Introduction: Cervical necrotizing fasciitis (CNF) is a rare, but serious condition that can develop as a result of an odontogenic infection spreading into the deep fascial planes of the neck. The infection is associated with significant morbidity and mortality due to septic shock and consequent multiple organ failure. Early diagnosis is of paramount importance with immediate surgical management and appropriate antimicrobial therapy being key in obtaining a good outcome. Patients require aggressive surgical resection necrotic tissues which can affect form and function in the head and neck. Surgeons dealing with cervical necrotizing fasciitis should be skilled in tracheostomy, have good knowledge of head and neck anatomy, able to deal with fasciitis around neck vessels, and the ability to reconstruction the neck as needed. Case Report: A case of CNF affecting a 31-year-old male, who was treated with multiple rapid surgical debridements, intravenous antibiotics, and tracheostomy, is presented. Transfer to a neighboring unit was needed due to concern of potential spread to the mediastinum necessitating cardio-thoracic intervention. After further debridements, artificial skin grafting and reconstruction were carried, and the patient was successfully discharged from the hospital. Conclusion: Cervical necrotizing fasciitis is a relatively uncommon, rapidly progressive, and often life-threatening soft tissue infection. Early diagnosis, aggressive antibiotic, and surgical treatment play a vital role in the management of the disease. In patients with resultant skin or soft tissue defects, advanced reconstructive techniques are needed to close resultant defects.

Percutaneous vs. surgical tracheostomy in the intensive care unit: clinical outcomes, complications, and hospital stay: a single retrospective observational study

To evaluate whether preoperative sodium-glucose cotransporter 2 inhibitor (SGLT2i) use is associated with postoperative complications in adults with type 2 diabetes mellitus (T2DM) undergoing open surgical tracheostomy (OST) METHODS: We performed a retrospective cohort study using a multi-institutional electronic health record network. Adults with T2DM who underwent OST between 2013 and 2024 were identified using CPT and ICD-10-PCS codes. Exposure was defined as an SGLT2i prescription within 180 days before surgery. One-to-one propensity score matching on demographics, comorbidities, preoperative ventilator dependence, medications, and laboratory values generated balanced SGLT2i and non-SGLT2i cohorts. Ninety- and 180-day postoperative complications were compared using odds ratios (ORs) with 95% confidence intervals, with Benjamini-Hochberg false discovery rate (FDR) correction. Of 36,840 eligible adults (1329 SGLT2i; 35,511 non-SGLT2i), 1327 patients remained in each cohort after matching. At 90 days, SGLT2i use was associated with higher odds of heart failure exacerbation (OR 1.70, 95% CI 1.36-2.14), which remained significant after FDR adjustment. At 180 days, SGLT2i use was associated with increased odds of hypoglycemia (OR 2.01, 95% CI 1.30-3.13) and heart failure exacerbation (OR 1.61, 95% CI 1.30-1.99), both significant after FDR correction. Signals for surgical site infection, tracheostomy stoma malfunction, and dizziness/vertigo did not remain significant after adjustment. In adults with T2DM undergoing OST, preoperative SGLT2i use was associated with increased postoperative hypoglycemia and heart failure exacerbation. These findings support careful perioperative management of SGLT2is in high-risk airway surgery and justify prospective studies to define optimal discontinuation strategies.

AIM: This study aimed to compare the efficacy and safety of ultrasound-guided percutaneous balloon dilatational tracheotomy (US-PDT) versus surgical tracheotomy (ST) in patients with acute respiratory failure (ARF). METHODS: In this retrospective cohort study, 278 patients with ARF were enrolled from January 2022 to January 2025. These patients were divided into the US-PDT group (n = 135) and the ST group (n = 143) based on the surgical method used. Perioperative indicators, procedural success rates, inflammatory markers, hospitalization outcomes, and complications were systematically compared between the two groups. RESULTS: The US-PDT group demonstrated superior outcomes across all measures. It was associated with a significantly shorter procedure time, smaller incision length, reduced intraoperative blood loss, and shorter duration of mechanical ventilation (all p < 0.001). The US-PDT group also showed a higher single-attempt procedural success rate, alongside a lower accidental extubation rate (all p < 0.001). Postoperative inflammatory markers (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP], and procalcitonin [PCT]) were significantly lower in the US-PDT group (p < 0.001). Furthermore, the US-PDT group experienced reduced ventilator-associated pneumonia (VAP) incidence, higher weaning success, shorter intensive care unit (ICU) and hospital stays, and lower ICU and overall mortality (all p < 0.05). Complication rates were also significantly lower in the US-PDT group (p < 0.05). CONCLUSIONS: US-PDT is a more efficient, safer, and less invasive alternative to ST for ARF patients, resulting in better clinical outcomes, reduced inflammation, fewer complications, and improved survival rates.

