Laryngotomy

Throattomy (traceotomy) is a common method of incision of the cervical trachea, placement of a metal tracheal cannula, and laryngectomy to relieve dyspnea caused by laryngeal dyspnea, ventilatory disorders, or secretion of lower respiratory tract. surgery. Treatment of diseases: laryngeal obstruction Indication (1) Laryngeal obstruction: Severe laryngeal obstruction caused by laryngeal inflammation, tumor, trauma, foreign body, etc., dyspnea is more obvious, and when the cause can not be quickly relieved, laryngectomy should be performed in time. The lesions in the adjacent tissues of the larynx make the pharyngeal cavity and throat cavity narrow and cause dyspnea. According to the specific circumstances, laryngectomy can also be considered. (2) Lower respiratory secretions: Respiratory secretion of lower respiratory tract caused by various reasons, in order to suck, keep the airway unobstructed, can consider laryngeal incision, such as severe craniocerebral injury, severe chest trauma, respiratory tumor, coma, neuropathy and so on. In the above-mentioned diseases, the cough reflex disappears or the cough is reluctant to cough, and the secretions are retained in the lower respiratory tract, which hinders the exchange of alveolar gas, lowers the blood oxygen content, increases the carbon dioxide concentration, and absorbs the secretion after the throat is opened. Gas exchange of alveoli. At the same time, the inhaled air does not pass through the pharynx and throat, which reduces the dead space of the respiratory tract, improves the gas exchange in the lungs, and is also conducive to the recovery of lung function. In addition, the use of manual assist is also provided after the throat is cut. (3) Preventive laryngeal incision: For some major operations in the mouth, nasopharynx, maxillofacial region, pharynx, and larynx, in order to perform general anesthesia, prevent blood from flowing into the lower respiratory tract, and maintain postoperative airway patency, laryngectomy can be performed (currently due to the extensive application of endotracheal intubation) Preventive laryngectomy has been reduced compared to previous ones). Some tetanus patients are prone to throat problems and preventive laryngeal incision to prevent suffocation. (4) taking the gas pipe foreign body: Tracheal foreign body was unsuccessful after endoscopic clamping. It is estimated that there is a risk of suffocation, or if there is no bronchoscopy equipment and technology, the foreign body can be removed through the laryngeal incision. (5) Patients with neck injuries Neck trauma with throat or trachea, cervical esophageal injury, for those who have difficulty breathing immediately after injury, should promptly perform laryngeal incision; no obvious breathing difficulties, should be closely observed, carefully examined, do a laryngeal surgery Everything is ready. Cut the throat as soon as it is needed. Contraindications 1. I and II have difficulty breathing. 2, temporary obstruction of the respiratory tract, can temporarily suspend the throat. 3, be cautious when there is a significant bleeding tendency. Preoperative preparation Antibiotics are routinely used before surgery. Surgical procedure Endotracheal intubation, or bronchoscopy, as well as a variety of rescue drugs. For children, especially infants and young children, intubation or placement of bronchoscope before surgery, after the relief of breathing difficulties, and then tracheotomy, more safe. 1. Position: generally take the supine position, a small pillow under the shoulder, the head tilts back, so that the trachea is close to the skin, the exposure is obvious, in order to facilitate the operation, the assistant sits on the head side to fix the head and maintain the median position. Routine disinfection, sterile towels. 2. Anesthesia: local anesthesia is used. Along the anterior middle of the neck from the lower edge of the thyroid cartilage to the upper sternal fossa, anesthesia was infiltrated with 1% nuevocaine. For patients with coma, critically ill or asphyxia, the patient may not be anesthetized if they are unaware. 3. Incision: more straight incision, from the lower edge of thyroid cartilage to the upper sternal fossa, cut the skin and subcutaneous tissue along the median line of the neck. 4. Separate the anterior tracheal tissue: use the vascular clamp to separate the sternohyoid muscle and sternal thyroid muscle along the midline, and expose the thyroid isthmus. If the isthmus is too wide, it can be slightly separated at the lower edge, and the isthmus is pulled upward with a small hook, if necessary. The isthmus can also be cut and sewn to expose the trachea. During the separation process, the force of the two hooks should be uniform, so that the surgical field is always in the middle line, and the ring cartilage and the trachea are often probed by fingers to maintain the position in the middle. 5. Incision of the trachea: After the trachea is determined, generally at the 2nd to 4th tracheal ring, use a sharp blade to pick up 2 tracheal rings from the bottom up (cutting 4 to 5 rings for low tracheotomy), the tip Do not insert too deep, so as not to stab the posterior wall of the trachea and the anterior wall of the esophagus, causing tracheoesophageal fistula. A part of the cartilage ring can be cut off on the anterior wall of the trachea to prevent the incision from being too small. When the tube is placed, the wall of the trachea is pressed into the inflating tube, resulting in a narrowing of the trachea. 6. Insert the tracheal tube: use a curved forceps or tracheotomy dilator to open the tracheal incision, insert a tracheal tube of appropriate size and with a tube core. After inserting the outer tube, immediately remove the tube core, put it into the inner tube, and suck Net secretions and check for bleeding. 