Cricothyroidotomy

Cricothyroidotomy is a technique usually reserved for emergency airway access. The cricothyroid space, easily palpated in most patients, marks a level where the trachea is quite close to the skin surface. Thus it is quickly accessible in the occasional acute airway crisis, for example acute upper airway obstruction in a patient who cannot be intubated successfully. The skin overlying the cricothyroid membrane is anesthetized (if time permits) with lidocaine (lignocaine), and a 2- to 3-cm vertical incision is made through the skin over the membrane. The membrane is palpated and a direct stab incision is made though it. The opening is spread with a hemostat, and a small tracheostomy tube (internal diameter of 4-6 mm) is inserted. The hemostat is removed, the cuff inflated, and the tube secured.

The simplicity and speed of the procedure are attractive, but the technique is not widely used in non-emergency situations because of the high morbidity attributed to it. In particular, a high incidence of subglottic stenosis has been ascribed to it by some authorities. Furthermore, because the space is small, the tube used must be of relatively small diameter, and this may pose problems in patients with difficult pulmonary toilet. However, the cricothyroid space has no adjacent important blood vessels and serious bleeding is rarely encountered. Moreover, owing to its high position in the neck, cricothyroidotomy is seldom complicated by pneumothorax. It seems that the potential for injury to the subglottic region relates in large part to previous translaryngeal intubation, and that subglottic stenosis is uncommon when cricothyroidotomy is undertaken in patients who have been intubated for less than 72 h. Electively, the technique may be advantageous in post-sternotomy patients, in whom standard low tracheostomy may predispose to sternotomy wound infection.

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