Tracheostomy refers to the creation of a surgical opening between the trachea & skin surface. It could be temporary or permanent.

Indications: 1- Relief of upper airway obstruction: which could be due to: a. Congenital (Bilateral choanal atresia, Laryngeal web or cyst) b. Traumatic External (penetrating or blunt injury). Internal (foreign body, corrosives, inhalation of irritating fumes). c. Infection: Acute laryngotracheobronchitis (croup) Acute epiglottitis Diphtheria d. Tumors: of the tongue, pharynx, larynx, upper trachea or thyroid gland. e. Bilateral vocal cord paralysis: as following thyroidectomy. f. Allergy: as in penicillin hypersensitivity which may result in a life- threatening laryngeal edema & upper airway obstruction.

2- Protection of tracheobronchial tree: from a 2- Protection of tracheobronchial tree: from a. Inhalation of saliva, food, blood or gastric contents b. Stagnation of bronchial secretions.

a & b might in the following conditions: overdose, i a & b might in the following conditions: overdose, i. Coma due to many causes (head injury,drug over dose, CVA...) ii. Poliomyelitis (bulbar type) iii Tetanus. iv. Myasthenia gravis. 3.Treatment conditions leading to respiratory insufficiency: any of of respiratory the conditions in 1 & 2 may cause 3-, in addition to: bronchitis, & severe chest injury (flail chest) larynx,

4.Elective: for major operations of the mouth, pharynx which constitute a potential risk on the airways. Surgical technique: Tracheostomy can be done under general & local anesthesia, by making a vertical skin incision (or horizontal in elective cases) between the cricoid & suprasternal notch. Separation of the strap muscles & division of the thyroid isthmus to reach the trachea. An opening is then made in the trachea between the 2nd 4th tracheal rings

Effect of tracheostomy By pass upper airway obstruction Decrease dead space Decrease air way resistance Allow suction of trachea &lower air way Allow for assisted ventilation

Tracheostomy tubes : Two main types: 1- Metal tube (Silver): Consists of inner & outer tubes. Longer half life, More traumatic,Without cuff. Can be used with laser, but not with radiotherapy 2- Plastic tube (Portex): Only one tube. Shorter half life , More comfortable. With cuff. Can't be used with laser, but used with radiotherapy

position: semi-sitting Post-operative care: position: semi-sitting Suction: repeated, regularly with sterile catheter humidification: tracheostomy using humidifier or gauze over the tube. Chart of vital signs, observation for any complication (as hematoma, emphysema) Changing the tube: after at least 72 hours.

Complications of tracheostomy 1- Immediate (during the operation or immediately after) Hemorrhage. Air embolism. Cardiac arrest. Apnea. Damage to the adjacent structures: as thyroid gland or recurrent laryngeal nerve

2- Intermediate (during the rest of patient stay in the hospital). Dislodgment or displacement of the tube: the tube should be fixed by sutures & tape. Obstruction of the tube: by crust, that's why humidification & suction are essential in the post- operative period. Surgical emphysema in the neck . Pneumothorax & pneumomediastinum: if there is damage to the pleura on the dome of the lung during the operation . Infection: of the tracheostomy site. Fistula: between the trachea & great vessels in the neck or between the trachea & esophagus. =

3- Late: Stenosis of the trachea. Persistent tracheo-coetaneous fistula (tracheostomy opening usually closed spontaneously by secondary intention after tube removal, this might not happen resulting in persistent opening which should be closed surgically)

Laryngotomy croico-thyroidotomy It is an opening through the crico-thyroid membrane. Indications: 1- Sudden laryngeal obstruction, when facilities or experience for tracheostomy or intubation are not available. 2- Impaction of a foreign body in the larynx is the commonest indication.

Surgical technique: It is an emergency done without anesthesia, using any sharp knife, making a transverse incision through the crico-thyroid membrane (can be felt between the thyroid cartilage above & the cricoid cartilage below), the incision is deepened & then any available tube (even a pen), or wide bore cannula is inserted into the airway. Laryngotomy usually provides relief of the airway obstruction for only few hours, until the facilities for tracheostomy or intubation are available.