TECHNICAL STRATEGY

Tracheostomy in Maxillofacial Surgery: A Simple and

Safe Technique for Residents in Training
Attilio Carlo Salgarelli, MD, DDS,* Marco Collini, MD, DDS, Pierantonio Bellini, MD,*
and Paolo Cappare`, MD
Background: Tracheostomy is a frequently performed surgical
procedure and may be required under emergency, semiurgent, or
elective conditions. In maxillofacial surgery, it is indicated in congenital, inammatory, oncologic, or traumatic respiratory obstruction and prolonged intubation. This article presents a simplied
tracheostomy procedure based on anatomic markers that gives the
best compromise between minimum invasiveness and safety.
Patients and Methods: A retrospective study analyzed the clinical aspects, treatment methods, and clinical course of 198 patients
who underwent tracheostomies performed by residents in training under the supervision of surgeons between October 2002 and
December 2007 at the Maxillofacial Surgery Department of Carlo
Poma Hospital, Mantova, and the Maxillofacial Unit, Head and Neck
Department, University of Modena and Reggio Emilia, Italy. Tracheostomies were performed in 127 patients (64.14%) with neoplastic
diseases (tumors of the tongue base, tonsils, and oral and pharyngeal
regions) and in 71 patients with trauma (35.86%). The patients were
followed up for 3 to 65 months.
Results: Acceptable clinical healing and outcomes were obtained
in all patients. Intraoperative complications occurred in 35 patients
(17.7%): bleeding in 32 patients (16.2%) and pretracheal or paratracheal tube placement in 3 patients (1.51%). Postoperative complications after tracheostomy closure included tracheostomy dehiscence
in 5 patients (2.52%) and subcutaneous emphysema in 26 patients
(13.12%). Tracheostomy dehiscence occurred in 3 patients with neoplasia (1.51%) and in 2 patients with trauma (1.01%). No symptomatic tracheal stenosis developed.
Conclusions: The standardized surgical technique presented here
reduces the associated surgical risk when the correct anatomic
markers are used and important structures are recognized and handled correctly.
Key Words: Maxillofacial surgery, tracheostomy, head and
neck cancer

From the *Unit of Maxillofacial Surgery, Department of Head and Neck,

Modena and Reggio Emilia University, Modena; and Maxillofacial Surgery Department, Carlo Poma Hospital, Mantova, Italy.
Received April 29, 2010.
Accepted for publication May 19, 2010.
Address correspondence and reprint requests to Attilio Carlo Salgarelli, MD,
DDS, Unit of Maxillofacial Surgery, Department of Head and Neck,
Modena and Reggio Emilia University, Via del Pozzo, 71, 41100
Modena, Italy; E-mail: attiliocarlo.salgarelli@unimore.it
The authors report no conicts of interest.
Copyright * 2011 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0b013e3181f7b6e8

The Journal of Craniofacial Surgery

(J Craniofac Surg 2011;22: 243Y246)

