Grand Rounds Cricothyroidotomy: When, Why, and Why Not? Ashley Anders Schroeder, MD, LCDR, MC, USNR A 25-year-old, otherwise healthy, active duty review selected data that have surrounded the Navy male patient was referred from a ship with recent debate regarding the use of cricothyroid- persistent pneumonia despite intravenous antibiot- otomy. I will conclude with some general guide- ics administered by the ship's medical officer. He lines that I propose based on my review of the was admitted to the intensive care unit, rapidly literature. I endeavor to provide a good overview developed adult respiratory distress syndrome and then discuss some specific areas that I found (ARDS), and required airway support. However, the particularly interesting in researching this topic for anesthesiologist on call was unable to successfully you to consider. I am not trying to convince you that translaryngeally intubate the patient; as the pa- we otolaryngologists should all be doing cricothy- tient's oxygen saturation began to drop rapidly, it roidotomies instead of tracheotomies. However, was clear that a surgical airway was going to be perhaps I will help us reconsider our thinking on necessary. The senior surgical resident performed a the subject, particularly with regard to when (or cricothyroidotomy, placed a #6 cuffed endotracheal whether) to convert a cricothyroidotomyto a trache- tube through the incision, and ventilated the pa- otomy. tient, who responded well with rapid return of good oxygen saturation. When things had settled down, the senior resident turned to me and asked what I, BRIEF HISTORY the otolaryngologist-to-be, thought we should do next. I realized I really did not know a good answer to his question, but my impression was that otolar- Before Chevalier Jackson's time, trache- yngologists rarely perform cricothyroidotomies be- otomy began to be used to manage laryngeal cause we are able to perform an emergency trache- obstruction from many causes but with high otomy in about the same time. I also thought that morbidity and mortality as high as 50% from the risk of subglottic stenosis was our reason for the procedure itself. In 1909, Jackson de- being so reluctant to perform cricothyroidotomy, but I was not certain where I had learned this scribed the first systematic approach to trache- "dogma." That is why I chose this topic to review otomy, emphasizing meticulous dissection and discuss with you. with proper planning and instrumentation, I will first review the history of cricothyroid- and devised nonirritating and appropriately otomy and the surgical technique. Next, I will shaped tubes. 1 He was able to reduce mortality discuss the indications and contraindications and then compare the complications of cricothyroid- from the procedure to approximately 3%. 2 In otomy with tracheotomy. Most importantly, I will 1921, he then described his care of more than 200 patients with chronic subglottic stenosis and summarily condemned "high trache- From the Department of Otolaryngology--Head and otomy" stating "... there should be taught Neck Surgery, Naval Medical Center, Portsmouth, VA. Presented at grand rounds with Eastern Virginia Medi- only one tracheotomy and that should be cal School on April 16, 1998, Norfolk, VA. 'low.' ,,3 Since that landmark paper, we have The views expressed in this article are those of the generally continued to condemn cricothyroid- author and do not reflect the official policy or position of the Department of the Navy, Department of Defense, nor otomy because of the impression that it inevi- the US government. tably leads to subglottic stenosis. This was Address reprint requests to Ashley Anders Schroeder, also extrapolated to imply that any cricothy- MD, LT, MC, USNR, Department of Otolaryngology-- Head and Neck Surgery, Naval Medical Center, Ports- roidotomy performed should be converted to a mouth, VA 23708-5100. tracheotomy in as expedient a fashion as pos- This is a US government work. There are no restric- sible. However, several points should be made tions on its use. 0196-0709/00/2103-000950.00/0 about Jackson's patient population: (1) many doi: 10.1053/A JOT.2000.6607 of his patients were children in whom the American Journal of Otolaryngology, Vo121, No 3 (May-June), 2000: pp 195-201 195 196 ASHLEY ANDERS SCHROEDER cricoid cartilage is known to be the narrowest However, there are some not-so-standard portion of the airway4; (2) all patients were indications that have been proposed for crico- referred from other surgeons, so there was no thyroidotomy or for maintaining an existing standardization of technique; (3) most cricothy- cricothyroidotomy. The relative ease with roidotomies were performed for inflammatory which a cricothyroidotomy can be performed processes such as diphtheria, tuberculosis, (relative to a tracheotomy) with minimal train- and epiglottitis, and (4) most of the patients ing makes it the emergency surgical airway had "high tracheotomies," which actually di- access procedure of choice for nonphysicians vided the cricoid and/or the thyroid carti- or nonsurgeons. It has been shown to be a lages. 