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Light of Life Endoscopy Aided Surgical Tracheostomy
Rajendra Patel*, Sumitra Mahapatro**, Kishore Sandu***, Manjiri Gupte****
 
Abstract
In a case of advanced carcinoma of larynx, a surgical tracheostomy was planned. Due to local spread of tumour, identification of trachea was difficult. Identification of the trachea was aided by an illuminated 0 degree STORZ sino-nasal endoscope (4 mm- adult) which was passed through a portex (PVC transparent) endo-tracheal tube.
 

Introduction
We discuss an unusual method to locate the trachea for a surgical tracheostomy in a case of an advanced carcinoma larynx with stridor.

Case Report
A seventy year old male, chronic tobacco smoker, presented to us in stridor with a three month history of worsening breathlessness and swelling in the neck. On indirect laryngoscopy, an anterior commisure growth with a fixed left vocal cord and restricted right vocal cord movement was noted. Examination of the neck revealed bilateral hard lymph nodes at level II, III, IV and induration of the skin over the neck from thyroid cartilage to the manubrium sternum (Fig. 1). Clinically, the growth had eroded the thyroid and cricoid cartilage with extensive soft tissue invasion. There was extreme difficulty in locating the trachea and bilateral carotid pulsations. Clinically, the lesion was staged as T4N3bM0. An emergency tracheostomy was planned and radiological evaluation was not done to avoid further delay.

In view of anticipated difficulty in performing the tracheostomy it was essential to secure the airway prior to the procedure. The patient was given general anaesthesia and the airway was secured by an 8.5 no cuffed portex (PVC- transparent) endotracheal tube. The patient was given hyperextension. A 3 cm long horizontal incision was taken two finger breadth above the sternal notch, which then was extended to 8 cms for wider exposure. The dissection for the tracheostomy had to be carried out through the tumour which had infiltrated the strap muscles. The normal anatomy was distorted due to the tumour and location of the trachea was difficult. A 0 degree STORZ sino-nasal (4 mm-adult) endoscope was passed through the endotracheal tube. The operation room was darkened which helped for better illumination and visualization of the tracheal glow. This helped in identifying the tracheal position (Fig. 2). Free aspiration of air through a 22 gauge needle attached to a syringe filled with lignocaine helped in confirmation of the trachea. The trachea was located at depth of around 5 ml mark of a disposable syringe (i.e. around 4 cm) from skin (Fig. 3). The syringe served as a handy sterile measuring tool. A cruciate incision was taken between the first and second tracheal ring, after withdrawing the endo-tracheal tube. The tracheostomy was successfully carried out and 9 number portex tracheostomy tube was passed. The patient had uneventful recovery and was advised palliative care.


Fig. 1 : Picture of the neck showing extensive
induration of the skin.


Fig. 2 : Tracheal glow seen after passage of illuminated
sino-nasal endoscope through endo-tracheal tube.
   


Fig. 3 : Depth at which trachea was located is appreciated
in the picture.

Discussion
Confirmation of the tracheal position during tracheostomy is of utmost importance. In cases of percutaneous surgical tracheostomy, bronchoscopic guidance reduces incidence of para- tracheal tube insertion and also reduces risk for development of pneumothorax, subcutaneous emphysema or posterior tracheal wall injury.1

In a surgical tracheostomy, the open field helps easy identification of the trachea. However, in cases of distorted anatomy due to malignant induration and infiltration, trachea may be difficult to locate. In such cases, the technique we have described is of help in localizing the trachea. Free aspiration of air followed by confirmation with carbon dioxide waveform by capnometer has been routinely followed.2 The glow produced by the sino-nasal endoscope passed through the endo-

tracheal tube helped in identification of the trachea prior to puncturing of any vital structure. This is of immense value especially in cases of carcinomas. Fortunately, we had used a portex endo-tracheal tube which conducted the glow well, hence advantageous over non-transparent re-usable endotracheal tubes. As the endoscope was passed through the suction port of the catheter mount, ventilation of anaesthetic gases could be continued throughout the procedure uninterrupted.

A similar use of the sino-nasal endoscope in a case of surgical tracheostomy has not yet been repored.

References

  1. Barba CA, Angood PB, Kauder DR, Latenser B, Martin K, Mc Gonigal MD. Bronchoscopic guidance makes percutaneous tracheostomy a safe, cost effective, and easy-to- teach procedure. Surgery 1995; 118 (5) : 879-83.
  2. Addas JM, Howes WJ, Hung OR. Light guided tracheal puncture for percutaneous tracheostomy. Addas JM Can J Anaesth 2000; 47 (9) : 919-22.

 

 

*Associate Professor; **Lecturer Dept. of Anaesthesiology; ***Lecturer; ****Resident, Dept. of ENT, Seth G.S. Medical College and King Edward the VII Memorial University Hospital, Acharya Donde Marg, Parel, Mumbai- 400 012.

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