TRACHEOSTOMY
(a life saving procedure)
DR. ABDUSSALAM M JAHAN
ENT DEPART, MISURATA UNIVERSITY,
FACULTY OF MEDICINE
Introduction
 Tracheostomy: is a surgical opening in
the anterior aspect of the
neck leading
directly to the trachea. It is maintained
open with tube called a Tracheostomy tube.
Relevant Surgical Anatomy
1 - Vocal cords
2 – Thyroid cartilage
3 - Cricoid cartilage
4 - Tracheal cartilages
5 - Balloon cuff
Indications:
1- upper airway obstruction, as mass or trauma,
where intubation may be impossible.
2- Assist respiration over prolonged periods.
3-prolonged
intubation
with
endotracheal
tube: (more than 7-10 days) to reduce the
possibility of subglottic stenosis.
4-
assist
cleaning
of
lower
respiratory
tract
secretions
5-Facial fractures that may lead to upper airway
obstruction (eg, comminuted fractures of the midface and
mandible)
6-Major operations on the head and neck.
 7- Reduce aspiration
 8-Severe obstructive sleep apnea. (if other
options failed).
Contraindications
 No absolute contraindications exist to tracheostomy
 RELATIVE

Laryngeal carcinoma
it may lead to increased incidence of stomal recurrence
(a diffuse infiltrate of neoplastic tissue at the junction of the amputated
trachea and skin
)
Types of Tracheostomy Tubes
Metal TT
Procedure
 Transverse Incision
 Incision 1 cm below
the cricoid or halfway
between the cricoid
and the sternal notch.
Procedure cont’d
 Blunt dissection of
subcut tissue
 Transversely retracted
as shown
Procedure cont’d
 Strap muscles are
divided
longitudinally at
midline
Procedure cont’d
 Thyroid
ismuth is
divided at midline by 2
hemostatic forcepses
and cut edge secured
by 2/0 vicryl
Procedure cont’d
 After
exposing
of
trachea, inverted U
opening is made in
trachea below 2nd ring
Procedure cont’d
 By
the Negus
forceps
the
trachea
dilated
and tracheostomy
tube inserted in
the inverted U
incision.
Procedure cont’d
 Fixation of the
tube.
Post-Op Management
 Repeat X-Ray soft tissue
neck
 Strong Analgesia
 Antibiotics
 IV fluid until able to
tolerate orally
Complications of Tracheostomy
 Complications 5-40%
 Mortality <2%
 Complications are more frequent in emergency
situations, severely ill patients
Immediate complications:
 Apnea due to blood clot obstructing the tube, wrong
insertion or displacement of the tube.
 Bleeding.
 Pneumothorax or pneumomediastinum: These can
result from direct injury to the pleura or the cupola of the
lung (especially in children).
 Injury to adjacent structures: paratracheal structures
vulnerable to injury are RLN, the great vessels, and the
esophagus.
Early complications:
 Early bleeding: This is usually the result of increased
blood pressure as the patient recovery from anesthesia and
begins to cough. Although this may necessitate a return to
the operating room, bleeding may be controlled with local
packing, cautery, control blood pressure.
 Plugging with mucus.
 Tracheitis: present in all patients with fresh
tracheostomies. humidification, minimization of
the fraction of inspired oxygen (FIO2) (because
high
oxygen
levels
exacerbate
irrigation are essential.
 Cellulitis.
 Displacement of the tube.
drying),
and
 Subcutaneous emphysema: This results from a
tight closure of tissue around the tube, tight packing
material around the tube, or false passage of the tube
into pretracheal tissues.
 Atelectasis: An overly long tube can mimic a
unilateral mainstem intubation, causing atelectasis
or collapse of the opposite lung.
Late complications:
 Bleeding: Bleeding more than 48 hours after the procedure is most
commonly
(50%)
caused
by
tracheo-innominate
erosion
(fistula).
 Stenosis (subglottic stenosis)
 Tracheoesophageal fistula: usually caused by friction
between a posteriorly displaced tracheostomy tube or
overinflated cuff and a rigid nasogastric tube. It manifests
as aspiration and subsequent chemical pneumonia.
 Tracheo-cutaneous fistula.
 Scarring: Both vertical and horizontal incisions
heal with small but visible scars.
Clinico-Pathology Seminar: Dept. of ORL, UITH.
The End
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