4,5,6 I propose to you that these points reliable means of airway access, with emer- would suggest that perhaps we should not gency medical technicians achieving tracheal extrapolate from Jackson's patient population intubation in 87% of attempts, flight nurses in to the patients we see today. Nonetheless, 96%, and "young physicians-in-training" be- certain principles from his observations are ing successful in 92% of attempts. 1° Masseter useful, such as avoiding cricothyroidotomy in spasm after succinylcholine is another some- patients with inflammatory processes and what specialized indication. 11 Altered anatomy avoiding division of the cricoid and/or thyroid that precludes tracheotomy is another indica- cartilages. tion. Examples would include large goiters or anomalous vessels that would make standard TECHNIQUE tracheotomy less reliable and more risky. Perhaps the most interesting of the less The basic steps in performing the procedure conventional indications for cricothyroid- are well known to you all, so I will only very otomy is in patients who have median sternoto- briefly discuss them and point out a few mies. Some surgeons have identified that these specific issues to consider. The most basic patients often require prolonged tracheal ac- steps are to identify the cricothyroid mem- cess for pulmonary toilet or ventilation postop- brane and stabilize it with 1 hand, make an eratively but desire to separate the airway incision through it, dilate the incision, and incision (and subsequent secretions) from the place a tube through it. Some extra steps that median sternotomy incision to reduce the risk are useful depending on the urgency of the of mediastinitis. 6 This is actually where the situation are preparing the site with an antisep- debate about the use of elective cricothyroid- tic solution, local anesthesia, using a trous- otomy began. Morain suggested the same ad- seau dilator to dilate the incision, and using vantage in patients requiring neck dissec- scissors to extend the incision laterally as tions. 8 He performed cricothyroidotomy necessary. The finer points in technique in- whenever tracheotomy was indicated in 16 volve being mindful to angle the scalpel inferi- head and neck cases, including 9 with compos- orly as the incision is made in order to avoid ite resections, and felt it was "superior to injury to the vocal cords, which are .5-2 cm traditional tracheotomy." He observed that it above the cricothyroid membrane. 7,8 Also, the better separated the airway incision and secre- intent with incising and with spreading should tions from the neck wound and therefore be to separate the thyroid cartilage from the reduced the incidence of sinus communica- cricoid cartilage--not to incise or fracture tion between the trachea and neck dissection either one. incision, especially with the McFee incision. This was not a randomized, controlled pro- INDICATIONS spective study and the numbers were too small to draw any significant conclusions. Some of the standard indications for crico- However, I find this proposal interesting. thyroidotomy include oral and maxillofacial trauma, suspected cervical spine injury, and CONTRAINDICATIONS inability to perform endotracheal intubation because of profuse oral hemorrhage, emesis, or The single most important contraindication anatomy that obscures visualization of the for cricothyroidotomy is laryngeal pathology. vocal cords. Specifically, conditions that cause inflamma- CRICOTHYROIDOTOMY: WHEN, WHY, AND WHY NOT? 197 tion are contraindications including trauma, pared the results with historical tracheotomy infection, and translaryngeal intubation.12 This data. Obviously, each study aimed to investi- latter condition is one of the most interesting gate a slightly different aspect of the problem. parts of the debate in the last several years. Therefore, there was great variability in method Another relative contraindication is in chil- of and vigilance in monitoring for sequelae. dren in whom it is generally felt to be contrain- There were a wide variety of definitions of dicated because of the possible increased risk complications (eg, chronic subglottic stenosis of subglottic stenosis and the fact that, with being separated from other laryngotracheal their smaller airway diameter, even minor injuries or stenoses that require further inter- stenosis is relatively more physiologically sig- vention). The patient populations