane is cut horizontally using a no. 15 scalpel blade (Figure 6-3).

◆ A hemostat is placed in the CT membrane and the tissue is spread open (Figure 6-4).

Incision

Cricothyroid muscle

Cricoid cartilage

FIGURE 6 –3

Cricothyroid membrane

FIGURE 6 –4

CHAPTER 6 • Cricothyroidotomy 81

◆ A small ETT is placed in the incision (Figure 6-5).

◆ Placement is conﬁ rmed with the return of CO

and the auscultation of bilateral breath

sounds.

◆ The tube is secured.

3. CLOSING

◆ Not applicable.

STEP 4: POSTOPERATIVE CARE

◆ The cricothyroidotomy is converted to a formal tracheotomy as soon as possible.

◆ See tracheotomy procedure (Chapter 5).

◆ If the previously described process is delayed, the ETT is replaced with a small tracheot-

omy tube.

Endotracheal tube

FIGURE 6 –5

82 Section I • Head and Neck and Endocrine Procedures

STEP 5: PEARLS AND PITFALLS

◆ Complications:

◆ Subglottic stenosis

◆ Chondritis

◆ Bleeding

◆ Cricoid fracture

◆ If the landmarks are nonpalpable or there is a hematoma present, a vertical midline

incision is made to gain wider exposure (see Figure 6-2, C). This incision can be

extended if necessary.

SELECTED REFERENCES

1. Myers EN: Tracheostomy. In Myers EN (ed): Operative Otolaryngology: Head and Neck Surgery.

Philadelphia, WB Saunders, 1997, pp 575-585.

2. Morris WM: Cricothyroidotomy. In Lore JM, Medina J (eds): An Atlas of Head and Neck Surgery, 4th ed.

Philadelphia, Elsevier, 2005, pp 82-83.

3. Tracheostomy. In Lore JM, Medina J (eds): An Atlas of Head and Neck Surgery, 4th ed. Philadelphia,

Elsevier, 2005, pp 1015-1023.

4. McWhorter AJ: Tracheotomy: Timing and techniques. Curr Opin Otolaryngol Head Neck Surg

2003;11:473-479.

STEP 1: SURGICAL ANATOMY

◆ The thyroglossal duct is a persistent remnant of the thyroid gland’s embryologic

descending tract from the ﬂ oor of the pharynx to its ﬁ nal position in the neck. Thyro-

glossal duct cysts occur most commonly in the midline, just inferior to the level of

the hyoid bone.

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ The exact location of the thyroid gland should be determined clinically, because aberrant

ectopic thyroid tissue may be mistaken for a thyroglossal cyst.

◆ When a thyroglossal cyst is infected, it should be ﬁ rst treated with antibiotics and/or

surgical drainage before complete excision.

◆ Imaging studies are not necessary (unless clinical examination ﬁ ndings are suspicious for

aberrant ectopic thyroid).

STEP 3: OPERATIVE STEPS

1. INCISION

◆ This operation (Sistrunk procedure) is performed with the patient under general anesthesia.

◆ The patient is positioned supine and the neck is hyperextended by placing a shoulder roll.

CHAPTER

Thyroglossal Duct Cyst

Dai H. Chung

◆ A transverse skin incision is made over the cyst; however, caution should be used to avoid

making a skin incision over the main prominence of the cyst, well away from the hyoid

bone (Figure 7-1).

◆ The subcutaneous dissection through the platysma is carried out using scissors and cautery.

Deep cervical fascia is cut in the midline to expose the cyst (Figure 7-2).

Incision

Cyst bulging

under skin

FIGURE 7 –1

Infrahyoid muscle fascia

FIGURE 7 –2

Section I • Head and Neck and Endocrine Procedures84