Tracheotomy is a surgical procedure that dates back to early history and medical advancement. The oral and maxillofacial surgeon routinely operates around the airway and should be able to master this procedure by adhering to the surgical principles outlined in this article.
Tracheotomy history
The term tracheotomy, from the Greek root words trachea arteria (rough artery) and tom (to cut), refers to the surgical procedure in which a tracheocutaneous airway is created in the patient’s neck. The term tracheostomy, from the Greek root stom (mouth), refers to the making of a semipermanent or permanent opening in the airway. Although the 2 terms have been used interchangeably, tracheotomy actually refers to the surgical procedure and tracheostomy, to the opening created by this surgical procedure.
Tracheotomy was first portrayed on Egyptian tablets in 3600 BC. Asclepiades of Persia was the first person to perform a tracheotomy in 100 BC. Antonio Musa Brasavola, an Italian physician, is the first person credited with documenting this surgical procedure in 1546 for a patient suffering from a laryngeal abscess.
In today’s world, tracheotomy is a time-honored procedure, used for the management of the airway in acute settings, such as maxillofacial and laryngeal trauma, and establishment of a secure airway in the management of head and neck infections. Tracheotomy is routinely performed in the intensive care unit for patients on prolonged mechanical ventilation and in management of head and neck oncological surgeries and reconstruction. The oral and maxillofacial surgeon is routinely involved with surgical procedures requiring a secure airway, acutely, or in the setting of long-term management of the airway.
Indications
The decision to perform a tracheotomy should be adapted to each patient and predisposing pathology. The patient’s and legal guardian’s wishes must be considered, with an informed consent based on understanding the risks of prolonged translaryngeal intubation and the complications of the surgical procedure. Indications for tracheotomy are outlined.
- 1.
Upper airway obstruction due to oncological pathology
- 2.
Expected prolonged intubation
- 3.
Inability to intubate
- 4.
Panfacial maxillofacial trauma
- 5.
Laryngeal and significant neck trauma
- 6.
Adjunct to head and neck surgery:
- a.
Ablative tumor surgery
- b.
Reconstruction of mandible and maxillary complex
- a.
- 7.
Obstructive sleep apnea.
Although there are no absolute contraindications to a tracheotomy procedure, relative contraindications have been reported to include significant burn injury or infection of the trachea.
Indications
The decision to perform a tracheotomy should be adapted to each patient and predisposing pathology. The patient’s and legal guardian’s wishes must be considered, with an informed consent based on understanding the risks of prolonged translaryngeal intubation and the complications of the surgical procedure. Indications for tracheotomy are outlined.
- 1.
Upper airway obstruction due to oncological pathology
- 2.
Expected prolonged intubation
- 3.
Inability to intubate
- 4.
Panfacial maxillofacial trauma
- 5.
Laryngeal and significant neck trauma
- 6.
Adjunct to head and neck surgery:
- a.
Ablative tumor surgery
- b.
Reconstruction of mandible and maxillary complex
- a.
- 7.
Obstructive sleep apnea.
Although there are no absolute contraindications to a tracheotomy procedure, relative contraindications have been reported to include significant burn injury or infection of the trachea.
Relevant surgical anatomy
The lower respiratory tract begins at the level of the vocal cords. Inferior to the vocal cords, the rigid cricoid cartilage extends about 1.5 to 2 cm vertically in an area called the subglottic region. The surgical cricothyrotomy enters the cricothyroid membrane in the subglottic region. Inferior to the cricoid cartilage is the trachea. The trachea is made up of 18 to 22 C-shaped rings, with rigidity and flexibility provided by rigid cartilaginous portions anteriorly and laterally and a soft membranous portion posteriorly. In the average adult, the distance from the cricoid cartilage to the carina is approximately 10 to 13 cm. On average, the trachea is 2.3 cm wide and 1.8 cm deep in the anterior-posterior direction. The trachea is generally wider in men than in women ( Fig. 1 ).
The sternohyoid and sternothyroid muscles meet at the midline of the neck and are fused together by an avascular fascia that must be incised and retracted laterally to reach the trachea. Motor nerves run deep and inferior to the sternohyoid and sternothyroid muscles, and if additional retraction is needed, it should be done superiorly to avoid damage to these nerves.
The thyroid gland is encased in the middle layer of the deep cervical fascia and is suspended in the anterior neck by a suspensory ligament from the cricoid cartilage. The posterior portion of the gland is attached to the side of the cricoid cartilage and first and second tracheal ring by the posterior suspensory ligament. This firm attachment allows movement of the thyroid gland during swallowing. The thyroid gland is found anterior to the trachea, with an isthmus crossing the trachea at the level of second or third tracheal rings. This tissue is vascular and should be divided and ligated for adequate hemostasis during this surgical procedure.
The blood supply relevant to surgical tracheotomy is the associated minor arterial and venous supply to the thyroid gland and the brachiocephalic trunk (innominate artery) in the superior outlet of the mediastinum. The superior thyroid artery is the first branch of the external carotid artery, and it descends laterally to the larynx and sternohyoid. It becomes superficial on the anterior part of the gland, supplying the isthmus and anastomoses with the contralateral superior thyroid artery. The inferior thyroid artery arises from the thyrocervical trunk, a branch of the subclavian artery. It is normally found in the tracheoesophageal groove and enters the larynx near the inferior part of the cricoid cartilage.
The great vessels (ie, carotid arteries and internal jugular veins) may be damaged if the dissection is carried too far laterally. The innominate artery or brachiocephalic trunk crosses from left to right in the anterior superior portion of the thoracic inlet, anterior to the trachea, and it is found under the sternum. This vessel can create significant life-threatening hemorrhage if it is damaged during surgical tracheotomy. Occasionally, a single vessel called the thyroid ima artery originates from the arch of the aorta or the innominate artery and enters the thyroid gland near the isthmus.
Venous drainage of the area is provided by the superior thyroid and middle thyroid veins, which drain into the internal jugular veins bilaterally. The inferior thyroid veins follow a different pathway on each side. On the right, the vein passes anterior to the innominate artery to the right brachiocephalic vein or anterior to the trachea to the left brachiocephalic vein. On the left, the vein drains into the left brachiocephalic vein. If bilateral inferior thyroid veins anastomose in the middle, they form the thyroid ima vein, which also drains into the left brachiocephalic vein. The anterior jugular vein begins just below the chin through the union of several small veins. It is found superficially and close to the midline of the neck as it descends over the isthmus of the thyroid. It may be encountered during the surgical approach in the midline of the neck.
The superior laryngeal nerve is found along the superior thyroid artery, and inadvertent damage to this nerve creates dysphonia by altering the pitch regulation. The recurrent laryngeal nerves travel in the tracheoesophageal grooves and may be damaged if dissection strays too far laterally. Damage to recurrent laryngeal nerves may result in hoarseness, aphonia, and an increased risk of aspiration.
Armamentarium
The armamentarium of the tracheotomy procedure is composed of basic surgical instruments and is really tailored to the surgeon’s preference and institutional capabilities. The authors present a basic tracheotomy surgical setup and tubes ( Fig. 2 ).
Tracheostomy tubes
Tracheostomy tubes are used to provide a surgical airway and ventilation for the patient, prevent aspiration of secretions, and assist in lower respiratory suctioning and clearance. They are available in multiple varieties of shapes, styles, and sizes made by numerous manufacturers. The basic components of a tracheostomy tube are illustrated in Fig. 3 . The dimension of the tubes are specified by inner diameter (ID) and outer diameter (OD).
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