ENT (Otorhinolaryngology) · MU Sofia

47. Tracheostomy.

Covers the definition of tracheostomy as a surgical opening in the anterior tracheal wall fitted with a tube, then its indications grouped into upper airway obstruction, lower airway protection, prolonged ventilation and bronchial hygiene. It lists relative contraindications, walks through the operative steps from positioning to fixation, and outlines post-operative care. The note closes with immediate, early and late complications, each sorted by timing.

Inside: 1 section · 3 labelled pictures · 15 flashcards · 3 min

Topic 47 of 52 in the MU Sofia syllabus for ENT (Otorhinolaryngology) (Medicine, Year 4). The free AceMed note covers it in 1 section, about 439 words (3 min of reading), with 15 flashcards.

In this note

  1. Tracheostomy.

Tracheostomy.

1. Definition: Tracheostomy is a surgical procedure in which an opening (stoma) is created in the anterior wall of the trachea, and a tracheostomy tube is inserted to establish a direct airway.

2. Indications

  1. 1. Upper Airway Obstruction: most common
  • Laryngeal carcinoma
  • Bilateral vocal cord paralysis
  • Laryngeal edema (infection, trauma, burns)
  • Foreign body
  • Congenital airway anomalies
  1. 2. Protection of the Lower Airway:
  • Prophylaxis against aspiration in patients with bulbar palsy or neurological disorders.
  • Management of severe head injuries where the cough reflex is absent.
  1. 3. Respiratory Failure (Prolonged Ventilation):
  • To reduce "dead space" and airway resistance.
  • Mechanical ventilation >7–10 days
  1. 4. Bronchial Hygiene:
  • To facilitate the removal of excessive secretions in patients with chronic lung disease, poor cough reflex or comatose patients

IV. CONTRAINDICATIONS (RELATIVE)

Severe coagulopathy

Local infection (relative)

3. Surgical Stages (Standard Operative Technique)

  • Positioning: Patient is supine with a shoulder roll to provide maximum neck extension.
  • Incision: A horizontal or vertical (emergency) incision is made between cricoid cartilage and suprasternal notch
  • Dissection: The strap muscles (sternohyoid and sternothyroid) are separated in the midline.
  • Thyroid Isthmus: The thyroid isthmus is either retracted superiorly or divided and sutured.
  • Tracheal Exposure: The pre-tracheal fascia is cleared.
  • Tracheotomy: An opening is made into the trachea, between the 2nd and 3rd or 3rd and 4th tracheal rings. A "window" or a "Bjork flap" (inferiorly based flap) may be created.
  • Tube Insertion: A tracheostomy tube is inserted, confirm air entry.
  • Fixation: The tube is secured with sutures to the skin and/or a tracheostomy tape around the neck.

Post-Operative Care

  • Humidification: Essential because the upper airway's natural humidification is bypassed.
  • Suctioningof secretions : To keep the tube patent.
  • Inner Cannula Cleaning: To prevent crusting.
  • Cuff Pressure Monitoring: Usually kept below 20–25 mmHg to prevent mucosal ischemia.
  • Speech rehabilitation (if long-term)

4. Possible Complications

A. Immediate (Intraoperative)

  • Hemorrhage: From the thyroid isthmus or anterior jugular veins.
  • Apnea: Due to sudden loss of hypoxic drive (in chronic obstructive patients).
  • Pneumothorax/Pneumomediastinum: Especially in children where the pleura is higher in the neck.
  • Injury to surrounding structures: Recurrent laryngeal nerve or esophagus (posterior wall puncture).
  • Tube displacement

B. Early (First week)

  • Tube Obstruction: By blood clots or thick secretions.
  • Dislodgement: Accidental decannulation before a mature tract has formed.
  • Subcutaneous Emphysema: Often due to wound closure that is too tight.
  • Infection: Tracheitis or wound cellulitis.

C. Late (Weeks to months)

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