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view of true cords on phonation. Ventricular dysphonia
secondary to laryngeal disorders is difficult to treat but
the functional type can be helped through voice therapy
and psychological counselling.
SECTION V — Diseases of Larynx and Trachea
FUNCTIONAL APHONIA (HYSTERICAL
APHONIA)
It is a functional disorder mostly seen in emotionally labile females in the age group of 15–30 years. Aphonia is
usually sudden and unaccompanied by other laryngeal
symptoms. Patient communicates with whisper. On examination, vocal cords are seen in abducted position and
fail to adduct on phonation; however, adduction of vocal
cords can be seen on coughing, indicating normal adductor function. Even though patient is aphonic, sound of
cough is good. Treatment given is to reassure the patient
of normal laryngeal function and psychotherapy.
PUBERPHONIA (MUTATIONAL
FALSETTO VOICE)
Normally, childhood voice has a higher pitch. When
the larynx matures at puberty, vocal cords lengthen and
the voice changes to one of lower pitch. This is a feature exclusive to males. Failure of this change leads to
persistence of childhood high-pitched voice and is called
puberphonia. It is seen in boys who are emotionally immature, feel insecure and show excessive fixation to their
mother. Psychologically, they shun to assume male responsibilities though their physical and sexual development is
normal. Treatment is training the body to produce lowpitched voice. Pressing the thyroid prominence in a backward and downward direction relaxes the overstretched
cords and low tone voice can be produced (Gutzmann’s
pressure test). The patient pressing on his larynx learns
to produce low tone voice and then trains himself to produce syllables, words and numbers. Prognosis is good.
PHONASTHENIA
It is weakness of voice due to fatigue of phonatory muscles. Thyroarytenoid and interarytenoids or both may be
affected. It is seen in abuse or misuse of voice or following
laryngitis. Patient complains of easy fatiguability of voice.
Indirect laryngoscopy shows three characteristic findings:
1. Elliptical space between the cords in weakness of thyroarytenoid.
2. Triangular gap near the posterior commissure in weakness of interarytenoid.
3. Key-hole appearance of glottis when both thyroarytenoid and interarytenoids are involved (Figure 63.1).
Treatment is voice rest and vocal hygiene, emphasiz-
ing on periods of voice rest after excessive use of voice.
DYSPHONIA
Dysphonia can be divided into three types: adductor, abductor and mixed.
Figure 63.1. Appearances of glottis in phonasthenia. (A) Weakness
of thyroarytenoid. (B) Interarytenoid. (C) Thyroarytenoid and interarytenoid.
ADDUCTOR DYSPHONIA
The adductor muscles of larynx go into spasm causing vocal cords to go into adduction. Voice becomes strained or
strangled, and phonation is interrupted in between leading to voice breaks. Larynx is however morphologically
normal. Severity of the condition differs from mild and
intermittent symptoms to those with moderate or severe
dysphonia. Flexible fibreoptic laryngoscopy is useful during which patient’s speech, sustained phonation and respiratory activities are studied. Patient may have tremors
of larynx, palate and pharynx.
Aetiology of the condition is uncertain but one should
exclude neurological conditions such as Parkinsonism,
myoclonus, pseudobulbar palsy, multiple sclerosis, cerebellar disorders, tardive dyskinesia and amyotrophic lateral sclerosis. CT scan and MRI are not useful but help to
rule out neurological conditions.
Treatment consists of botulinum toxin injections in
the thyroarytenoid muscle on one or both sides to relieve
spasm. Percutaneous electromyography (EMG) guided
route through cricothyroid space is preferred. Dose of
botulinum toxin depends on severity of the condition.
Toxin injections relieve voice breaks due to spasms and
improve airflow but the benefit lasts only up to 16 weeks
or so when repeat injection may be needed. Sometimes, if
dose of toxin is not regulated it may cause breathiness of
voice and discomfort to swallow.