Simulation of pediatric surgical tracheotomy: Development of a high-fidelity modular task trainer

Aim: Tracheostomy provides airway patency by inserting an intratracheal cannula through a window in the anterior tracheal wall. Patients treated in intensive care units often require tracheostomy owing to prolonged endotracheal intubation and mechanical ventilation. This study aimed to evaluate the complication rates, safety, and clinical outcomes of percutaneous dilatational tracheostomy performed by anesthesiologists over a ten-year period in a tertiary intensive care unit. Material and Methods: This retrospective study was conducted between 2015 and 2024 in the Anesthesiology Intensive Care Unit of Duzce University. Among patients older than 18 years who received treatment for more than 48 h in intensive care unit, 85 who underwent bedside percutaneous dilatational tracheostomy using the Griggs technique performed by anesthesiologists were included. The patients were evaluated for demographic and clinical features, duration of ventilation and hospitalization, complications, and mortality. Results: The mean age of the patients was 72.81±16.15 years, and 65.9% were male. The most common complications were bleeding (23.5%), hypoxemia (10.6%), and pneumothorax (4.7%). None of the patients required conversion to surgical tracheostomy. Use of ultrasound, fiberoptic bronchoscopy, and laryngeal mask airway guidance was associated with a significantly lower incidence of hypoxemia (p=0.016). Conclusion: Percutaneous dilatational tracheostomy performed by anesthesiologists in the intensive care unit is a safe, practical, and effective bedside procedure, with a low rate of major complications. Ultrasound, fiberoptic bronchoscopy, and laryngeal mask airway guidance enhance procedural safety and reduce the risk of complications. Routine implementation by experienced anesthesiologists is recommended in critically ill patients requiring prolonged mechanical ventilation.

This case report described the entire process of a 72-year-old Chinese woman undergoing resection of a giant thyroid tumor. The novelty of this case report lies in its emphasis on the crucial role of anesthetic management for giant thyroid tumors, particularly in patients with concurrent cardiac comorbidities. We present a 72-year-old Chinese female with a giant thyroid tumor caused respiratory compromise due to tracheal compression, complicated by atrial septal defect. She required general anesthesia for tumor resection. A multidisciplinary team developed critical contingency strategies: (1) awake endotracheal intubation under direct laryngoscopy, (2) a remimazolam/sufentanil combination for procedural tolerance, (3) improved tracheal catheter preparation, and (4) surgical tracheostomy readiness. Anesthesia maintenance was achieved with sevoflurane, supplemented by sufentanil and remifentanil for multimodal analgesia and vecuronium/mivacurium neuromuscular blockade. Successful tumor resection achieved complete decompression, with no postoperative complications documented during 30-day follow-up. This case demonstrates that meticulous interdisciplinary communication and structured perioperative protocols form the cornerstone of safe anesthesia practice for patients with dual pathology of airway compromise and cardiac comorbidities, providing crucial insights for managing such complex clinical scenarios.

Safe (re)tracheostomy in critically ill patients with previous neck surgery using the minimally-invasive tracheostomy approach.