racheostomy is one of the oldest surgical procedures, dating

back 3000 years to ancient Egypt and India.1 Currently, it is one
of the most frequent operations required in intensive care units and
hospitals and may be performed under emergency, semiurgent, and
elective conditions.2
The indications cited in the literature include all of the conditions in which it is necessary to bypass a high airway obstruction,
such as congenital (subglottic stenosis and laryngeal web), inammatory (angioneurotic edema), neoplastic (laryngeal cancer or high
aerodigestive tumor), traumatic (maxillofacial fractures, neck trauma), neurologic (bilateral recurrent laryngeal nerve paralysis, neurologic pathologic lesions with bulbar dysfunction, or low level of
consciousness), or neuromuscular (Guillain-Barre syndrome, myasthenia gravis, and skull trauma) defects.
Given the low morbidity and exceptionally low mortality
of this operation,3 the indications for tracheostomy have been expanded to include translaryngeal intubation for more than 10 days.
Tracheostomy has many advantages over prolonged translaryngeal
intubation4Y6: (a) reduced laryngeal, supraglottic, and vocal cord
damage; (b) reduced oral damage to the tongue, teeth, and palate;
(c) decreased dead space and resistance to gas ow; (d ) reduced
sedation requirements; (e) increased patient comfort; ( f ) better facilitation of patient mobilization and nursing care; ( g) glottic competence; (h) better oral and gastric secretion removal; (i ) improved
communication with the patient and early return to speech; ( j ) better
clearance of the lower airway; and (k) more rapid weaning from
mechanical ventilation.
In maxillofacial surgery, the indications for tracheostomy
include conditions and operations of the upper aerodigestive system
correlated with dyspneic symptoms: inammatory disease (Ludwig
angina, dental abscess), neoplastic disease (tumors of the tongue
base, tonsils, and oral and pharyngeal regions), and trauma (multiple
fractures, ethmoidal fractures increasing the risks of nasotracheal
intubation, and jaw fractures that need intermaxillary rigid xation
and contraindicate orotracheal intubation, where the patient has to be
under control or needs mechanical ventilation postoperatively).
The indications are extended to tumor resection in the oral
cavity and maxillofacial reconstruction involving observation in the
intensive care unit. Such patients are often ventilated mechanically
via orotracheal intubation, but tracheostomy can be used to facilitate
weaning from mechanical ventilation to avoid reintubation in patients
with intermaxillary xation or edema of the tongue, palate, or oral
region or when pushing on structures reconstructed with a pedicle
ap, free graft, or microvascular free tissue transfer with a laryngoscope is contraindicated.
In maxillofacial surgery, as in other disciplines, tracheostomy is most often an elective procedure and it must be performed
with high standards. Compared with translaryngeal intubation, tracheostomy places the patient at surgical risk. In addition, the new
percutaneous minimally invasive techniques have some early and

& Volume 22, Number 1, January 2011

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Salgarelli et al

late complications.7,8 As described by Ciaglia et al9 in 1985, the

surgeons learning curve10 is still relevant with these recent techniques. In addition, there are many clinical and anatomic contraindications to their use, including obesity, a previous tracheostomy,
radiotherapy, anatomic abnormality of the trachea or thyroid, infection at the puncture site, unstable cervical spine, or unstable
coagulopathies.
Therefore, it is important to know how to perform a conventional tracheostomy and its surgical risks and complications.11
These include (a) damage to nerves, arteries, veins, the thyroid,
and esophageal wall; (b) damage to the tracheal walls; (c) barotrauma (subcutaneous emphysema, pneumomediastinum, or pneumothorax); (d ) bleeding; (e) hypoxia; ( f ) loss of the airway; and
( g) bronchospasm.
While in training, residents require an effective, standardized,
and simplied surgical procedure. This can reduce the complications
during surgery and make the technique safer and more precise.
This article presents a simplied surgical procedure, based on
the recognition of anatomic markers and the execution of several
surgical steps, which gives the best compromise between minimum
invasiveness and safety.

PATIENTS AND METHODS

We retrospectively analyzed the clinical aspects, treatment
methods, and the course of 198 patients who underwent tracheostomies performed by residents under the supervision of established
surgeons between October 2002 and December 2007 at the Maxillofacial Surgery Department at Carlo Poma Hospital, Mantova, and
the Maxillofacial Unit, Head and Neck Department, University of
Modena and Reggio Emilia, Italy. Tracheostomies were performed
in 127 patients (64.14%) with neoplastic diseases (tumors of the
tongue base, tonsils, and oral and pharyngeal regions) and in 71
patients with trauma (35.86%; Table 1). Of the patients with neoplasia, 44 were females (22.22%) and 83 were males (41.92%). In
all cases of oncologic surgery, tracheostomy was the rst step.
Similarly, of the patients with trauma, 23 were females (11.62%)
and 48 were males (24.24%). The procedure usually takes from 18
to 45 minutes; more complex tracheostomies (short or very thick
neck) were performed by more expert surgeon and were excluded by
this study. The patients were then observed for 3 to 65 months.