Voice therapy is useful to improve voice and the duration of benefit. Voice therapy alone without injection
does not help much. Earlier disease was considered to
be psychological in origin but psychotherapy was not
found useful. Section of recurrent laryngeal to paralyze
the cord/cords has been used in the past but it interferes
with glottic closure leading to breathy and weak voice
and swallowing discomfort. This treatment is still used
when injection treatment fails and the spasms are severe.
ABDUCTOR DYSPHONIA
It is due to spasms of posterior cricoarytenoid muscle (the
only abductor) and thus keeping the glottis open. Patient
gets a breathy voice or breathy breaks in voice. The condition is gradually progressive and the symptoms get aggravated during periods of stress or when patient uses telephone.
Chapter 63 — Voice and Speech Disorders
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Like adductor spasm dysphonia, cause of abductor
spasmodic dysphonia is not known.
Treatment is injection of botulinum toxin in posterior
cricoarytenoid muscles. It can be done by percutaneous
or endoscopic route. The former being used with EMG
guidance. Results of injection are not as good as in adductor spasmodic dysphonia. Only about 50% of patients
improve and the duration of improvement is also less.
Disadvantages of injection treatment are that it may
compromise vocal cord movements with respiration leading to airway obstruction.
Patients who do not respond to toxin injection can be
treated by thyroplasty type I or fat injection. A prior gelfoam injection can be used to judge the effectiveness of
the above procedure.
Speech therapy should be combined with injection
treatment as speech therapy alone may not be effective.
MIXED DYSPHONIA
It is more complex, both the adductor and abductor function may be affected.
HYPONASALITY (RHINOLALIA CLAUSA)
It is lack of nasal resonance for words which are resonated
in the nasal cavity, e.g. m, n, ng.
It is due to blockage of the nose or nasopharynx. Important causes are listed in Table 63.2.
HYPERNASALITY (RHINOLALIA APERTA)
It is seen when certain words which have little nasal
resonance are resonated through nose. The defect is in
failure of the nasopharynx to cut off from oropharynx
TABLE 63.2 CAUSES OF HYPONASALITY AND
HYPERNASALITY
Hyponasality Hypernasality
Common cold
Nasal allergy
Nasal polypi
Nasal growth
Adenoids
Nasopharyngeal mass
Familial speech pattern
Habitual
Velopharyngeal insufficiency
Congenitally short soft palate
Submucous palate
Large nasopharynx
Cleft of soft palate
Paralysis of soft palate
Postadenoidectomy
Oronasal fistula
Familial speech pattern
Habitual speech pattern
or abnormal communication between the oral and nasal
cavities. The causes are listed in Table 63.2.
STUTTERING
It is a disorder of fluency of speech and consists of hesitation to start, repetitions, prolongations or blocks in the
flow of speech. When well-established, a stutterer may
develop secondary mannerisms such as facial grimacing, eye blink and abnormal head movements. Normally,
most of the children have dysfluency of speech between
2 and 4 years. If too much attention is given or child reprimanded by parents and peers, this behaviour pattern
may become fixed and child may develop into an adult
stutterer. Stuttering can be prevented by proper education
of the parents, not to overreact to child’s dysfluency in
early stages of speech development. Treatment of an established stutterer is speech therapy and psychotherapy
to improve his image as a speaker and reduce his fear of
dysfluency.
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Chapter 64
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Tracheostomy and Other Procedures
for Airway Management
TRACHEOSTOMY
Tracheostomy is making an opening in the anterior wall
of trachea and converting it into a stoma on the skin
surface. Sometimes, the term tracheotomy has been interchangeably used but the latter actually means opening the trachea, which is a step in the tracheostomy
operation.
FUNCTIONS OF TRACHEOSTOMY
1. Alternative pathway for breathing. This circumvents
any obstruction in the upper airway from lips to the
tracheostome.
2. Improves alveolar ventilation. In cases of respiratory
insufficiency, alveolar ventilation is improved by:
(a) Decreasing the dead space by 30–50% (normal
dead space is 150 mL).
