OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD &

NECK OPERATIVE SURGERY

TRACHEOSTOMY Johan Fagan

Tracheostomy refers to the creation of a tion due to cervical and mediastinal tu-
communication between the trachea and the mours, or traction on the trachea due to
overlying skin. This may be done either by fibrosis (Figure 1).
open or percutaneous technique. This chap-
ter will focus on the open surgical technique
in the adult patient.

Indications

Tracheostomy is done for airway obstruc-

tion, respiratory support (assisted ventila-
tion), pulmonary hygiene, elimination of
dead space, and treatment of obstructive
sleep apnoea.

Preoperative evaluation
Figure 1: Tracheal deviation due to tuber-
Level of obstruction: A standard tracheos- culosis
tomy will not bypass obstruction in the dis-
tal trachea or bronchial tree Laryngeal cancer: If airway obstruction is
because of laryngeal cancer, then one
Anatomy of the neck: The surgeon should should attempt not to enter the tumour
anticipate a difficult tracheostomy in pa- during tracheostomy. This may require a
tients with short necks, thick necks, and lower tracheostomy if tumour involves the
necks that cannot be extended due to e.g. cervical trachea. It is prudent to send a sam-
rheumatoid or osteoarthritis of the cervical ple from the tracheal window for histologi-
spine cal examination as involvement by tumour
might be useful information for the surgeon
Coagulopathy: A coagulopathy should be subsequently doing the laryngectomy.
corrected prior to surgery. If not complete-
ly corrected, then have electrocoagulation Tracheostomy procedure
available at surgery to aid haemostasis
A tracheostomy is best done in the opera-
Cardiorespiratory status: Patients with up- ting room with good lighting, instrumenta-
per airway obstruction may have cor pul- tion, suction, diathermy and assistance. Pa-
monale, or respiratory acidosis. Some pa- tients may cough on inserting the tracheo-
tients may be dependent on physiological stomy tube; hence eye protection is recom-
PEEP to maintain O2 saturation, or an eleva- mended to prevent transmission of infec-
ted pCO2 to maintain respiratory drive; re- tions such as HIV and hepatitis.
lieving upper airway obstruction with a tra-
cheostomy may paradoxically cause such Anaesthesia: Unless the patient can safely
patients to stop breathing and become hypo- be intubated or the patient can be ventilated
xic. with a mask, a tracheostomy should be done
under local anaesthesia. If there is concern
Deviation of cervical trachea: A chest X- about the anaesthetist’s ability to maintain
ray will alert the surgeon to tracheal devia- an airway, then the surgeon should be pre-
sent during induction; the skin, soft tissue
and trachea (into the lumen) should be
infiltrated with local anaesthesia with adre-
naline before induction; and a set of trache-
Thyroid
ostomy instruments should be set out prominence
before induction of anaesthesia so that an Cricothyroid
membrane
emergency tracheostomy can be done if
Cricoid
required.

Positioning and draping

• Place the patient in a supine position

with neck extended by a pillow or bag Thyroid
prominence
placed under the shoulders to deliver the Cricothyroid
trachea out of the thorax and to give membrane

adequate access to the cervical trachea Cricoid

• Such extension may not be possible in

patients with neck injuries, or rheuma-
toid and osteoarthritis of the cervical
spine
• Some patients with impending airway
obstruction may not tolerate a recum-
bent position; the tracheotomy may then
be done with the patient in a sitting posi-
tion with neck extended
Figure 2: Surface anatomy
• Sterilise the skin of the anterior neck
and chest and drape the neck
Minimum instruments: A minimum set of
• If the tracheostomy is being done under
instruments is demonstrated in Figure 3.
local anaesthesia, the face be uncovered

Surface landmarks (Figure 2)

• The tracheostomy is created below the

1st tracheal ring to avoid subglottic ste-
nosis as a result of scarring
• Run your finger up the midline of the
neck starting inferiorly at the sternal
notch: the 1st prominence encountered is
the thyroid isthmus, followed by the cri-
coid
• Alternatively, identify the thyroid pro-
minence or “Adam’s apple”. Moving
inferiorly the finger slips into the de-
pression of the cricothyroid membrane,
followed by the solid prominence of the
cricoid cartilage
Figure 3: Minimum set of instruments

