A 58-year-old male who completed radiation therapy for a large supraglottic tumor 4 months ago now presents to the Emergency Department in significant respiratory distress with biphasic stridor. He is somewhat agitated and prefers to remain in a semi-sitting position. He is cachectic, a heavy smoker but nondrinker. He is not taking any medications and has no allergies. His oxygen saturation is 88% on room air and improves to 94% with supplemental oxygen. He is cooperative enough to allow the otolaryngologist to perform a flexible nasopharyngoscopy at the bedside, which reveals extensive supraglottic edema, completely obscuring identification of normal laryngeal landmarks, and any visualization of the upper airway (see Figure 15–1). The otolaryngologist suspects there is recurrent tumor below this edema.
Endoscopic view of the upper airway showing extensive supraglottic edema, completely obscuring identification of normal laryngeal landmarks, and any visualization of the upper airway.
What Is the Historical Evolution of the Development and Acceptance of Surgical Tracheotomy?
Tracheotomy is one of the oldest surgical procedures in recorded history and often viewed historically as intimidating and inherently dangerous to perform. The Italian anatomist and surgeon Fabricius ab Aquapendente (1537–1619) stated, “The terrified surgeons of our times have not dared to exercise this surgery and I also have never performed it. Even the mention of this operation terrifies the surgeons; hence it is called the “scandal of surgery.”1 Tracheotomy was performed during the diphtheria epidemic in the early 19th century for cases of severe upper airway obstruction. In 1833, Armand Trousseau, a French internist, recounted his experiences with the procedure: “I have now performed the operation in more than 200 cases and I have the satisfaction of knowing that one fourth of these operations were successful.”2 Faint praise indeed!
Throughout the 19th and into the early 20th centuries, tracheotomy was employed only in extreme circumstances, in order to avoid total upper airway obstruction from infectious processes involving the larynx and upper trachea. The “modern” technique of tracheotomy was formally presented and described in detail by Chevalier Jackson3 in 1909. Among other pearls, Dr. Jackson emphasized precise surgical technique with adequate exposure, careful hemostasis, and the prevention of damage to the cricoid cartilage. He is generally credited with vastly decreasing the morbidity and mortality of the procedure as well as the long-term complication of subglottic stenosis.
With the introduction of endotracheal intubation, positive pressure ventilation and ongoing advancements in intensive care leading to requirements for long-term ventilation, we have seen a significant shift in the indications for tracheotomy. Some two-thirds of all tracheotomies performed today are now done semi-electively for critically ill patients in an intensive care setting.
While a common procedure, tracheotomy can be one of the most straightforward ...