(b) Reducing the resistance to airflow.
3. Protects the airways. By using cuffed tube, tracheo-
bronchial tree is protected against aspiration of:
(a) Pharyngeal secretions, as in case of bulbar paraly-
sis or coma.
(b) Blood, as in haemorrhage from pharynx, larynx or
maxillofacial injuries. With tracheostomy, pharynx
and larynx can also be packed to control bleeding.
4. Permits removal of tracheobronchial secretions.
When patient is unable to cough as in coma, head in-
juries, respiratory paralysis; or when cough is painful,
as in chest injuries or upper abdominal operations, the
tracheobronchial airway can be kept clean of secre-
tions by repeated suction through the tracheostomy,
thus avoiding need for repeated bronchoscopy or in-
tubation which is not only traumatic but also requires
expertise.
5. Intermittent positive pressure respiration (IPPR). If
IPPR is required beyond 72 h, tracheostomy is superior
to intubation.
6. To administer anaesthesia. In cases where endotra-
cheal intubation is difficult or impossible as in laryn-
gopharyngeal growths or trismus.
INDICATIONS OF TRACHEOSTOMY
There are three main indications (Table 64.1)
1. Respiratory obstruction.
2. Retained secretions.
3. Respiratory insufficiency.
TYPES OF TRACHEOSTOMY
• Emergency tracheostomy
• Elective or tranquil tracheostomy
• Permanent tracheostomy
• Percutaneous dilatational tracheostomy
• Mini tracheostomy (cricothyroidotomy)
1. emergency tracheostomy. It is employed when
airway obstruction is complete or almost complete and
there is an urgent need to establish the airway. Intubation or laryngotomy are either not possible or feasible in
such cases.
2. electiVe tracheostomy (syn. tranquil, orderly
or routine tracheostomy). This is a planned, unhur-
ried procedure. Almost all operative surgical facilities are
available, endotracheal tube can be put and local or general anaesthesia can be given. It is of two types:
(a) Therapeutic, to relieve respiratory obstruction, remove
tracheobronchial secretions or give assisted ventilation.
(b) Prophylactic, to guard against anticipated respiratory
obstruction or aspiration of blood or pharyngeal secretions such as in extensive surgery of tongue, floor
of mouth, mandibular resection or laryngofissure.
Elective tracheostomy is often temporary and is closed
when indication is over.
3. permanent tracheostomy. This may be required
for cases of bilateral abductor paralysis or laryngeal stenosis. In laryngectomy or laryngopharyngectomy, lower tracheal stump is brought to surface and stitched to the skin.
Tracheostomy has also been divided into high, mid or
low. A high tracheostomy is done above the level of thyroid
isthmus (isthmus lies against II, III and IV tracheal rings). It
violates the first ring of trachea. Tracheostomy at this site
can cause perichondritis of the cricoid cartilage and subglottic stenosis and is always avoided. Only indication for high
tracheostomy is carcinoma of larynx because in such cases,
total larynx anyway would ultimately be removed and a
fresh tracheostome made in a clean area lower down. A mid
tracheostomy is the preferred one and is done through the
II or III ring and would entail division of the thyroid isthmus
or its retraction upwards or downwards to expose this part of
trachea. A low tracheostomy is done below the level of isthmus. Trachea is deep at this level and close to several large
vessels; also there are difficulties with tracheostomy tube
which impinges on suprasternal notch.