7. Wound treatment: The strap on the tracheal cannula is tied to the neck and tied into a knot to securely fix. The incision is generally not sutured to avoid subcutaneous emphysema. Finally, an open gauze pad is used between the wound and the cannula. complication (1) Subcutaneous emphysema: It is the most common complication after operation, and it is too much separation from the soft tissue before the trachea, and the short internal length of the tracheal incision or the suture of the skin incision is too tight. Gas escaping from the tracheal cannula can enter the subcutaneous tissue space along the incision and spread along the subcutaneous tissue. The emphysema can reach the head surface and the chest and abdomen, but it is generally limited to the neck. Most can be absorbed by themselves after a few days without special treatment. (B) pneumothorax and mediastinal emphysema: when the trachea is exposed, the separation is too much downward, too deep, after the damage to the pleura, can cause pneumothorax. The position of the pleural apex on the right side is higher, especially in children, so the chance of injury is more than that on the left side. Lighter people have no obvious symptoms, and severe cases can cause suffocation. If the patient's throat is found to be open, the difficulty in breathing is relieved or disappeared, and if breathing difficulties occur again soon, the pneumothorax should be considered and X-ray film can be diagnosed. At this time, pleural cavity puncture should be performed to remove the gas. In severe cases, closed drainage is feasible. Excessive separation of the anterior fascia of the trachea during surgery, the gas enters the mediastinum along the anterior fascia of the trachea, forming a mediastinal emphysema. For more mediastinal gas, it can be separated down the sternum along the anterior wall of the trachea to allow air to escape upwards. (3) Bleeding: a small amount of bleeding during intraoperative wounds can be stopped by compression or by filling with gelatin sponge. If there is more bleeding, there may be vascular injury. The wound should be examined and the bleeding point should be ligated. (D) difficulty in extubation: during surgery, if the opening part is too high, damage the cartilage, can cause subglottic stenosis after surgery. The tracheal incision is too small, and the wall of the trachea is pressed into the trachea when the tracheal cannula is placed; postoperative infection, granulation tissue hyperplasia can cause tracheal stenosis, resulting in difficulty in extubation. In addition, the inserted tracheal tube type is too large to be successfully pulled out. Some patients with long tube lengths are afraid of breathing difficulties after extubation. When they are blocked, they may consciously have poor breathing. They should gradually replace the small cannula. Finally, when the tube is not breathing, the tube is removed. For patients with difficulty in extubation, the cause should be carefully analyzed, X-ray film or CT examination, direct laryngoscope, bronchoscopy or fiber bronchoscopy, according to different reasons, as appropriate. (5) Tracheal esophageal fistula: rare. In the case of laryngeal dyspnea, due to the negative pressure in the trachea, the posterior wall of the trachea and the anterior wall of the esophagus protrude into the tracheal lumen, and the posterior wall of the trachea can be damaged when the trachea is cut. Smaller, less prolonged pupils can sometimes heal themselves. The fistula is larger or longer. The epithelium has grown into the mouth and can only be repaired. (vi) Wound infection: Throat incision is a relatively contaminated clean incision. Soon the strain will grow in the wound, usually Pseudomonas and E. coli. Because the wound is open and beneficial for drainage, there is generally no need for prophylactic antibiotics. Real infections are rare and require only partial treatment. Antibiotic treatment is only needed when there is a cellulitis around the wound. (7) Displacement of the cannula: Early intubation displacement or premature replacement of the intubation poses a risk of ventilatory obstruction. The multi-layered subcutaneous fascia, the muscle bundle, and the anterior tracheal fascia overlap each other, and it is easy to make the newly formed passage disappear. If the cannula's channel cannot be re-discovered immediately, the cannula should be intubated immediately. Slitting the breastplate on either side of the endotracheal tube to the skin prevents the cannula from shifting. The suture placed on the tracheal cartilage ring at both ends of the laryngeal incision can be retained early in the postoperative period, and once the cannula is displaced, it can help to quickly retrieve the intubation channel. The fascia of each layer can be more and more together 5-7 days after surgery, and it is safe to replace the tracheal intubation at this time. (8) Pharyngeal Disorder: The main swallowing problem associated with laryngeal incision is aspiration. Both mechanical and neurophysiological factors can cause abnormal swallowing. Mechanical factors include (1) weakened laryngeal lifting capacity; (2) tracheal intubation cuff compression and obstruction of the esophagus, allowing the contents of the esophagus to overflow into the airway. Neurophysiological factors include (1) a decrease in sensitivity of the larynx leading to the disappearance of protective reflexes; and (2) a chronic upper airway shunt causing a laryngeal closure disorder. The main thing to reduce aspiration is to strengthen postoperative care.