C H A P T E R

Cricothyroidotomy
Anna M. Pou

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 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 semirecumbent 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).

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Hyoid bone Omohyoid muscle Sternohyoid muscle Thyroid notch Anterior jugular vein Cricoid cartilage Sternocleidomastoid muscle Thyroid isthmus Thyroid gland Trachea Thyroid cartilage

Sternal notch
MC

FIGURE 61

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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 patients 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 epinephrine.

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 nger, the surgeon palpates the CT membrane in the wound (Figure 6-2, C).

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Incision

MC

A
Incision

Cricothyroid muscle

Thyroid cartilage

Cricoid cartilage

Finger placed on Cricothyroid membrane

C FIGURE 62

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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).

Cricothyroid muscle

Incision Cricoid cartilage

MC

FIGURE 63

Cricothyroid membrane

FIGURE 64

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

Placement is conrmed with the return of CO2 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 tracheotomy tube.

Endotracheal tube

FIGURE 65

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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.