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SECTION V — Diseases of Larynx and Trachea
TABLE 64.1 INDICATIONS FOR TRACHEOSTOMY
1. Respiratory obstruction
(a) Infections
(i) Acute laryngo-tracheo-bronchitis, acute epiglottitis,
diphtheria
(ii) Ludwig’s angina, peritonsillar, retropharyngeal or
parapharyngeal abscess, tongue abscess
(b) Trauma
(i) External injury of larynx and trachea
(ii) Trauma due to endoscopies, especially in infants and
children
(iii) Fractures of mandible or maxillofacial injuries
(c) Neoplasms
(d) Foreign body larynx
(e) Oedema larynx due to steam, irritant fumes or gases,
allergy (angioneurotic or drug sensitivity), radiation
(f) Bilateral abductor paralysis
(g) Congenital anomalies
– Laryngeal web, cysts, tracheo-oesophageal fistula
– Bilateral choanal atresia
2. Retained secretions
(a) Inability to cough
(i) Coma of any cause, e.g. head injuries,
cerebrovascular accidents, narcotic overdose
(ii) Paralysis of respiratory muscles, e.g. spinal injuries,
polio, Guillain–Barre syndrome, myasthenia gravis
(iii) Spasm of respiratory muscles, tetanus, eclampsia,
strychnine poisoning
(b) Painful cough
(c) Aspiration of pharyngeal secretions
3. Respiratory insufficiency
Chronic lung conditions, viz. emphysema, chronic bronchitis,
bronchiectasis, atelectasis
Conditions listed in A and B
Figure 64.1. Skin incisions in tracheostomy. (A) Vertical midline
incision. (B) Transverse incision.
TECHNIQUE
Whenever possible, endotracheal intubation should be
done before tracheostomy. This is specially important in
infants and children.
Position. Patient lies supine with a pillow under the
shoulders so that neck is extended. This brings the trachea forward.
Anaesthesia. No anaesthesia is required in unconscious patients or when it is an emergency procedure. In
conscious patients, 1–2% lignocaine with epinephrine
is infiltrated in the line of incision and the area of dissection. Sometimes, general anaesthesia with intubation
is used.
STEPS OF OPERATION
1. A vertical incision is made in the midline of neck, ex-
tending from cricoid cartilage to just above the sternal
notch. This is the most favoured incision and can be
used in emergency and elective procedures. It gives
rapid access with minimum of bleeding and tissue dis-
section. A transverse incision, 5 cm long, made two
fingers’ breadth above the sternal notch can be used in
elective procedures. It has the advantage of a cosmeti-
cally better scar (Figure 64.1).
2. After incision, tissues are dissected in the midline.
Dilated veins are either displaced or ligated.
Figure 64.2. Mid tracheostomy. Thyroid isthmus is divided and
ligated.
Scan to play Tracheostomy.
3. Strap muscles are separated in the midline and retracted laterally.
4. Thyroid isthmus is displaced upwards or divided between the clamps, and suture ligated.
5. A few drops of 4% lignocaine are injected into the trachea to suppress cough when trachea is incised.
6. Trachea is fixed with a hook and opened with a vertical incision in the region of third and fourth or third
and second rings. This is then converted into a circular
opening. The first tracheal ring is never divided as perichondritis of cricoid cartilage with stenosis can result
(Figure 64.2 ).
7. Tracheostomy tube of appropriate size is inserted and
secured by tapes (see p. 524 for different types and size
of tracheostomy tubes).
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TABLE 64.2 COMMON INDICATIONS OF
TRACHEOSTOMY IN INFANTS AND CHILDREN
• Infants below 1 year (mostly congenital lesions)
• Subglottic haemangioma
• Subglottic stenosis
• Laryngeal cyst
• Glottic web
• Bilateral vocal cord paralysis
• Children (mostly inflammatory or traumatic lesions)
• Acute laryngo-tracheo-bronchitis
• Epiglottitis
• Diphtheria
• Laryngeal oedema (chemical/thermal injury)
• External laryngeal trauma
• Prolonged intubation
• Juvenile laryngeal papillomatosis
361
Figure 64.3. Tracheotomized patient of laryngeal cancer with
suction-aid tracheostomy tube and receiving oxygen through a side
port.
8. Skin incision should not be sutured or packed tightly as it may lead to development of subcutaneous
emphysema.
9. Gauze dressing is placed between the skin and flange
of the tube around the stoma.
TRACHEOSTOMY IN INFANTS
AND CHILDREN
Important conditions requiring tracheostomy in this age
group are listed in Table 64.2.