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Skin incision

• Make a horizontal incision one finger-

breadth below the cricoid prominence. Cricoid cartilage

It is cosmetically preferable to a verti- Anterior jugular vein

cal midline incision Thyroid isthmus
• Extend the incision through skin and Sternohyoid and
subcutaneous tissue (platysma is gene- sternothyroid muscles

rally absent in the midline)

• Take care not to transect the anterior
jugular veins which are just superficial
to the strap muscles within the investing Figure 5: Exposure of anterior jugular
cervical fascia. They can be preserved veins and cervical fascia
and retracted laterally (Figure 4)

Infrahyoid strap muscles

• Figure 4 illustrates the infrahyoid strap

muscles

Thyroid cartilage

Cricoid cartilage

Thyroid gland

Sternohyoid muscle

Sternothyroid muscle

Figure 6: Retracting sternohyoid and ster-

nothyroid muscles exposes the thyroid isth-
Figure 4: Infrahyoid strap muscles mus

• Dissect towards the trachea by parting Thyroid isthmus

the tissues with scissors, remaining
strictly in the midline in a vertical • The thyroid isthmus overlies the 2nd/3rd
plane to avoid injury to the inferior thy- tracheal rings
roid veins • Retract the isthmus superiorly with
• Identify the midline cervical fascial Langenbeck retractors to expose the tra-
plane between the sternohyoid muscles chea (Figure 7)
• Divide this intermuscular plane by • Only very rarely does the thyroid isth-
spreading with a pair of scissors (Figure mus need to be doubly clamped, divi-
5) ded, and (suture) ligated, or if small,
• Repeat this manoeuvre to separate the divided with eletrocautery
sternothyroid muscles and retract the
muscles laterally (Figure 6) Expose trachea
• The trachea and cricoid can now be pal-
pated • Expose the infrathyroid trachea by care-
fully parting the overlying soft tissues

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 with a pair of scissors, taking care not to the tube passing into a false tract ante-
tear the inferior thyroid veins rior to the trachea (Figure 8)
• Ensure that the surgical field is comple- • Alternately one may remove an anterior
tely dry before proceeding, as it is diffi- cartilage segment of the 2nd, 3rd or 4th
cult to achieve haemostasis once the tra- tracheal rings
cheostomy tube has been inserted
• Should there be doubt about the location
of the trachea, or there be concern it
being confused with the carotid artery,
aspirating air with a needle attached to a
syringe will confirm its location

Figure 8: Flap reflected inferiorly with

traction suture attached to flap
Figure 7: Thyroid isthmus retracted supe-
riorly and an inferiorly based flap cut Insertion of tracheostomy tube
(along red lines) in anterior tracheal wall
• Assess the size of the trachea and select
Create a tracheostoma the largest cuffed tracheostomy tube
that comfortably fits the tracheal lumen
• In the awake patient, inject lignocaine • Inject air into the inflatable cuff of the
into tracheal lumen prior to incising the tracheostomy tube to test the integrity of
trachea and inserting the tube to reduce the cuff
coughing • Insert the introducer into the tracheos-
• A tracheal hook inserted under a tra- tomy tube (Figure 12)
cheal ring may be used to pull superior- • If the patient has been intubated, the
ly to deliver the trachea from the chest anaesthetist slowly withdraws the endo-
and to stabilise the trachea tracheal tube until the tip of the tube is
• The safest tracheostomy in adults is to visible in the stoma
create an inferiorly based flap raised • Insert the tracheostomy tube into the
from the anterior wall of the 3rd and 4th tracheostomy under direct vision while
tracheal rings applying traction to the silk traction su-
• A silk traction suture is passed through ture attached to the tracheal flap
this anterior tracheal flap and loosely • Ensure that the tube has been inserted
secured to the skin (Figure 8). into the tracheal lumen, and not into a
• Traction on the suture facilitates rein- false passage in the paratracheal soft
sertion of the tracheostomy tube in case tissues
of accidental decannulation and avoids

