Cricoid Cartilage Fracture Research Articles

A novel approach to maintain positive pressure ventilation during difficult Montgomery T-tube placement

To the Editor, The Montgomery tracheal tube (T-tube) is a surgical device used to maintain a compromised airway following complex tracheal injury. We report an effective and novel use for the endobronchial multiport airway ventilating adapter (Cook , Bloomington, IN, USA) to maintain positive pressure ventilation during difficult Montgomery T-tube placement. A 50-yr-old man with a body mass index of 38 kg m and clinically significant bilateral airspace disease was scheduled for micro-direct laryngoscopy, bronchoscopy, and Montgomery T-tube placement after he had sustained blunt laryngotracheal injuries (thyroid and cricoid cartilage fractures with posterior displacement of anterior cartilage and significant superglottic hematoma). The patient underwent a tracheostomy (size 8.0 cuffed Shilley) to secure his airway. During the Montgomery T-tube placement under general anesthesia, difficulty in ventilation arose while attempting to occlude the upper intralaryngeal section of the T-tube with a Fogarty vascular catheter (Edwards Lifesciences , Irvine, CA, USA) via the extratracheal lumen. This procedure is designed to prevent leaks of volatile anesthetic and fresh gas flows during positive pressure ventilation (as originally described by Montgomery). In discussion with the otorhinolaryngologists, a plan was devised to ventilate the patient’s lungs following re-insertion of the T-tube. A standard endobronchial multiport airway adapter (Cook ) was attached to the extratracheal limb of the Montgomery T-tube via a standard 15 mm endotracheal tube connector (7.5 mm polyvinyl endotracheal tube). The Ttube was re-inserted, and a Fogarty vascular catheter was passed through the 30 angled port of the Cook Multiport Airway Adapter. The catheter was then fed into the upper limb of the T-tube under direct laryngoscopy, and the balloon was inflated to create a tight seal. The right-angled port of the multiport adapter was used for positive pressure ventilation and standard end-tidal carbon dioxide monitoring (Fig. 1). The Montgomery T-tube was secured, and proper positioning of the upper intratracheal stem was confirmed by direct laryngoscopy. Ventilation of the patient’s lungs was maintained through the multiport airway adapter during these critical maneuvers. The Montgomery T-tube can present various challenges to anesthesiologists during its placement, including the potential for acute loss of the airway, inadequate administration of inhalation agents, and inadequacy of controlled mechanical ventilation. Various insertion techniques were developed to overcome some of these difficulties. This case was unique because the patient’s complex laryngotracheal injuries and associated hypopharyngeal and supraglottic lesions precluded the use of the laryngeal mask airwayMontgomery T-tube technique as described by Guha et al. Described, in this case, is a ‘‘combined technique’’ of passing an endotracheal tube through the extratracheal lumen and the intratracheal portion of the T-tube distal to the tracheal lesion. While it can be argued that this ‘‘combined technique’’ may offer the benefit of a secured airway through which positive pressure ventilation can be performed, we would argue that our method is feasible and effective with little interruption to monitoring of ventilation. Placement of the endotracheal tube fed through the extratracheal lumen of the T-tube to the distal trachea may also be complicated by potential kinking and acute loss of the airway. Furthermore, it may not be apparent during this difficult placement whether the kink was due to the endotracheal tube or due to the T-tube. F. Kailash, MD (&) S. L. DaSilva, MD F. E. Block Jr., MD University of Arkansas for Medical Sciences, Little Rock, USA e-mail: kailashkailash@uams.edu

Role of spiral computed tomography with 3-dimensional reconstruction in cases with laryngeal stenosis—a radioclinical correlation