Great care and caution is required when doing trache-
ostomy in infants and children lest it is attended with
complications that are avoidable.
1. Trachea of infants and children is soft and compressible and its identification may become difficult and the
surgeon may easily displace it and go deep or lateral
to it injuring recurrent laryngeal nerve or even the carotid. It is always useful to have an endotracheal tube
or a bronchoscope inserted into trachea before operation. Tracheostomy in infants and children is preferably done under general anaesthesia.
2. During positioning, do not extend the neck too much
as this pulls structures from chest into the neck and
thus injury may occur to pleura, innominate vessels
and thymus or the tracheostomy opening may be
made too low near suprasternal notch.
3. Before incising trachea, silk sutures are placed in the
trachea, on either side of midline.
4. Tracheal lumen is small, do not insert knife too deep; it
will injure posterior tracheal wall or even oesophagus
causing tracheo-oesophageal fistula.
5. Trachea is simply incised, without excising a circular
piece of tracheal wall.
6. Avoid infolding of anterior tracheal wall when inserting the tracheostomy tube.
7. Selection of tube is important. It should be of proper
diameter, length and curvature. A long tube impinges
on the carina or right bronchus. With high curvature,
lower end of tube impinges on anterior tracheal wall
while upper part compresses the tracheal rings or cricoid (see Appendix II, p. 509).
8. Use soft silastic or portex tube. Metallic tubes cause
more trauma.
9. Take a postoperative X-ray of the neck and chest to
ascertain the position of the tracheostomy tube.
POSTOPERATIVE CARE
1. Constant supervision. After tracheostomy, constant
supervision of the patient for bleeding, displacement
or blocking of tube and removal of secretions is essential. A nurse or patient’s relative should be in attendance. Patient is given a bell or a paper pad and a pencil
to communicate.
2. Suction. Depending on the amount of secretion, suction may be required every half an hour or so; use sterile catheters with a Y-connector to break suction force.
Suction injuries to tracheal mucosa should be avoided.
This is done by applying suction to the catheter only
when withdrawing it (Figure 64.3).
3. Prevention of crusting and tracheitis. This is achieved
by
(a) Proper humidification, by use of humidifier, steam
tent, ultrasonic nebulizer or keeping a boiling kettle in the room.
(b) If crusting occurs, a few drops of normal or hypo-
tonic saline or Ringer’s lactate are instilled into the
trachea every 2–3 h to loosen crusts. A mucolytic
agent such as acetylcysteine solution can be instilled to liquify tenacious secretions or to loosen
the crusts.
4. Care of tracheostomy tube. Inner cannula should be
removed and cleaned as and when indicated for the
first 3 days. Outer tube, unless blocked or displaced,
should not be removed for 3–4 days to allow a track
to be formed when tube placement will become easy.
After 3–4 days, outer tube can be removed and cleaned
every day.
If cuffed tube is used, it should be periodically deflated
to prevent pressure necrosis or dilatation of trachea.
Decannulation. Tracheostomy tube should not be
kept longer than necessary. Prolonged use of tube leads to
tracheobronchial infections, tracheal ulceration, granulations, stenosis and unsightly scars.
To decannulate a patient, tracheostomy tube is plugged
and the patient closely observed. If the patient can tolerate it for 24 h, tube can be safely removed. In children,
the above procedure is done using a smaller tube. After
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SECTION V — Diseases of Larynx and Trachea
tube removal, wound is taped and patient again closely
observed. Healing of the wound takes place within a few
days or a week. Rarely a secondary closure of wound may
be required.
Observe the following principles when decannulating
an infant or a young child:
1. Decannulate in the operation theatre where services of
a trained nurse and an anaesthetist are available.
2. Equipment for reintubation should be available immediately. It consists of a good headlight, laryngoscope,
proper-sized endotracheal tubes and a tracheostomy
tray.