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• Inflate the cuff, attach the anaesthetic cause jugular vein compression, throm-
tubing bosis, venous outflow obstruction and
• Hand-ventilate while correct placement flap failure; the tracheostomy should
of the tube within the trachea is confir- preferably be sutured to the suprastomal
med by checking the expired pCO2, skin (Figure 11)
checking for chest movement or listen-
ing for breath sounds (Figure 9)
• Do not suture the skin tightly around the
tracheostomy tube as this can promote
surgical emphysema

Epiglottis

Glottis

Thyroid cartilage

Cricoid Figure 10: Tracheostomy tube secured with

Thyroid gland Velcro tape
Innominate artery

Sternum

Figure 9: Position of tracheostomy tube

Securing the tracheostomy tube

• Thread tapes through the holes in the

flanges of the tracheostomy tube and
pass them around the neck Figure 11: Tracheostomy tube sutured to
• Tie them with the neck flexed suprastomal skin
• If the tapes are tied with the neck exten-
ded, then they will be too loose when Pitfalls
the patient flexes the neck
• The ties should be tight enough to admit Low tracheostomy: A tracheotomy should
no more than a single finger under the not be placed below the 4th tracheal ring as:
tape (Figure 10) • The distance between the skin and the
• The author sutures the tracheotomy tube trachea increases inferiorly, which ma-
to the skin for the first few days until kes tracheal intubation more difficult
maturation of the tracheocutaneous tract • A low tracheostomy may compress and
(Figure 11) erode the innominate artery which pass-
• The sutures can then be removed, and es between the manubrium sterni and
only traditional tracheotomy tapes used the trachea (Figure 9). This may cause
• Following free microvascular transfer innominate artery erosion and fatal hae-
flap reconstruction, tracheostomy tapes morrhage. This may be preceded by a
should be avoided as tracheal tapes may so-called “sentinel bleed”

5
High tracheostomy: It is important not to Choice of Tracheostomy Tube
place the tracheotomy above the 2nd tra-
cheal ring, as inflammation may cause sub- A variety of tube designs and materials are
glottic oedema, chondritis of the cricoid available. The choice of tube should con-
cartilage, and subglottic stenosis. form to the indication for which it is to be
used. All tubes should have an inner can-
Paratracheal false tract (Figure 12): Inad- nula; this can safely be removed and
vertent extratracheal placement of the trach- cleaned without a need to remove the outer
eostomy tube can be fatal. It is recognised cannula and hence avoids risking losing the
by the absence of breath sounds on airway (Figure 13).
auscultation of the lungs, high ventilatory
pressures, failure to ventilate the lungs,
hypoxia, absence of expired CO2, surgical
emphysema, and an inability to pass a
suction catheter down the bronchial tree,
and on chest X-ray.

Figure 12: Tracheostomy tube visible in a Figure 13: Plastic low pressure cuffed tra-
paratracheal false tract cheostomy tube with outer cannula, inner
cannula and introducer (L to R)
Surgical emphysema, pneumomediasti-
num, and pneumothorax: Injury to the The following factors may influence the
pleural domes is more likely to occur in choice of tube:
children, struggling patients and patients on
positive pressure ventilation. It can be com- Tube diameter: Because airway resistance
plicated by a tension pneumothorax. Hence is related to the 4th power of the radius with
auscultation of the chest and a CXR should laminar flow, and the 5th power of the radius
be performed after tracheostomy, especially with turbulent flow, it is important to select
in ventilated patients. Surgical emphysema a tube that that fits the trachea snugly. A
may also be promoted by suturing the tra- range of sizes should be available. It also
cheostomy wound around the tracheos- underscores the importance of keeping the
tomy tube. tube clean, as accumulation of mucus in-
creases airway resistance not only by redu-
Airway fire: Do not enter the trachea with cing the diameter, but also by causing tur-
diathermy as this may cause an airway fire bulent air flow.
in a patient being ventilated with a high
concentration of oxygen.
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Tracheal seal: A cuffed, plastic tracheosto-
my tube is used to create a seal with the
trachea in patients on positive pressure ven-
tilation, and with fresh tracheostomy
wounds (Figure 13) to prevent saliva or
blood entering the lower airways. The cuf-
fed tube may be replaced with an uncuffed
tube, either plastic or metal (Figure 14) in
patients who do not require positive pres-
sure ventilation once the tract between the
skin and the trachea has become well defi-
ned by granulation tissue at 48hrs, and tra- Figure 15: Tracheostomy tube with adjust-
cheostomal bleeding has settled. table flange