Purpose To study the efficacy of spiral computed tomography with 3-dimensional reconstruction (SCT-3DI) and endoscopy in cases with laryngeal stenosis with regard to site, type, grade, and length of stenosis and to determine the correlation among the findings of SCT-3DI, endoscopy, and surgery. Material and methods This prospective study on 30 cases of laryngotracheal stenosis (acquired = 28 cases, congenital = 2 cases) was conducted in the Department of Otorhinolaryngology and Head Neck Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India, from 2001 to 2003. All patients were evaluated by SCT-3DI and rigid endoscopy. Twenty-three patients underwent open surgical procedure, and 7 patients underwent endoscopic dilatation. Correlation was established among the findings of SCT-3DI, endoscopy, and surgery by Pearson correlation coefficient ( r), paired t test, and χ 2 test. Results Findings of SCT-3DI, endoscopy, and surgery were found to well correlate with each other. SCT-3DI was found to be less accurate in measuring the exact length of stenosis but could measure the length of stenosis in all cases, whereas by endoscopy, the measurements could be made accurately in 14 cases (46.6%). The endoscopy was more accurate in diagnosing the site and grade of stenosis ( P < .01). SCT-3DI gave 18.6% false-positive result regarding involvement of glottis in stenosis. A significant difference was found between endoscopy and SCT-3DI for grade III and IV stenoses ( P < .01), and SCT-3DI found to give false-positive result in 19.2% cases for grade IV stenosis. SCT-3DI was found to be a better diagnosing modality in differentiating the circumferential Gupta and Parida. SCT-3DI was found to give a false-positive result in 19.2% cases for grade IV stenosis. SCT-3DI was found to be better a diagnosing modality in differentiating the circumferential and eccentric stenosis ( P < .01) and to detect the cricoid and thyroid cartilage fracture, double stenosis, and laryngocele. A false-positive rate of 33.3% was seen in diagnosing fracture of cricoid cartilage on radiology. Conclusion The findings of SCT-3DI, endoscopy, and surgery well correlated with each other. Findings of SCT-3DI and rigid endoscopy are complementary to each other for a better surgical planning and outcome.

Chirurgie des plaies et traumatismes du larynx et de la trachée cervicale

Blunt and penetrating laryngotracheal injuries can be isolated or integrated into a complex cervical trauma or several traumas. The aim of early surgical treatment is to preserve the functional prognosis and to prevent stenosis. Thyrotomy allows exploration and repair of soft tissues. Restoring normal anatomic relationships is essential. Vocal cords and false vocal cords are resuspended. Thyroid and cricoid cartilage fractures can be managed with wires or miniplates. Partial laryngectomy techniques are sometimes useful in case of cartilage avulsion. Avulsion of the cricoid cartilage is treated either by different reconstructive techniques or by thyro-crico-tracheal anastomosis. Complete laryngotracheal separations are undertaken by crico-tracheal or thyro-crico-tracheal anastomosis. Tracheal traumas without avulsion are treated by sutures or anastomosis. In case of avulsion, tracheal sleeve resection techniques are employed. Tracheal grafts are still experimental. Stents maintain airway patency and permit stabilization of fractures. They should be removed as early as possible.

Cricothyrotomy technique: standard versus the rapid four-step technique

Standard cricothyrotomy technique uses a tracheal hook cephalad to the opening to stabilize the trachea during endotracheal (ET) tube passage. A newly described Rapid Four-Step Technique (RFST) uses the tracheal hook caudal to the opening to stabilize the trachea during ET tube passage. This experimental crossover trial compared standard cephalad tracheal hook traction to caudad traction as recommended by RFST in a cadaver model of cricothyrotomy. Outcome measures included the incidence of complications and the size of ET tube able to be passed with each technique. The anterior necks of 30 formalin-fixed cadavers were dissected to completely reveal the cricothyroid membranes and surrounding structures. Two emergency medicine residents performed all cricothyrotomies. Each cadaver was randomly assigned to undergo either standard open technique followed by RFST, or RFST followed by standard open technique. Standard open technique was performed using a #11 scalpel blade, a Trousseau dilator for widening the opening, and a tracheal hook held cephalad through the thyroid cartilage. RFST was performed using a #11 scalpel blade and a tracheal hook held caudad through the cricoid cartilage. Cuffed ET tubes without stylettes were passed in progressively larger sizes until significant resistance was met as determined independently by two physicians. The size of the largest ET tube passed for each technique was recorded. After each attempt the trachea was inspected for evidence of structural damage and the balloon cuff was checked to assess for cuff rupture. There were no complications with standard technique; five cadavers (16.7%) had complications with RFST including one (3.3%) with balloon cuff rupture and four (13.3%) with cricoid cartilage fractures. Tracheal damage prevented standard technique performance on three of the cadavers. There was no significant difference between maximal ET tube sizes for standard technique (median size 7.0, mean 6.95 mm internal diameter) versus RFST (median size 7.0, mean 6.82 mm internal diameter). We conclude that RFST may be associated with a higher incidence of complications than standard technique as demonstrated by our cadaver model of cricothyrotomy. We were unable to demonstrate a difference between the two techniques with regards to size of ET tube able to be passed.

Laryngeal injury during weight lifting

A case of injury to the cricoid cartilage, with loss of voice, during weight lifting is presented. Fracture of the cricoid cartilage with injury of the cricothyroid ligaments and muscles appears to be responsible for the loss of voice. Treatment by shifting the attachments of the cricothyroid muscles and low voltage electrical stimulation gave a fair recovery of voice. It is presumed that the damage and subsequent fibrosis of the cricothyroid ligament and lateral cricoarytenoid muscle on the left side prevented further recovery.