Elective use of surgical cricothyroidotomy for maxillofacial fracture fixation with contraindication of nasotracheal intubation: a case report
© The Author(s) 2015
Received: 10 June 2015
Accepted: 12 October 2015
Published: 16 October 2015
We report three cases of airway management with elective surgical cricothyroidotomy (SCT) for anesthetic management during surgical repair of maxillofacial injury involving basal skull fracture or nasal-bone fracture. In all patients, general anesthesia was induced, a supraglottic airway (SGA) device inserted, and SCT performed. Tracheal intubation was performed through SCT site, and the SGA device was removed. After surgery of maxillofacial fixation, the SGA device was re-inserted and the tracheal tube was removed. No major complications, such as subglottic stenosis or voice change, occurred. SCT holds potential as an alternative to tracheostomy because of ease of performance, fewer complications, and better cosmetic outcomes.
KeywordsSurgical cricothyroidotomy Maxillofacial surgery Tracheostomy Subglottic stenosis
Surgical cricothyroidotomy (SCT) has become known as a suitable procedure for emergency surgical airway management, and elective use of SCT is currently rare. In anesthetic management for open reduction and fixation surgery (ORF) of maxillofacial fracture with intermaxillary fixation, the nasotracheal intubation technique is often used, as oral intubation may need to be avoided for particular reasons. For instance, the surgeon may require intermaxillary fixation to inspect fracture reduction and maintenance of the reduction during surgery, and it is not desirable to fumble with a tracheal tube during surgery that requires an intraoral approach. However, nasotracheal intubation may be contraindicated in patients simultaneously suffering from a skull-base fracture, particularly those with cerebrospinal fluid rhinorrhea, because of the increased rate of intracranial infection and the fact that nasotracheal intubation may aggravate the trauma . In such a situation, tracheostomy is often selected for ORF of the maxillofacial fracture with intermaxillary fixation in patients with a skull-base fracture. However, tracheostomy may have certain disadvantages, such as serious complications (8–24 %)  and tracheal stenosis (1–20 %) . In contrast, SCT is easier, quicker, and safer to perform than tracheostomy , but few studies have investigated the usefulness of SCT for temporary airway management in maxillofacial bone surgery [4–6].
Here, we report three cases in which airway management was achieved with elective SCT for anesthetic management, without major complications, during surgical repair of maxillofacial injury with a skull-base fracture or a nasal-bone fracture.
Anesthetic management with SCT for maxillofacial surgery
A 47-year-old man sustained extensive maxillofacial trauma, including basal skull fracture. ORF of the maxillofacial bones with elective SCT was performed 9 days after the injury. In this patient, a deformation of the larynx due to a childhood injury made it difficult to identify the cricothyroid membrane (CTM) accurately. At the 4-month follow-up after surgery, the surgical scar at the SCT site was inconspicuous and subglottic stenosis of the larynx was not observed on radiography (Fig. 3b).
A 62-year-old woman sustained multiple maxillofacial trauma injuries and nasal-bone fracture after being hit by a truck while walking. Her elective SCT was performed using the same procedure as above. The duration of SCT was 12 min. When the patient was discharged on postoperative day 7, she was reportedly very satisfied with the small size of the skin incision. No complication of SCT was observed at the 8-month follow-up (Fig. 3c).
We report three cases in which anesthetic management was achieved with elective SCT, without major complications, during maxillofacial surgery. Tracheostomy is often selected over SCT in similar cases because of concerns about subglottic stenosis , largely owing to a paper published by Jackson in 1921 [6, 7], which warned of a high incidence of subglottic stenosis after high tracheostomy (cricothyroidotomy), in a study based on 158 cases. In addition, other reports have been published supporting the theory about increased risk of subglottic stenosis with SCT [8–10]. However, Brantigan and Grow  reported that no subglottic stenosis was observed in 655 cases in which they performed elective SCT, and Holst et al.  found no severe perioperative or postoperative complications in their 103 elective SCT cases. Recently, Teo et al.  reported that the incidence of subglottic stenosis was very low (0.5–0.7 %), after reviewing 1916 cases of SCT, and thus recommend the use of elective SCT rather than tracheotomy in cases where intermaxillary fixation is required.
Other complications of SCT, besides subglottic stenosis, are major bleeding and voice changes [5, 6, 13]. Brantigan et al.  reported an incidence of intraoperative or postoperative bleeding of 1.5 % (10/664) in elective SCT cases, although no case required transfusion. However, if the tracheal tube is removed from the CTM after a short period of time, bleeding may reoccur from the incision. In fact, we observed blood entering the trachea from the CTM in Case 1. In subsequent cases reported here, we were able to identify the branches of the anterior jugular vein in the incision site. In cases in which the SCT tube will remain in place for a short period of time, we recommend applying hemostasis by ligation if these vessels are observed.