& Volume 22, Number 1, January 2011

FIGURE 1. The thyroid cartilage (1 arrow), cricoid cartilage

(2 arrows), and sternal notch are marked (3 arrows), and the
skin incision is made.
midline vertically. Then, 4 retractors are placed superiorly, inferiorly,
and laterally to the right and left to expose the sternohyoid and
sternothyroid muscles. The medial edge of the muscles is dissected
and retracted (Fig. 3A). It is important to place the retractors symmetrically, so that the trachea is precisely in the middle. The thyroid
isthmus is exposed, and its position is compared to the chosen level
of the tracheostomy, allowing the surgeon to choose between retraction and transection of the thyroid isthmus. The structures are
split to expose the second and third tracheal rings.
A cross-shaped incision is made in the anterior tracheal wall
with a no. 11 scalpel blade, taking care to avoid damaging the endotracheal tube balloon cuff, and sacricing 1 tracheal ring only,
usually the third (Fig. 3A). The 4 tracheal aps of the cross-shaped
incision are removed with a conchotome to create a large stoma
(Fig. 3B). Then, the translaryngeal tube is removed, any secretions
are aspirated, and an adequate-sized tracheostomy tube is placed in
the airway. After placing the tracheostomy tube correctly, under the
control of an aspiration probe, the anesthesiologist controls the
correct airway ventilation and oxygenation. Then, the skin is sutured

Surgical Technique
With the patient supine on the operating table with a pillow
under the shoulders to extend the neck, the skin is disinfected and
the thyroid cartilage, cricoid cartilage, and sternal notch are marked
(Fig. 1). After the local inltration of anesthetic and a vasoconstrictor (if not contraindicated) such as carbocaine with adrenaline
1:100,000, a 3-cm horizontal skin incision is made halfway between
the marks on the cricoid cartilage and sternal notch (Fig. 1). Two
Klemmers are placed on the superior and inferior skin aps to open
and lift these aps. Then, the subcutaneous fat is dissected with
scissors (Fig. 2). The subcutaneous tissue dissection follows the

TABLE 1. Frequency of Patients Undergoing Tracheotomies

Tumors
Trauma
Total

244

Females, n (%)

Males, n (%)

Total, n (%)

44 (22.22)
23 (11.62)
67 (33.84)

83 (41.92)
48 (24.24)
131 (66.16)

127 (64.14)
71 (35.86)
198 (100)

FIGURE 2. Tissue dissection in the midline.

* 2011 Mutaz B. Habal, MD

Copyright 2011 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

The Journal of Craniofacial Surgery

& Volume 22, Number 1, January 2011

Tracheostomy for Residents in Training

TABLE 2. Intraoperative Complications

Bleeding,
n (%)

Paratracheal or Pretracheal
Tube Placement, n (%)

Total,
n (%)

32 (16.2)

3 (1.51)

35 (17.7)

emphysema occurred in 11 patients with neoplasia (5.55%) and 15

patients with trauma (7.57%). Postoperative complications occurred in 7.06% of the patients with neoplasia and in 6.58% of
patients with trauma. Complete healing of all dehiscences was obtained within 6 weeks. Subcutaneous emphysema was treated with
compression and resolved clinically within 1 week in all cases. There
were no emergency before, during, or after the surgery procedure.
FIGURE 3. A, Tracheal exposure with cartilage rings II and
III marked. B, The tracheal stoma.
around the wound according to the dimensions of the tube, and the
tube is secured to the skin directly or to the neck with circumferential
ties (Fig. 4). All patients underwent tracheostomy closure 7 days
after the surgery.

RESULTS
Completely acceptable clinical healing and outcomes were
obtained from all patients. Intraoperative complications occurred
in 35 patients (17.7%; Table 2). Bleeding during tracheotomy occurred in 32 patients (16.2%). Bleeding identied shortly after the
skin incision was due to the laceration of an anterior jugular vein.
Bleeding deeper within the wound arose from the highly vascular
thyroid gland. Bipolar cautery or suturing was sufcient to control
bleeding.
There were 3 cases (1.51%) of paratracheal or pretracheal
placement of the tracheal tube after what seemed to be accurate
passage of the tube into the trachea. The problem was rapidly
identied by the lack of end-tidal CO2 registration on the capnograph monitor. The false placement of tube was caused by incorrect
tissue retraction.
As summarized in Table 3, postoperative complications occurring after tracheostomy closure included tracheostomy dehiscence in 5 patients (2.52%) and subcutaneous emphysema in 26
patients (13.12%) for a total of 31 patients (15.64%). Clinical evaluation revealed no symptomatic tracheal stenosis.
Tracheostomy dehiscence occurred in 3 patients with neoplasia (1.51%) and 2 patients with trauma (1.01%). Subcutaneous

