Babak Saedi MD OTOLARYNGOLOGIST TEHRAN UNIVERSITY OF MEDICAL SCIENSES

Voice change Dyspnea Local pain Cough

Stridor Hoarseness Retraction (intercostal- suprasternal-supraclavicular) Drooling - bleeding - emphysema

Simplest adequate form of control should be selected Lower level Other medical problems

Prolonged intubation Ventilation support Manage bronchopulmonary secretion Upper airway obstruction Obstructive sleep apnea Bilateral vocal cord paralysis Inability to intubate Major head & neck surgery or trauma

Advantages lower risk of laryngotracheal injury improved comfort/mobility improve airway stabilization allows for oral nutrition improved secretion clearance

Sternal notch Thyroid cartilage Cricoid cartilage - cricothyroid membrane - innominate artery - thyroid gland (isthmus) - recurrent laryngeal nerve

Venous supply Superior and middle thyroid v. drain into the IJ Inferior thyroid v. drains into the brachiocephalic trunk

Anatomy variant: thyroid ima artery, in 1.5% to 12%, in front of the trachea.

Emergent (slash trach) Urgent (awake) Elective

Optimally under general anesthesia Incision between sternal notch and cricoid Dissection in a vertical plane Thyroid isthmus (third and fourth ring) Entrance into trachea Tracheotomy tube insertion

Hemorrhage False route Electrocautery fire Injury to adjacent structures

Hemorrhage [most common ] Infection Subcutaneous emphysema Pneumomediastinum Pneumothorax [most common in infant ] Obstruction of tacheotomy tube Displacement of tube

Hemorrhage Tracheoesophageal fistula Tracheal stenosis Tracheocutaneous fistula