3. After decannulation, watch the child for several hours
for respiratory distress, tachycardia and colour oxymetry is very useful to monitor oxygen saturation. It may
require blood gas determinations. When attempts at
decannulation are not successful, look for the cause. It
may be:
(a) Persistence of the condition for which tracheos-
tomy was done.
(b) Obstructing granulations around the stoma or
below it where tip of the tracheostomy tube had
been impinging.
(c) Tracheal oedema or subglottic stenosis.
(d) Incurving of tracheal wall at the site of tracheos-
tome.
(e) Tracheomalacia.
(f) Psychological dependence on tracheostomy and
inability to tolerate the resistance of the upper
airways.
A case of difficult decannulation may require endo-
scopic examination of the larynx, trachea and bronchi
preferably under magnification using telescopes or a flexible endoscope.
COMPLICATIONS
1. Immediate (at the time of operation):
(a) Haemorrhage.
(b) Apnoea. This follows opening of trachea in a patient
who had prolonged respiratory obstruction. This is
due to sudden washing out of CO2 which was acting
as a respiratory stimulus. Treatment is to administer
5% CO2 in oxygen or assisted ventilation.
(c) Pneumothorax due to injury to apical pleura.
(d) Injury to recurrent laryngeal nerves.
(e) Aspiration of blood.
(f) Injury to oesophagus. This can occur with tip of knife
while incising the trachea and may result in tracheo-
oesophageal fistula.
2. Intermediate (during first few hours or days):
(a) Bleeding, reactionary or secondary.
(b) Displacement of tube.
(c) Blocking of tube.
(d) Subcutaneous emphysema.
(e) Tracheitis and tracheobronchitis with crusting in tra-
chea.
(f) Atelectasis and lung abscess.
(g) Local wound infection and granulations.
3. Late (with prolonged use of tube for weeks and
months):
(a) Haemorrhage, due to erosion of major vessel.
(b) Laryngeal stenosis, due to perichondritis of cricoid
cartilage.
(c) Tracheal stenosis, due to tracheal ulceration and
infection.
(d) Tracheo-oesophageal fistula, due to prolonged use of
cuffed tube or erosion of trachea by the tip of tracheostomy tube.
(e) Problems of decannulation. Seen commonly in in-
fants and children.
(f) Persistent tracheocutaneous fistula.
(g) Problems of tracheostomy scar. Keloid or unsightly scar.
(h) Corrosion of tracheostomy tube and aspiration of its
fragments into the tracheobronchial tree.
PROCEDURES FOR IMMEDIATE AIRWAY
MANAGEMENT
When airway obstruction is so marked as to allow no
time to do an orderly tracheostomy, following measures
are taken:
1. jaw thrust. Lifting the jaw forward and extending
the neck improves the airway by displacing the soft tissues. Neck extension should be avoided in spinal injuries.
2. oropharyngeal airway. It displaces the tongue an-
teriorly and relieves soft tissue obstruction. Ventilation
can be carried out by face mask placed snugly over the
face and covering both nose and mouth. Ambu bag can
be used for inflation of air or oxygen.
3. nasopharyngeal airway (trumpet). It is inserted
transnasally into the posterior hypopharynx and relieves
soft tissue obstruction caused by the tongue and pharynx.
It is better tolerated than oropharyngeal airway in awake
patients.
4. laryngeal mask airway. It is a device with a tube
and a triangular distal end which fits over the laryngeal
inlet (Figure 64.4). Oxygen can be delivered directly into
the trachea. Though most commonly used for nonemergent airway control, it can be used as an alternative if
standard mask ventilation is inadequate and intubation
unsuccessful (see Appendix II on Instruments).
5. transtracheal jet Ventilation. It is an invasive
procedure. An intravenous catheter of 12 or 14 gauge with
Figure 64.4. Laryngeal mask airway.
