Five years experience of coniotomy

Elective surgical cricothyroidotomy in oral and maxillofacial surgery

Surgical Cricothyroidotomy is regarded as an emergency procedure today even though it has a good evidential record as an elective surgical airway. A misunderstanding of Jackson's landmark paper in 1921 has made the simple and safe procedure unpopular because of the fear of subglottic stenosis. We present the incidence of subglottic stenosis after surgical cricothyroidotomy, discuss evidence for elective surgical cricothyroidotomy, and suggest potential applications in oral and maxillofacial surgery.

Emergency percutaneous tracheostomy is feasable in experienced hands

One of most stressful situations for a physician occurs when a patient is unable to breathe and endotracheal intubation is not possible. The establishment of an open airway by surgery is indicated only if the physician is unable to do so with an endotracheal tube. Surgical tracheostomy is not indicated in emergency situations because it takes a long time and can result in death if respiratory support cannot be provided during the procedure. Percutaneous dilatational tracheostomy in experienced hands takes only a few minutes. We describe six patients, including two trauma patients, in whom emergency percutaneous tracheostomy was rapidly and successfully performed under conditions of the imminent loss of airway and inability to intubate the patient. As this procedure is safe and can be performed easily by experienced personnel, we propose its addition to the armamentarium of emergency airway management.

Percutaneous dilatational cricothyroidotomy: outcome with 44 consecutive patients

OBJECTIVE

To assess the value of the percutaneous dilatational technique in elective cricothyroidotomy.

DESIGN

Forty-four consecutive patients requiring prolonged mechanical ventilation.

SETTING

The general 14-bed intensive care unit of a university hospital.

INTERVENTIONS

Fourty-four percutaneous dilatational cricothyroidotomies using a multiple-dilator wire-guided procedure.

MEASUREMENTS AND RESULTS

The average duration for the procedure was 11 min in 37 patients. No significant complications occurred intraoperatively except for one paratracheal cannula insertion. Postoperative complications were one case of stoma infection, three cases of transient phonatory changes, two cases of a small peristomal granuloma, and one case of persistent stoma. Of 21 decannulated patients, 16 survived to discharge. Long-term follow-up was possible in 14 surviving patients. All were asymptomatic several months after decannulation.

CONCLUSIONS

Percutaneous dilatational cricothyroidotomy can be a quick, safe technique, as good as the percutaneous subcricoidal approach in ventilated, critically ill patients.

The cricothyroid muscle after cricothyroidotomy. A porcine experimental study

Cricothyroidotomy in elective use or emergency situations has been discussed by several authors during recent years. The main complication reported has been subglottic stenosis. We have used this method for several years and among our patients there has been no case of stenosis. The major complication in our material has been voice dysfunction. Some of the patients had a change in voice quality consistent with dysfunction in the cricothyroid muscles (diminished voice range and a lowered pitch). The aim of this study was to investigate whether cricothyroidotomy and insertion of a tracheostomy tube caused physiological or morphological changes in the cricothyroid muscle, by direct injury or secondary to a peripheral nerve lesion. In the six animals that were cricothyroidotomized during 7-9 days and examined after 9-15 weeks, we found neither changes in the EMG nor in the muscle morphology indicating injury to the muscle or its peripheral nerve supply.

Use of cricothyroidostomy in oral and maxillofacial surgery

Surgical entry into the upper airway is not only important in emergency situations but also in the treatment of certain elective maxillofacial procedures. The procedure of choice by which surgical access is gained has traditionally been a tracheostomy. Although a cricothyroidostomy is easier and quicker to perform, with a higher degree of safety, it has generally been relegated to only emergency situations. The purpose of this paper is to present the anatomy, indications, and surgical technique of cricothyroidostomy. It is concluded that cricothyroidostomy, and not tracheostomy, is the preferred procedure for surgical establishment of an upper airway, either in elective maxillofacial surgical procedures, or in an emergency situation.