Tracheotomy:
The word tracheotomy comes from two Greek words: the root tom means “ to cut” and the
word trachea, while the root stom means in Greek , mouth referring to making a semipermenant or permanent opening, and to the opening itself, so tracheotomy is to cut through
trachea while tracheostomy is to make an opening in the trachea, the word tracheotomy usually
refers to operation while tracheostomy refers to opening created in the trachea, with the time
the two terms were used interchangeably
Tracheotomy was first in Egyptian artifacts 3600 B.C. also Homerus had written that Alexander
the great had saved a soldier from suffocation by making incision with the tip of his sword in the
mans’ trachea. This was also described in Indian and Arabian literatures.
Anatomy:
Trachea is consisted of incomplete hyaline cartilage rings which are connected dorsally
by trachealis muscle between the rings of trachea there are bands of the of fibroelastic
tissue “unnuler ligaments” the tracheal wall in cross-section consists of an inner mucosa
and submucosa followed by fibrocartilagious ring and outer adventitia in the cervical
trachea or serosa in the intrathoracic trachea.
Trachea receives a segmental blood supply from cranial and caudal thyroid arteries, at
the level of the carina , the source of blood supply shift primarily to the bronchoesophageal arteries venous drainage
via thyroid, internal jugular and
bronchoesophageal veins lymph flows to the deep cervical, cranial mediastinal, medial
retropharyngeal and tracheobronchial nodes main innervation from right vagus and
reccurent laryngeal nerve.
Indications:
Tracheotomy is indicated for various conditions that results in upper airway obstruction.
Figure 1 show three means of creating tube tracheostomy A. transvers tracheotomy, B.
tracheal flap
Temporary tracheostomy (indications)
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Trauma.
Anaphylaxis
Neoplasia.
Conformational defects.
Swelling of the tongue due to some cases of snake bites
During surgical manipulation of oral cavity.
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7- Bilateral epistaxis.
N.B. permanent tracheostomy: creation of stable stoma by suturing tracheal mucosa
to the skin.
Permanent tracheostomy (indications):
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Laryngeal masses.
Laryngeal paralysis or collapse.
Irresolvable trauma.
Laryngeal resection or reconstruction.
Anesthesia:
Most of the cases that needs tracheostomy are emergency cases, so in this case the
operation will be done under local infiltration, in other cases the operation might be
done without any preparation and without any type of anesthesia.
Also the operation might be done under general anesthesia (example: surgical
interventions in oral cavity or sinuses).
Site of operation:
Ventral midline of neck [in standing position or decumbency] at the junction of the
upper and middle third neck.
If time and airway status allow the ventral cervical site should be clipped, shaved
and prepared surgically, infiltrated with local anesthetic, if this is not possible all the
priorities should be directed at opening the tracheal airway, a7 cm. skin incision is
made through the skin at mid-cervical area where the trachea is most easily palpable
(junction of cranial and middle third of cervical trachea.
The musculature ventral to the trachea (a sternohyoideus and sternothyrodeus
muscle is paired and has a midline raphe. Separated bluntly to expose the ventral
aspect of trachea with a surgical blade, the membrane between two tratracheal
rings is incised parallel to the tracheal rings over approximately one third of its
circumference, care must be taken not incise a cartagious ring. Stay sutures are used
to mobilize the trachea, tracheostomy tube can be inserted to maintain an open
airway, if the tube cannot be inserted a semilunar section of tracheal ring can be
cut.(fig 1&2)
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Figure 1: A, transverse inscision between
two tracheal rings. B, stay suture are used to
mobilised the trachia , if desired portions of
the cartilage may be removed to reduse
irretation (dotted line )
figure 2 : A, transverse tracheotomy :B tracheal flap C.
vertical tracheotomy
The tube is secured with umbilical tape after surgery, tracheostomy site should be
removed and cleaned daily, tracheostomy site should be cleaned and all secretion s
removed during each cleaning, petroleum jelly should be liberally applied ventrally
to the tracheostomy site to prevent scalding by tracheal secretions.
**The tube is removed once the primary respiratory obstruction is resolved and the
tracheostomy site is allowed to granulate in.
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More extensive exposure is required for permanent tracheostomy as all local
musculature, excessive skin and portions of 3-4 tracheal rings are excised. And the
tracheal mucosa is sutured to skin to produce the desired stoma.
Postoperative systemic antibiotic is needed anti-inflammatory therapy is also
indicated (in horses anti tetanic serum is indicated postoperatively also).
///Another technique for permanent tracheotomy include placing mattress sutures
to oppose the sternohyoideus muscles dorsal to the trachea, then a segment of
cartilage is removed and the mucosa is incised, then interrupted sutures are used to
attach mucosa to the skin at the corners of the stoma, finally simple continuous
pattern is then used to meticulously attach the tracheal mucosa to the skin.(Figure
3)
Complications:
Immediate complication:
1- Plugging of the tube with debris.
2- Tube removal.
3- Coughing.
4- Vomiting.
5- Subcutaneous emphysema.
6- Pneumomediastinum
7- Pneumothorax.
8- Infection.
9- Respiratory distress and dyspnea
10- Perforation or esophagus or carotid a. or jugular v. isconsidered as technical
error complication.
Long term complication:
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Tracheal stenosis.
Trachea-esophageal fistula
Carotid A. erosion.
Granuloma formation.
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