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363
a syringe attached is inserted into the cricothyroid membrane and directed caudally. Once intraluminal placement
is confirmed by aspiration, needle is withdrawn leaving
the catheter in position and jet ventilation started. In thin
individuals where trachea can be palpated, catheter can
be inserted easily. Expiration of air should be insured otherwise pulmonary barotrauma with pneumothorax, pneumomediastinum and surgical emphysema can result.
6. endotracheal intubation. This is the most rapid
method. Larynx is visualized with a laryngoscope and endotracheal tube or a bronchoscope inserted. No anaesthesia is required. This helps to avoid a hurried tracheostomy
in which complication rate is higher. After intubation, an
orderly tracheostomy can be performed.
7. cricothyrotomy or laryngotomy or mini
tracheostomy. This is a procedure for opening the air-
way through the cricothyroid membrane. Patient’s head
and neck is extended, lower border of thyroid cartilage
and cricoid ring are identified. Skin in this area is incised
vertically and then cricothyroid membrane cut with a
transverse incision. This space can be kept open with a
small tracheostomy tube or by inserting the handle of
knife and turning it at right angles if tube is not available. It is essential to perform an orderly tracheostomy
as soon as possible because perichondritis, subglottic
oedema and laryngeal stenosis can follow prolonged laryngotomy.
“Mini tracheostomy is an emergency procedure to buy
time to allow patient to be carried to operation theatre.
Commercial emergency kits are also available for this. As
an elective procedure it has been done to clear the bronchial secretions following thoracic surgery.”
Cricothyroid needle puncture is a procedure where a
large-bore intravenous catheter is introduced through the
cricothyroid membrane. It is only an emergency procedure till patient can be intubated or tracheostomized. The
procedure does not provide adequate ventilation.
8. emergency tracheostomy. Technique of emergency tracheostomy is as follows: Patient’s neck is extended,
trachea identified and fixed between surgeon’s left thumb
and index finger. A vertical incision is made from lower
border of thyroid to suprasternal notch cutting through
skin and subcutaneous tissues. Lower border of cricoid
cartilage is identified and a transverse incision made in
pretracheal fascia. The thyroid isthmus dissected down to
expose upper three tracheal rings. Vertical tracheal incision is made in second and third rings, opened with a
haemostat and the tube inserted. Bleeding can be controlled by packing with gauze.
Emergency tracheostomy on a struggling patient with
inadequate lighting, suction and instruments is fraught
with many complications. If possible, an endotracheal
tube should be put for a more orderly procedure to be
carried out.
PERCUTANEOUS DILATATIONAL
TRACHEOSTOMY
This type of tracheostomy is done in ICU where patient is
already intubated and being monitored. It is done under
sedation. Neck is extended with a pad under the shoulders. Neck is prepared and draped and 1.5–2 cm incision
is made 2 cm below the lower border of cricoid. Trachea is
exposed by dissection and palpation. Thyroid isthmus is
pushed down. Now a small caliber flexible bronchoscope,
to which a camera has been attached, is passed through
the endotracheal tube to monitor the passage of the needle, guide wire and dilator/s. It is important to enter the
trachea in the midline and avoid any lateral entry. Entry
into the trachea is made between second and third rings.
After dilatation tracheostomy tube is inserted.
Advantages of the procedure include: (i) No need to
transport the patient to operation theatre, (ii) avoiding
operation theatre (OT) expenses, and (iii) avoiding ICU
nosocomial infections to be carried to OT and earlier discharge of patient.
The procedure is avoided in patients who are obese,
have a neck mass, difficult to intubate, difficult to extend
the neck, larynx and trachea are not easily palpable or
have uncorrectable coagulopathies.
Complications of the procedure include paratracheal
entry of dilator or tracheostomy tube into the lumen,
haemorrhage, damage to posterior tracheal wall and surgical emphysema.
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Chapter 65
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Foreign Bodies of Air Passages
A foreign body aspirated into air passage can lodge in the
larynx, trachea or bronchi. Site of lodgement would depend
on the size, shape and nature of the foreign body.