DISCUSSION
The tracheostomy procedure described here is a simplied
variant of the reported procedures presented as a stepwise procedure from skin incision to tube insertion. On the basis of our results,
tracheostomy has a high success rate and predictable outcome when
performed using these standardized procedures.
A horizontal skin incision is used because of the cervical skin
tension lines and because it gives the most aesthetic closure. The midline position of the tracheal wall incision simplies the surgery and
facilitates the subsequent management of the tracheostomy tube, preventing displacement with head movement, torsion, and overextension.
The management of the soft tissue above the tracheal plane
is minimally invasive, preserving the structures while giving the
best exposure of the tracheal wall. Similarly, retraction of the thyroid isthmus is preferable over a transisthmic access when possible.
However, tracheal wall access remains controversial.12 The
incisions described in the literature include (a) a horizontal incision
between the cartilage rings, (b) a vertical incision, (c) a U-shaped
incision or Bjork ap with a horizontal intercartilagenous incision
and 2 vertical incisions to create an inferiorly or superiorly based
ap in Guptas variant,13 and (d ) a cross-shaped incision to create a
window in the anterior tracheal wall of adequate dimensions to enable passage of the tracheostomy tube. Each has complications. A
horizontal incision between the cartilage rings, if extended too far
laterally, can damage the recurrent laryngeal nerve and the cartilage
rings in older patients because of their lack of compliance. With
difcult passage of the tube requiring force, the vertical incision
can be extended irregularly, resulting in bleeding. The U-shaped
incision has a risk of obstruction in the case of ap dislocation and
difcult reintubation with accidental displacement of the tube,
making it necessary to anchor the ap to the skin to keep the airway
open. Tracheal stenosis is often cited as a severe complication of
tracheotomy, but it may often be caused by prolonged translaryngeal
intubation before tracheotomy.
The reported incidence of symptomatic tracheal stenosis
after tracheostomy ranges from 0% to 21%. Stenosis can be cicatricial or membranous, or it may involve the anterior wall collapse
TABLE 3. Postoperative Complications
Subcutaneous
Symptomatic
Stenosis,
Dehiscence, Emphysema,
n (%)
n (%)
n (%)

FIGURE 4. The tracheal tube.

Tumors
Trauma
Total

0
0
0

3 (1.51)
2 (1.01)
5 (2.52)

11 (5.55)
15 (7.57)
26 (13.12)

* 2011 Mutaz B. Habal, MD

Copyright 2011 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

Total,
n (%)
14 (7.06)
17 (6.58)
31 (15.64)

245

The Journal of Craniofacial Surgery

Salgarelli et al

or complete stenosis.1,14Y19 In a series of 1130 tracheotomies,

Goldenberg et al1 reported 21 cases of tracheal stenosis, all of which
occurred in patients who had been intubated for at least 12 days
before the tracheotomy.
The type of incision into the trachea has less to do with
subsequent tracheal stenosis than does the duration of intubation
preceding the tracheotomy. A dog study by Bryant et al20 comparing
vertical, horizontal, and window excision tracheal entries failed to
show a signicant difference in the reduction of the tracheal lumen
diameter.
Lin et al12 compared the surgical procedure and postoperative complications between a horizontal tracheal incision and window tracheal-type excision for elective tracheostomy in patients
with oral cancer and found that the complication rates did not differ signicantly between groups. In head and neck surgery patients
undergoing elective tracheostomy (with a horizontal incision or
window), there was narrowing of the trachea in 92% of cases, but
this narrowing was not signicant in terms of causing symptoms; in
addition, a gradual narrowing was observed in patients in whom
decannulation was performed after 14 days.19
The technique presented here creates a window as a safe,
effective compromise between the risk of tracheal stenosis and the
risks related to the management of accidental displacement of the
tube. These are the 2 most important factors affecting the surgeons
choice. With minimal tracheal sacrice, the window can be made to
t the tracheal tube perfectly, with complete control of the introduction of the tube, avoiding the risk of extending the incision in the
tracheal wall or bleeding. This access enables easy reintubation, and
there are no healing defects related to excessive tension, the tube
cuff, or stomal infection.
With the expanded indications for tracheostomy, percutaneous minimally invasive tracheostomy is not always possible; therefore, head and neck surgeons should know how to perform a
conventional tracheostomy. The standardized surgical technique
presented here reduces the associated surgical risk when the correct
anatomic markers are used, and the important structures are recognized and handled correctly. We believe that residents can readily
master this technique to broaden their surgical armamentarium.

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* 2011 Mutaz B. Habal, MD

Copyright 2011 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.