1. Trachea and esophagus
Ehab ZAYYAN, MD, PhD

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

3. 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 incomplete cartilage rings (U- shaped)

4. 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.

7. 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

11. Posterior relations Right and left recurrent laryngeal nerves
Esophagus
Vertebral column

13. Lateral relations
Thyroid gland lateral lobes
Carotid sheath

14. 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.

15. Lymphatic drainage
pretracheal and paratracheal lymph nodes

16. Nerve supply vagus, recurrent laryngeal, sympethatic trunk

17. 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.

23. 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

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

27. 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

28. 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.

30. 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

33. Compromised airways
Top Emergency !!!!!

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

35. Upper respiratory airways

36. Urgent airways management
Endotracheal intubation
Cricothyroidotomy
Tracheostomy

37. Anatomic axes for endotracheal intubation

41. 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

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

47. 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

48. 1966 Karakoçan, Elazığ

49. Indications of tracheotomy
Upper respiratory airway obstruction
Pulmonary care
Long ventilation

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

51. 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

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

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

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

55. Extension of the neck

56. 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

65. Sutures

66. Vertical incision in 3,4,5

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