Trachea and esophagus Ehab ZAYYAN, MD, PhD

Trachea Cartilaginous and membranous tube Starts from the lower border of the cricoid cartilage (6th cervical vertebra)

In adults the trachea is about 11.25 cm long and 2.5 cm in diameter Ends at the (Carina) by dividing into two main bronchi at the level of the sternal angle (opposite to 4th and 5th thoracic vertebrae) Consists of 16- 20 incomplete cartilage rings (U- shaped)

The fibroelastic tube is kept patent by the presence of U-shaped cartilaginous bar (rings) of hyaline cartilage embedded in its wall. The posterior free ends of the cartilage are connected by smooth muscle, the trachealis muscle. The mucous membrane of the trachea is lined with pseudostratified ciliated columnar epithelium and contains many goblet cells and tubular mucous glands.

Anterior relations of the trachea Skin Fascia Sternothyroid and sternohyoid muscles Isthmus of the thyroid Inferior thyroid veins Jugular arch Thyroid ima artery Left bracheoceohalic vein

Posterior relations Right and left recurrent laryngeal nerves Esophagus Vertebral column

Lateral relations Thyroid gland lateral lobes Carotid sheath

Trachea in the neck Blood supply The upper two thirds is supplied by the inferior thyroid arteries and the lower third is supplied by the bronchial arteries.

Lymphatic drainage pretracheal and paratracheal lymph nodes

Nerve supply vagus, recurrent laryngeal, sympethatic trunk

Esophagus Muscular tube 25 cm long From the pharynx to stomach Begins at the level of the cricoid cartilage, 6th cervical vertebra It descends in the midline slightly to the left.

Relations of the esophagus in the neck Anterior: trachea and RLN Posterior: prevertebral fascia and vertebral column Lateral: lobes of the thyroid and carotid sheath

Esophagus in the neck Blood supply: inferior thyroid arteries and veins Lymph: deep cervical lymph nodes Nerves: RLN and sympathetic trunks

Midline structures in the neck Symphysis menti Submental triangle Body of the hyoid bone: at the level of 3rd cervical vertebra Thyrohyoid membrane Upper border of thyroid cartilage: level of 4th cervical vertebra Cricothyroid ligament Cricoid cartilage: level of 6th cervical vertebra Cricotracheal ligament First ring of trachea Isthmus of the thyroid gland Thyroid ima artery Jugular arch Suprasternal notch

In young children, the thymus gland may extend above the suprasternal notch as far as the isthmus of the thyroid gland, and the brachiocephalic artery and the left brachiocephalic vein may protrude above the suprasternal notch.

Symphysis menti Submental triangle Hyoid bone body Thyrohyoid membrane Thyroid cartilage Cricothyroid ligament Cricoid cartilage Cricotracheal ligament First ring of trachea Thyroid gland isthmus Thyroid ima artery Jugular arch Suprasternal notch

Compromised airways Top Emergency !!!!!

Resuscitation A: Airways B: Breathing C: Circulation D: Drugs

Upper respiratory airways

Urgent airways management Endotracheal intubation Cricothyroidotomy Tracheostomy

Anatomic axes for endotracheal intubation

Cricothyroidotomy Performed in top urgent situations When endotracheal intubation is impossible When there is no time even for tracheostomy Incision is made through the skin, fasciae and cricothyroid membrane and a tube is inserted

Complications of cricothyroidotomy Esophageal injury (young children!!) Larynx injury Hemorrhage

Tracheostomy The history of tracheotomy refers to 200 years BC In 1800 the most common indication was laryngeal diphtheria Infectious causes of tracheotomy are decreasing while congenital causes are increasing

1966 Karakoçan, Elazığ

Indications of tracheotomy Upper respiratory airway obstruction Pulmonary care Long ventilation

Upper respiratory airway obstruction Congenital Craniofacial anomalies Laryngeal anomalies Bilateral vocal cord paralysis Tracheal anomalies Lymphatic anomalies

Upper respiratory airway obstruction Acquired Trauma - intubation - external trauma - corrosive substance - Burns - F.B Tumors - Papillomatosis - Hemangioma - OSAS Infectious - croup - trachitis - epiglottitis - diphteria - deep neck infections

Pulmonary care Aspiration (IX or X paralysis) Laryngeal cleft Tracheoesophageal fistula Insufficient cough reflex (hypotonia, CP) Chronic infections

Long term ventilation Respiratory distress syndrome Muscle weakness Congenital heart diseases Thorax trauma Central respiratory insufficiency (intoxication..)

Surgical technique Urgent vs elective In urgent cases intubate if possible, and then tracheotomy General anesthesia and operation room.

Extension of the neck

Midline vertical incision Horizontal incision Stay in the midline Thyroid isthmus ligation High or low (above/below the ishmus) Thru 2nd, 3rd, or 4th ring

Sutures

Vertical incision in 3,4,5

Complications Organ injury (larynx, esophagus..) Nerve injury Hemorrhage (ant jugular veins, thyroid arteries) Pneumothorax …..