BackgroundTracheostomy is a commonly performed procedure for patients requiring prolonged mechanical ventilation. It can be performed at the bedside using percutaneous dilatational tracheostomy (PDT) under bronchoscopic guidance (BG), which reduces the need for surgical tracheostomies. The aim of this study was to compare early versus late BG-PDT in terms of complications and survival.MethodsThis retrospective study included patients who underwent BG-PDT between 2012 and 2022 at the Pulmonary Institute of Rabin Medical Center. Data was collected by reviewing demographic and clinical parameters from electronic medical records, with a minimum follow-up of 24 months after the BG-PDT procedure. Early BG-PDT was defined as a procedure performed within 7 days of intubation and late PDT was performed from day 8 onward.ResultsA total of 207 BG- PDT procedures were performed between 2012 and 2022, of which 188 patients were included in the final analysis. The mean age of the patients was 69 years, with 57.5% being male. Patients who underwent early BG-PDT were younger (mean age 63 vs. 71, p < 0.01).The most common indications for PDT were respiratory disorders (47.8%) and neurological disorders (19.1%). Patients in the early PDT group had a median overall hospitalization duration of 14 days post BG-PDT (IQR 21–31), compared to 33.5 days (IQR 26–47) in the late group (p < 0.01). The overall 1-year survival rate was 54.3% in the early BG-PDT group versus 30.1% in the late BG-PDT group (p = 0.04). The overall 3-year survival for both groups was 24.2%, with 45.4% in the early BG-PDT group and 19.6% in the late BG-PDT group (p = 0.008). Younger age was found to correlate better survival (OR 1.05, 95% CI: 1.02–1.08, p < 0.001) and a higher one-year (54.3% vs. 30%, p = 0.04) and 3-year survival rate of 45.4% in the early vs. 19.6% in the late (p = 0.008).ConclusionsBronchoscopy guided percutaneous dilatational tracheostomy is associated with shorter hospitalization duration and has possible survival advantages when performed within 7 days of intubation.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12890-025-04043-8.

To evaluate stoma placement accuracy using computed tomography (CT) in patients undergoing open surgical (OST) versus percutaneous dilational (PDT) tracheostomy, and identify factors associated with high placement. We retrospectively reviewed adults who underwent OST or PDT at a tertiary center (July 2012-July 2024) with CT imaging ≤ 30 days post-procedure. The primary outcome was vertical distance from the inferior cricoid border to cannula center (mm). Placement was classified as high (≤ 10 mm) or non-high (> 10 mm). Multivariate regression identified predictors. Subgroup analysis was performed for otolaryngology cases. Of 503 patients (mean age 59.5 ± 18 years, 69.2% male), 421 (83.7%) underwent PDT and 82 (16.3%) OST. Mean distance was 12.6 ± 9.3 mm, shorter in PDT than OST (mean difference -2.4 mm; 95% CI: -4.6 to -0.2; p = 0.03), with no difference in high placement rates (37.1% vs. 31.7%; p = 0.36). Independent predictors of shorter distance were older age, higher BMI, general surgery team, and larger cannula diameter. Female gender was associated with greater distance. Predictors of high placement included older age, higher BMI, and larger cannula diameter. In the otolaryngology-only subgroup (n = 189), no differences in distance (mean difference 1.6 mm; 95% CI: -0.9 to 4.2; p = 0.22) or high placement rates were observed between groups; BMI was not associated with placement. Technique alone did not determine high placement; patient factors, team, and cannula size were more influential. When performed by otolaryngologists, PDT achieves placement comparable to OST.

This study consisted of an integrative review aimed at analyzing and comparing the clinical outcomes associated with percutaneous and surgical tracheostomy in patients admitted to intensive care units (ICUs). Tracheostomy is an essential procedure to ensure airway maintenance and adequate ventilation in critically ill patients, with the choice of technique influenced by clinical, anatomical, and institutional factors. Data were collected from PubMed, SciELO, LILACS, and BVS databases using DeCS descriptors and MeSH terms, and studies published between 2020 and 2025 in English, Portuguese, and Spanish were selected. Quantitative and qualitative studies addressing relevant clinical outcomes were included, while isolated case reports, pediatric studies, and articles without primary data were excluded. Nine studies were analyzed, showing that percutaneous tracheostomy is generally associated with shorter procedural time, reduced ICU stay, shorter duration of mechanical ventilation, and acceptable complication rates. On the other hand, surgical tracheostomy proved advantageous in cases of higher anatomical complexity or increased risk of bleeding. Limitations include methodological heterogeneity and small sample sizes. The findings highlight the need for individualized decision-making, considering the patient’s clinical profile and the team’s experience. Future research should prioritize multicenter trials and standardization of techniques, enabling more robust comparisons and supporting evidence-based clinical practice to optimize safety and recovery in critically ill patients.

