Surgical cricothyroidotomy in a patient of ankylosing spondylitis.

Dear Editor,

A 65-year-old male, a known case of ankylosing spondylitis presented to our hospital with a nasotracheal tube in place. The patient had a limited mouth opening and involvement of cervical spine [Figure 1]. He had suffered from an acute exacerbation of chronic obstructive pulmonary disease (COPD) a week back and had been intubated at his previous hospital using awake fiberoptic technique. After a week of treatment with bronchodilators, systemic steroids and intravenous antibiotics, a trial of weaning was given to the patient, which had failed and subsequently the patient had been referred to our hospital.

Figure 1

Patient with limited mouth opening and chin on chest deformity

His Mallampati score was 4, the thyroid and cricoid cartilages were palpable in the neck and the first tracheal ring was barely palpable. After reviewing the clinical status and investigations of patient, a decision to perform tracheostomy was taken and the department of ENT was consulted for the possibility of surgical tracheostomy. They opined that surgical tracheostomy was nearly impossible as the patient had no neck extension. Classical technique for percutaneous dilatational tracheostomy was also opined to be out of favor considering the difficult airway of the patient.

We felt that cricothyroidotomy was the only possible front of neck access in the patient. The patient’s family was then counseled regarding the impossibility of tracheostomy in this case and the possible side effects of cricothyroidotomy like difficult decannulation, high chances of laryngeal stenosis etc. After their consent, a decision to perform a cricothroidotomy was made. The patient was then taken up in the operating room with complete preparation of an anticipated difficult airway which included fibreoptic bronchoscopy, videolaryngoscope, laryngeal mask airway and Sanders jet ventilation device. Surgical ENT team backup was also sought. A pillow was provided to rest the neck of patient and the operation table was adequately padded to prevent any positioning injuries [Figure 2]. 100 micrograms of fentanyl and sevoflurane in oxygen were used to sedate the patient. The existing naso-tracheal tube (NTT) was used for mechanical ventilation. With complete surgical precautions, a 2 cm horizontal skin incision was made 1 cm above the sternal notch. The dissection had to proceed blindly due to limited visibility of the neck structures. After the fascial layers of the neck was dissected, the anesthesiologist’s little finger was used to palpate and to achieve separation of the muscles of the neck.

Figure 2

Positioning of patient for cricothyrotomy

After we reached the cricothyroid membrane (CTM), a 1 cm incision was made, guided by palpation. The NTT was then withdrawn using fibre scope guidance to visualize the stab incision made in the CTM and the NTT was positioned just above the incision to continue oxygenation. A guidewire available in the percutaneous dilatational cricothyroidotomy set was then introduced via the CTM and its endotracheal position confirmed via the fibrescope. A 6.0 mm internal diameter tracheostomy tube (TT) was then railroaded over the guidewire into the trachea over the CTM [Figure 3]. The position of the TT in the trachea was confirmed by FOB, capnography and bilateral chest auscultation.

Figure 3

Patient with tracheostomy tube in situ

Jackson, in his landmark paper, had suggested that cricothyrotomy was associated with a high incidence of subglottic stenosis and the procedure had subsequently fallen out of favor.[1] Since then studies by Brantigan et al. and O’Connor et al. have demonstrated the safety of the procedure and they did not observe any subglottic stenosis in a large case series of patients.[23] In a registry study by Rehm et al. it was stated that elective cricothyroidotomy done for patients with unfavorable neck anatomy was not associated with increased rate of complications.[4]

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