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Cricothyrotomy for elective difficult airway management

last modified on: Mon, 09/18/2023 - 12:26

return to: Tracheotomy - Tracheostomy

Modified operative note at bottom of page

Modified Operative Note

60 y.o. male with history of intermittent acute respiratory failure associated with loss of consciousness resulting from dystonic paradoxical vocal cord motion indicated for tracheostomy.

Preop Dx: Upper airway obstruction with frequent syncope, possible laryngeal dystonia, difficult airway for intubation due to trismus, dentition, low-set larynx

Postop Dx: Same

Procedure: Awake cricothyrotomy

                   Microdirect laryngoscopy with intubation (by Oto team)

                   Tracheostomy with Bjork flap and thyroid isthmusectomy with anterior neck fat removal

Surgeons: xxxxxx

Anesthesia: local w/o sedation for cricothyrotomy (12 cc of 1% with 1:100,000)

            Conversion to general via 4-0 MLT then intubation with 6-0 MLT via glide scope

Findings: cricothyrotomy done w/o complications (two large arteries over membrane addressed appropriately); difficult intubation (despite using glide scope - anesthesia unable, done by Oto)

Procedure Details

Informed consent was reviewed with the patient is brought back to the operating room and positioned with the head of bed elevated on the operating room table. A surgical timeout was then completed. The patient was maintained with head toward anesthesia. The patient's neck landmarks were palpated and the proposed cricothyrotomy site was injected with 1% lidocaine with 100,000 epinephrine and time was allowed to take effect. The patient was prepped and draped in the standard sterile fashion.

A vertical incision was designed starting approximately at the inferior border of the thyroid cartilage and extending below the cricoid cartilage. The skin was incised sharply and dissection was carried through to the subcutaneous tissue. A limited anterior cervical lipectomy was performed using monopolar cautery. The strap muscles were identified and retracted laterally using Allis forceps. The cricothyroid membrane was identified in the soft tissue was cleared using Kitners. There were several blood vessels which were controlled with bipolar cautery and suture ligation. A cricothyrotomy incision was made and a 4.0 MLT endotracheal tube was placed into the airway. At this point general anesthesia was induced. Using a glide scope the patient was then intubated from above using a 6.0 MLT endotracheal tube.

We then proceeded with conversion of the cricothyrotomy to a tracheotomy having maintained neck and equipment sterility during the intubation.

The vertically oriented skin incision was extended further inferiorly. The thyroid isthmus was identified and resected after dissecting free from the anterior tracheal wall. Hemostasis of the medial aspects of the thyroid lobes was assured with placement of 3-0 silk running sutures.

The first, second and third tracheal rings were identified with an inferiorly based Bjork flap created encompassing the second tracheal ring. At this point the anesthesia team deflated the cuff and advanced endotracheal tube to avoid cuff injury. The airway was entered using the tip of a hemostat followed by scalpel enlargement of the membranous trachea between the first and second rings. Mayo scissors were used to create the Bjork flap with bilateral cuts through the second ring laterally. The Bjork flap was sutured to the skin inferiorly using 3 interrupted 3-0 Vicryls. At this point the endotracheal tube was then withdrawn and a 8.0 cuffed Shiley tracheostomy tube was placed in the airway without difficulty.

The endotracheal tube was removed and the circuit was connected the tracheostomy tube with good ventilation. The superior extent of the incision was then closed with 4 interrupted 3-0 Vicryls. The tracheostomy tube was then secured with straps and trach sponges were placed. This concluded our procedure. The patient tolerated procedure without complications and was turned back to anesthesia in good condition.


Boon JM, Abrahams PH, Meiring JH, Welch T. Cricothyroidotomy: a clinical anatomy review. Clin Anat. 2004 Sep;17(6):478-86. doi: 10.1002/ca.10231. PMID: 15300867.