Percutaneous tracheostomy (PT) has gained increasing acceptance over surgical tracheostomy (ST) in the last few decades due to lower rates of postoperative infections, less bleeding, and cost-effectiveness. However, there has been little information regarding the PT practice in Malaysian adult general intensive care units (ICU). The objective of the study was to assess the current practice of PT in Malaysia. This observational cross-sectional study used a validated questionnaire with 15 items. A total of 61 ICUs consisting of adult general ICUs under Ministry of Health (MOH) hospitals and adult general ICUs in university teaching hospitals were recruited into the study whereas ICUs in private hospitals and specialist ICUs were excluded from this study. The questionnaire was subsequently distributed to the heads of those 61 ICUs through existing WhatsApp or Telegram groups and the data collection period lasted four months. Fifty-three out of 61 ICUs participated. Ninety point six percent of the responses came from MOH hospitals, whereas 9.4% came from university hospitals. The heads in participating ICUs comprised 35.8% intensivists and 64.2% anaesthetists. At the time of the survey, 45.3% of ICUs were still practicing PT, 13.2% had performed PTs in the past but stopped whereas 41.5% were not. The rate of PT (both actively practising and formerly practised combined) in intensivist-led ICUs was 94.7% compared to 38.2% in anaesthetist-led ICUs. Intensivists performed PTs in almost two-thirds of ICUs, while anaesthetists did so in another two-thirds. The vast majority of assistants were medical officers at 96.8%. The Ciaglia Blue Rhino technique was the predominant technique (71.0%) while airway management during the technique was solely via endotracheal tube. Ninety-six point eight percent of the ICUs employed routine infiltration of local anaesthetics prior to PT. Thirty-eight point seven percent of performers of PT routinely used fibreoptic bronchoscopy but only 6.4% used ultrasonography. Seventy-four point two percent used tracheostomy tubes with inner cannulae and 83.9% routinely followed up with patients post-discharge from the ICU. Seventy-nine point two percent of respondents believed PT was the method of choice for elective tracheostomy in the ICU but only 49.1% perceived PT to be safer compared to ST. PT is commonly practised in intensivist-led ICUs. PT is generally preferred for elective tracheostomy but there is a variability in perceptions regarding its safety compared to ST.

Abstract Introduction Tracheotomy is a common procedure in intensive care patients requiring long-term mechanical ventilation. The need for this procedure increased during the COVID-19 pandemic. Two main techniques are used: surgical tracheotomy (ST) and percutaneous dilatation tracheotomy (PDT). It is unclear whether the choice of technique affects survival or blood gas parameters postoperatively. We aimed to compare 30-day survival and changes in arterial blood gases between patients who underwent ST and PDT during the COVID-19 pandemic. Method A retrospective cohort study was conducted at Södersjukhuset, Stockholm. A total of 139 patients with COVID-19-associated acute respiratory distress syndrome who underwent tracheotomy between 2020-03-07 and 2021-09-17 were included (73 ST, 66 PDT). The primary outcome was 30-day survival. Secondary outcomes included changes in pCO₂, pO₂ and pH before and after the procedure. Statistical analyses were performed using Student’s t-test and Fisher’s exact test. Result No significant difference in 30-day mortality was observed between the groups (26% ST vs 32% PDT, p = 0.358). The ST group had significantly higher postoperative pCO₂ (p = 0.047) and lower pH (p &amp;lt; 0.001) compared with PDT. Within the ST group, a significant increase in pCO₂ and decrease in pH were seen postoperatively. Discussion The choice of tracheotomy method did not affect 30-day survival. However, small but statistically significant differences were seen in blood gases, where ST was associated with poorer ventilation postoperatively compared to PDT. Since PDT and ST appear equivalent in terms of survival outcomes, the choice of technique should be guided by the patient’s clinical profile and the procedural context.

A Case of Surgical Tracheostomy for Severe Obesity

IntroductionTracheostomy is a regularly performed procedure for patients requiring prolonged ventilatory support in the intensive care unit (ICU). Our community hospital implemented a new percutaneous tracheostomy (PT) program in an attempt to decrease operational costs and navigate operating room limitations. After the successful rollout, we performed a study comparing PT and surgical tracheostomy (ST) in terms of efficiency, ICU stay, and cost after one year to determine the outcomes a community hospital could expect in the early stages of PT implementation. MethodsThis is a cohort study with retrospective data collected from hospital records for both ST and PT over the years 2023-2024. Outcomes measured included consult-to-procedure time, procedural duration, ICU stay, and cost. Statistical significance was set at p<0.05. ResultsPT had a significantly shorter consult-to-procedure time (p=0.0039), with a mean of 1.76 days, compared to 4.139 days for ST. PT was also faster in procedural duration (p=0.0001), averaging 8.66 minutes, versus 53.93 minutes for ST. ICU length of stay showed no statistical difference (p=0.3919), with PT patients staying three days versus 3.79 days for ST. Cost analysis revealed PT was significantly more cost-effective, averaging $971.93, compared to $2,397.98 for ST. ConclusionPT is a more efficient and cost-effective alternative to ST, significantly reducing consult-to-procedure time and procedure duration. Although ICU length of stay did not reach statistical significance, PT demonstrates clear advantages in terms of resource utilization and cost savings.