Voice change was indicated by Holst et al.  as one of the main complications. Brantigan et al.  observed severe voice changes in 1.1 % (7/664) of elective SCT cases. Voice change may occur due to dysfunction of the cricothyroid muscles. Therefore, disruption of the cricothyroid muscle during dissection of the CTM should be avoided. On the other hand, change in voice quality is not a specific complication of SCT. Rehm et al.  examined the incidence of voice change with both SCT and tracheostomy in trauma patients, and found no significant difference between the two groups.
Clinical characteristics of three patients with elective surgical cricothyroidotomy
Maxilb facial Fx.
Maxilb facial Fx.
Basal skull fracture
Duration from injury to surgery (day)
Size of SGA
D of intubated tube (mm)
Duration of SCT (min)*1
Duration of surgery (min)
Duration of anesthesia (min)
Airway management at emergence
Issures with SCT procedure
Duration of follow-up (month)
Long term complication with SCT*2
We here reported three cases of airway management with elective SCT for anesthetic management in ORF of maxillofacial injuries involving basal skull fracture or nasal-bone fracture. SCT holds potential as an alternative technique to tracheostomy, because it is easy to perform, has fewer complications, and has better cosmetic outcomes.
Written informed consent was obtained from the patients for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.
Open reduction and fixation surgery
We thank Misato Kuroyanagi and Toshihiro Yoshitake for their quality control in the surgical procedure of SCT.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.
- Coyle, MJ, Shrimpton, A, Perkins, C, Fasanmade, A, Godden, D: First do no harm: should routine tracheostomy after oral and maxillofacial oncological operations be abandoned? Br. J. Oral Maxillofac. Surg. 50, 732–5 (2012)View ArticlePubMedGoogle Scholar
- van Hasselt, EJ, Bruining, HA, Hoeve, LJ: Elective cricothyroidotomy. Intensive Care Med. 11, 207–9 (1985)View ArticlePubMedGoogle Scholar
- Henderson, JJ, Popat, MT, Latto, IP, Pearce, AC, Difficult Airway Society: Difficult airway society guidelines for management of the unanticipated difficult intubation. Anaesthesia 59, 675–94 (2004)View ArticlePubMedGoogle Scholar
- Feinberg, SE, Peterson, LJ: Use of cricothyroidostomy in oral and maxillofacial surgery. J. Oral Maxillofac. Surg. 45, 873–8 (1987)View ArticlePubMedGoogle Scholar
- Ward Booth, RP, Brown, J, Jones, K: Cricothyroidotomy, a useful alternative to tracheostomy in maxillofacial surgery. Int. J. Oral Maxillofac. Surg. 18, 24–6 (1989)View ArticlePubMedGoogle Scholar
- Teo, N, Garrahy, A: Elective surgical cricothyroidotomy in oral and maxillofacial surgery. Br. J. Oral Maxillofac. Surg. 51, 779–82 (2013)View ArticlePubMedGoogle Scholar
- Jackson, C: High tracheotomy and other errors. The chief causes of chronic laryngeal stenosis. Surg. Gynecol. Obstet. 32, 392–8 (1921)Google Scholar
- Kennedy, TL: Epiglottic reconstruction of laryngeal stenosis secondary to cricothroidostomy. Laryngoscope 90, 1130–6 (1980)View ArticlePubMedGoogle Scholar
- Kirchner, J: Cricothyroidotomy and subglottic stenoses. Plast. Reconstr. Surg. 68, 828–9 (1981)View ArticlePubMedGoogle Scholar
- Kuriloff, DB, Setzen, M, Portnoy, W, Gadelata, D: Laryngotracheal injury following cricothyroidotomy. Laryngoscope 99, 125–30 (1989)PubMedGoogle Scholar
- Brantigan, CO, Grow Sr, JB: Cricothyroidotomy: elective use in respiratory problems requiring tracheotomy. J. Thorac. Cardiovasc. Surg. 71, 72–81 (1976)PubMedGoogle Scholar
- Holst, M, Hedenstierna, G, Kumlien, JA, Schiratzki, H: Elective coniotomy. A prospective study. Acta Otolaryngol. 96, 329–35 (1983)View ArticlePubMedGoogle Scholar
- Holst, M, Hertegård, S, Persson, A: Vocal dysfunction following cricothyroidotomy: a prospective study. Laryngoscope 100, 749–55 (1990)PubMedGoogle Scholar
- Rehm, CG, Wanek, SM, Gagnon, EB, Pearson, SK, Mullins, RJ: Cricothyroidotomy for elective airway management in critically ill trauma patients with technically challenging neck anatomy. Crit. Care 6, 531–5 (2002)PubMed CentralView ArticlePubMedGoogle Scholar