This document describes two surgical procedures - tracheostomy and cricothyrotomy. Tracheostomy involves making an incision through the skin and other tissues of the neck to access the trachea. The trachea is then opened with either a U, T, or inverted U incision. Cricothyrotomy involves locating the cricothyroid membrane below the thyroid cartilage and making a short horizontal incision through the membrane to access the airway. For both procedures, landmarks are identified, the incision site is prepared, and a tube is placed to access the airway.

1. Tracheostomy

2. Introduction
It is one of the oldest surgical procedure.
Mentioned in rig veda 2000BC and in Egyptian manuscripts 3500 yrs
back.
Hieronymous, Fabricius, Habicot gave the first technical descriptions of
the surgical procedure.
Negas coined the term TRACHEOSTOMY

6. Procedure
Skin
Subcutaneous tissue
Platysma
Invsesting layer of deep cervical facsia divides into 2 layer and is
attached to the anterior and posterior sternum- the space of Burns.
The space contains fat, loose connective tissue, anterior jugular vein
with their anastamoses.
Infrahyoid fascia
Infrahyoid muscle

7. Thyroid isthmus
Pretracheal fascia
In between these two fascia is the infrathyroid artery. The
branchiocephalic artery and the left common carotid artery can be seen
inferiorly.
Trachea

8. The skin incision is marked with the patient in a normal head position.
Then the head is hyperflexed with the shoulder supported with a towel
roll.
Infiltration of LA is given.
Both vertical and horizontal incisions can be given.
4 to 5 cm incision is made 2cm below the cricoid cartilage.
Incision extended thru all the layers.
Expose the thyroid gland. Reflect or transect the thyroid gland isthmus.

9. Trachea is exposed.
Trachea is a tube with an external diameter of 1.5 to 2 cm.
It is a u shaped ring connected by a fibrocartilage posteriorly.
Expose the first 4 tracheal ring
Cricoid cartilage and the 1st tracheal ring must not be injured.
Incision into the trachea must not extend below the 4th tracheal ring.
U, T, cruciform or an inverted U shaped incision can be given on the
trachea.
Inverted U shaped incision is most commonly preferred.

11. Cricothyrotomy

14. Procedure
Palpate - Adams apple/ thyroid cartilage.
Cricoid cartilage is found 2 to 3 cm below the thyroid cartilage
prominence.
The space between the 2 cartilage is the cricothyroid membrane is the
location for the procedure.
The head and neck is placed in a extended position.
Skin is prepared with a antiseptic solution.
Firmly grasp the thyroid cartilage with the non dominant hand.
A horizontal skin incision, almost 2cm is placed through the skin and the
sc tisuue.

15. Vertical incision can be placed, because once the incision is made the
surgeon himself can retract using the non dominant hand.
The incision is made just superior to the cricoid cartilage to avoid the
anastomosis of the superior thyroid artery located in the superior
portion of the membrane.
Use the index finger to palpate the membrane through the investing
layer of deep cervical fascia.
Incision is deepened with the help of a trousseau dilator, finger or using
the handle of the scalpel.
Tracheostomy tube is inserted.

16. 1. Identification of the land mark and cricothyroid membrane.
2. A short transverse incision is placed through the skin, SC tissue and
membrane, all the way into the airway.
3. Inferior traction using the tracheal hook
4. Tube placement.