Intraoperative Tracheostomy Complications.

Age-Related Complications in Percutaneous Dilational Tracheostomy (PDT) And Traditional Open Surgical Tracheostomy: A Randomized Controlled Trial

We report a rare case of tracheostomy tube malfunction due to asymmetric cuff inflation, a complication scarcely discussed in medical literature and distinct from more commonly reported tracheostomy cuff herniation. This case highlights a less recognized cause of air leak and inadequate ventilation, contributing to the understanding of rare tracheostomy complications.A 71-year-old male, recovering from Ivor Lewis esophagectomy and requiring surgical tracheostomy for prolonged ventilatory support, presented with a persistent air leak and reduced tidal volume soon after tube placement. This occurred despite an adequate cuff pressure (28 cm H₂O) and confirmed correct tube positioning. Direct laryngoscopy revealed air escaping through the glottis with each delivered breath, with the tracheostomy cuff visibly intact and no herniation.The findings led to the diagnosis of asymmetric tracheostomy cuff inflation. The therapeutic intervention involved the replacement of the problematic tracheostomy tube with a new non-fenestrated tube. This intervention immediately and completely resolved the air leak and restored normal ventilation.This case underscores the importance of prompt recognition and considering asymmetric cuff inflation in the differential diagnosis of tracheostomy tube malfunction. Differentiating between tracheostomy cuff herniation and a merely asymmetric cuff is crucial for healthcare professionals to manage these situations effectively and in an evidence-based manner.Keywords: Airway Management, Critical Care, Tracheostomy.

Background: Airway management in otolaryngology presents unique challenges due to shared airway access, altered anatomy, and specific procedural requirements. This article examines current techniques and oxygenation strategies across various ENT procedures to provide a guide for otolaryngologists. Methods: A narrative review was performed of the contemporary literature, focusing on airway techniques in ENT surgery, including laryngeal surgery, pediatric bronchoscopy, transoral surgery, and trauma and emergency scenarios. A systematic search for difficult airway guidelines was performed using the EMBASE, Pubmed, and Cochrane databases to examine where guidelines are published. Results: The key areas for specialist airway management included laryngeal surgery in the tubeless field and adjuncts for emergency situations. High-flow nasal oxygen (HFNO), jet ventilation, video laryngoscopy, and specialized tubes emerged as key technological advances, improving safety and outcomes. A systematic search identified 947 difficult airway articles across 82 publishers. These were predominantly in anesthetic journals (n = 301), with limited representation in the otolaryngology literature (n = 8) and limited guidance concerning awake surgical tracheostomies under local anesthetic. Awake tracheal intubation and emergency front-of-neck access were identified as key techniques across multiple publications. Conclusions: Modern ENT airway management requires multidisciplinary planning, advanced equipment familiarity, and procedure-specific techniques. Despite having the expertise to perform the gold standard, the limited otolaryngology literature on difficult airways suggests that guidelines are primarily developed by the anesthetic community.

Background Delays in surgical tracheostomy can impact patients, families, and ICU systems. This case highlights the consequences of delays and gives suggestions on how to optimize care delivery. Patient case A 32-year-old female diagnosed with severe pneumococcal pneumonia presented with progressive shortness of breath, chest pain and cough. She continued to deteriorate despite non-invasive respiratory support, resulting in tracheal intubation and prolonged invasive ventilation. Intervention She required surgical tracheostomy to aid weaning because of anticipated difficulty with bedside percutaneous dilatational tracheostomy (PDT). Logistical and operating room scheduling problems led to a five-day delay. Outcome Delayed surgical tracheostomy resulted in significantly prolonged sedation burden, likely contributed to post-emergence delirium, delayed laryngeal and physical rehabilitation, distress for the relatives, and pressure on the healthcare system in terms of bed-days and economic costs. Conclusion Minimizing delays between decision for ICU tracheostomy and insertion improves outcomes for patients, their relatives, and hospital systems. Innovations enabling more ICU bedside PDT to be undertaken could reduce delays.