Tube material: Metal tubes are thinner Neck Flange: The neck flange should con-
walled, and hence have a better ratio of form to the shape of the neck and fit snugly
outer to inner wall diameter, thereby opti- against the skin to avoid excessive tube
mising airway resistance (Figure 14). movement, accidental decannulation, and
soft tissue trauma

Phonation: Patients with uncuffed tubes or

fenestrated tubes (Figure 16) can phonate
by occluding the end of the tracheostomy
tube with a finger which permits air to by-
pass the tube and to pass through the larynx.

Figure 14: Metal tracheostomy tube with

outer cannula, inner cannula and introdu-
cer (L to R)

Tube length: Patients with very thick necks

can be fitted with a tracheostomy tube with
a flange that can be adjusted up or down the
shaft of the tube (Figure 15). Tube length
may also need to be adjusted when the cari- Figure 16: Fenestrated tracheostomy tube
na is close to the tracheostoma or with tra-
cheal stenosis or tracheomalacia distal to Speaking valves fitted to the ends of tra-
the tracheostoma that needs to be stented by cheostomy tubes are one-way valves that
the tube. Chest and neck X-rays are of value open on inspiration, but close on expiration,
to determine the required length. thereby directing expired air through the
larynx and permit hands-free speech (Figu-
Tube shape: Laryngectomy patients require re 17).
shorter tubes with a gentler curvature to
conform to the stoma and the trachea
7
 pressures. It may be corrected by CPAP or
positive pressure ventilation.

Respiratory arrest: This may occur imme-

diately following insertion of the tracheo-
stomy tube and is attributed to the rapid re-
duction in arterial pCO2 following restora-
tion of normal ventilation, and hence loss of
Figure 17: Speaking valve that fits onto the respiratory drive.
end of a tracheostomy tube and permits
hands-free speech Humidification: Tracheostomy bypasses
the nose and upper aerodigestive tract
Fenestrated tubes with speaking valves are which normally warms, filters, and humidi-
particularly well suited to patients with ob- fies inspired air. To avoid tracheal desicca-
structive sleep apnoea, as they can have nor- tion and damage to the respiratory cilia and
mal speech by day with the valve in place epithelium and obstruction due to mucous
but uncap the tracheostomy tube at night to crusting, the tracheostomy patient needs to
ensure unobstructed breathing. breathe humidified warm air by means of a
humidifier, heat and moisture exchange
Suction port: In patients with secretions filter, or a tracheostomy bib (Figure 19).
pooling above the cuff e.g. a laryngectomy
patient with a pharyngocutaneous fistula,
one can protect the patient from aspirating
saliva or feeds by inserting a tracheostomy
tube with a suction channel that is connec-
ted to negative suction (Figure 18).

Figure 19: Tracheostomy bib

Figure 18: Tracheostomy with suction port Pulmonary Toilette: The presence of a tra-
cheostomy tube and inspiration of dry air ir-
Postoperative care ritates the mucosa and increases secretions.
Tracheostomy also promotes aspiration of
Pulmonary oedema: This may occur fol- saliva and food as tethering of the airway
lowing sudden relief of airway obstruction prevents elevation of the larynx during
and reduction in high intraluminal airway swallowing. Patients are unable to clear se-