A large foreign body, unable to pass through the glottis, will lodge in the supraglottic area while the smaller
one will pass down through the larynx into the trachea
or bronchi. Foreign bodies with sharp points, e.g. pins,
needles, fish bones, etc. can stick anywhere in the larynx
or tracheobronchial tree.
AETIOLOGY
Children are more often affected; more than half of them
are below 4 years. Accidents occur when they suddenly
inspire during play or fight while having something in
the mouth. In children, peanut is the most common vegetable foreign body; others include almond seed, peas,
beans, gram or wheat seed, watermelon seed, pieces of
carrot or apple. Nonvegetable matters include plastic
whistle, plastic toys, safety pins, nails, all-pin, twisted
wires or ball bearings.
In adults, foreign bodies are aspirated during coma,
deep sleep or alcoholic intoxication. Loose teeth or denture may be aspirated during anaesthesia.
NATURE OF FOREIGN BODIES
1. Nonirritating type. Plastic, glass or metallic foreign
bodies are relatively nonirritating and may remain
symptomless for a long time.
2. Irritating type. Vegetable or foreign bodies like pea-
nuts, beans, seeds, etc. set up a diffuse violent reaction
leading to congestion and oedema of the tracheobron-
chial mucosa—a condition called “vegetal bronchitis.”
They also swell up with time causing airway obstruc-
tion and later suppuration in the lung. Areca nut is a
common foreign body in Rajasthan (India) due to hab-
it of chewing these nuts frequently, peanuts are com-
mon in USA, watermelon seeds in Egypt and pumpkin
seeds in Greece.
CLINICAL FEATURES
Symptomatology of foreign body is divided into three
stages:
1. initiaL PerioD oF choking, gagging anD wheez-
ing. This lasts for a short time. Foreign body may be
coughed out or it may lodge in the larynx or further
down in the tracheobronchial tree.
2. SyMPtoMLeSS intervaL. The respiratory mucosa
adapts to the presence of foreign body and initial symptoms disappear. Symptomless interval will vary with the
size and nature of the foreign body. It may last a few
hours or a few weeks.
3. Later SyMPtoMS. They are caused by airway obstruction, inflammation or trauma induced by the foreign body and would depend on the site of its lodgement
(Table 65.1).
(a) Laryngeal foreign body. A large foreign body may to-
tally obstruct the airway leading to sudden death
unless resuscitative measures are taken urgently. A
partially obstructive foreign body will cause discomfort or pain in the throat, hoarseness of voice, croupy
cough, aphonia, dyspnoea, wheezing and haemoptysis. (Figure 65.1).
(b) Tracheal foreign body. A sharp foreign body will only
produce cough and haemoptysis. A loose foreign body
like seed may move up and down the trachea between
the carina and the undersurface of vocal cords causing “audible slap” and “palpatory thud.” Asthmatoid
wheeze may also be present. It is best heard at patient’s open mouth.
(c) Bronchial foreign body. Most foreign bodies enter the
right bronchus because it is wider and more in line
with the tracheal lumen. A foreign body may totally
obstruct a lobar or segmental bronchus causing atelectasis or it may produce a check valve obstruction,
allowing only ingress of air but, not the egress, thus
leading to obstructive emphysema. For pathogenesis
and clinical picture of bronchial foreign body, see
Figure 65.2.
Emphysematous bulla may rupture causing spontane-
ous pneumothorax. A foreign body may also shift from
TABLE 65.1 SYMPTOMS AND SIGNS OF FOREIGN
BODIES AT DIFFERENT LEVELS
Site of foreign
bodies Symptoms and signs
Larynx • Completeobstructionleadingtodeath
• Partialobstruction:stridor,hoarseness,
cough, respiratory difficulty
Trachea • Choking,stridor,wheeze,cough,palpatory
thud, audible slap
Bronchi • Cough,wheezeanddiminishedairentryto
lung forms a “triad”
• Respiratorydistresswithswellingofforeign
body
• Lungcollapse,emphysema,pneumonitis,
bronchiectasis or lung abscess are late
features
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