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cretions as effectively as a tracheostomy going past the cuff with a stethoscope
prevents generation of subglottic pressure, applied to the side of the neck near the
hence making coughing and clearing secre- tracheostomy tube (ventilated patient)
tions ineffective; it also disturbs ciliary • Minimal Leak Technique: The same
function. Therefore, secretions need to be procedure as above, except that once the
suctioned in an aseptic and atraumatic man- airway is sealed, slowly to withdraw
ner. approximately 1ml of air so that a slight
leak is heard at the end of inspiration
Cleaning the tube: Airway resistance is • Pressure gauge: Regular or continuous
related to the 4th power of the radius with monitoring of cuff pressures
laminar flow, and the 5th power of the radius • Transport in unpressurised aircraft:
with turbulent flow. Therefore, even a small Fill the cuff with water or saline as the
reduction of airway diameter and/or conver- reduction in air pressure during flight
sion to turbulent airflow as a result of secre- causes an air-filled cuff to expand
tions in the tube can significantly affect air-
way resistance. Therefore, regular cleaning Decannulation
of the inner cannula is required using a pipe
cleaner or brush. A tracheostomy tube can be removed once
the cause of the airway obstruction has been
Securing the tube: Accidental decannula- resolved. If any doubt exists about adequa-
tion and failure to quickly reinsert the tube cy of the airway e.g. following pharyngeal
may be fatal. This is especially problema- or laryngeal surgery, then the tracheostomy
tic during the 1st 48hrs when the tracheocu- tube is first downsized so that the patient
taneous tract has not matured and attempted can breathe freely past the tube. The tube is
reinsertion of the tube may be complicated then plugged. The patient should be closely
by the tube entering a false tract. Therefore, observed during this time and may be moni-
the tightness of the tracheostomy tapes tored with pulse oximetry. If the patient can
should be regularly checked. Traction sutu- tolerate the tracheostomy tube being plug-
res on the tracheal flap facilitate reinsertion ged overnight, it can then be removed. The
of the tracheotomy tube. tracheostomy wound is covered with an oc-
clusive dressing, and generally heals within
Cuff pressures: When tracheostomy tube
a week without suturing the skin.
cuff pressures against the tracheal wall mu-
cosa exceed 30cm H20, mucosal capillary
Percutaneous dilational tracheostomy
perfusion ceases, ischaemic damage en-
surgical technique
sues and tracheal stenosis may result. Mu- https://vula.uct.ac.za/access/content/group/ba5f
cosal injury has been shown to occur within b1bd-be95-48e5-81be-
15 minutes. Therefore, cuff inflation pres- 586fbaeba29d/Percutaneous dilational
sures of >25cm H20 should be avoided. tracheostomy surgical technique.pdf
Several studies have demonstrated the in-
adequacy of manual palpation of the pilot Cricothyroidomy
balloon to estimate appropriate cuff pressu- https://vula.uct.ac.za/access/content/group/ba5f
res. Measures to prevent cuff related injury b1bd-be95-48e5-81be-
include: 586fbaeba29d/Cricothyroidotomy%20and%20
• Only to inflate the cuff if required needle%20cricothyrotomy.pdf
(ventilated, aspiration)
• Minimal Occluding Volume Technique: Paediatric tracheostomy
https://vula.uct.ac.za/access/content/group/ba5f
Deflate the cuff, and then slowly rein-
flate until one can no longer hear air
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b1bd-be95-48e5-81be-
586fbaeba29d/Paediatric%20tracheostomy.pdf

Closure of paediatric tracheocutaneous

fistula – surgical technique
https://vula.uct.ac.za/access/content/group/ba5f
b1bd-be95-48e5-81be-
586fbaeba29d/Closure%20of%20paediatric%2
0tracheocutaneous%20fistula%20-
%20surgical%20technique.pdf

Video

Managing the difficult airway in laryngeal

cancer: https://youtu.be/4Iqm2Xc7ibg

Author & Editor

Johan Fagan MBChB, FCS(ORL), MMed

Professor and Chairman
Division of Otolaryngology
University of Cape Town
Cape Town, South Africa
johannes.fagan@uct.ac.za

THE OPEN ACCESS ATLAS OF

OTOLARYNGOLOGY, HEAD &
NECK OPERATIVE SURGERY
www.entdev.uct.ac.za

The Open Access Atlas of Otolaryngology, Head & Neck Operative

Surgery by Johan Fagan (Editor) johannes.fagan@uct.ac.za is
licensed under a Creative Commons Attribution - Non-Commercial
3.0 Unported License

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