The clinical application of an innovative tracheotomy fixation belt in critically ill patients

BACKGROUND: Tracheotomy is one of the first-aid measures for rescuing critically ill patients. OBJECTIVE: This study was designed to observe the clinical effect of using an innovative tracheotomy fixation belt in critically ill patients and to explore the feasibility of using this fixation method. METHODS: Eighty critically ill patients requiring a tracheotomy in Putuo District Central Hospital of Shanghai were enrolled in this study and divided into the observation group and control group (n= 40, each). In the control group, fixation was performed with conventional cotton twill tape, while in the observation group the fixation was carried out using a tracheotomy fixation belt. The differences in neck skin injury, the occurrence of eczema, and the rate of detachment of the tracheotomy tube in the two groups were compared. RESULTS: The rate of neck skin injury was 7.5% lower in the observation group than in the control group (30%), and the difference was statistically significant (p< 0.05). The incidence of skin eczema was 5% lower in the observation group than in the control group (22.5%), and the difference was statistically significant (p< 0.05). The detachment rate of the tracheotomy tube was 5% lower in the observation group than in the control group (20%), and the difference was statistically significant (p< 0.05). CONCLUSION: The use of an innovative tracheotomy fixation belt can effectively reduce skin damage to the patient’s neck, the incidence of eczema, and the incidence of detachment of the tracheotomy tube.

COMPLICATED FOREIGN BODY OF THE CERVICAL ESOPHAGUS

Patient P., 42 years old, was admitted to the ENT department of the regional hospital on the 4th day of the disease with severe pain and dysphagia, hyperthermia, and inspiratory dyspnea. Given the data of laryngoscopy and laryngoscopy, examination and palpation of the neck, lateral radiography according to Zemtsov and contrast radiography of the esophagus, the diagnosis was made: a complicated foreign body of the esophagus. The patient was consulted by a thoracic surgeon. It was decided to remove the foreign body by esophagoscopy under intubation anesthesia, and if ineffective, perform cervical esophagotomy on the left with bone removal and tracheotomy in connection with reactive laryngeal edema. During an esophagoscopy with a Mezrin esophagoscope, tube No. 2 in the area of the 1st narrowing of the esophagus revealed a bone (cervical vertebra of the chicken) of impressive size with numerous spikes and protrusions, which is wedged into the side wall of the larynopharynx and esophagus. After repeated attempts, moving the foreign body in various planes, it was not possible to remove the foreign body due to wedging and the threat of rupture of the esophagus wall. A left-sided cervical esophagotomy was performed with a cut along the front edge of the sternocleidomastoid muscle. During the operation, the esophagus between the trachea and the cervicothoracic spine is exposed. The wall of the esophagus is palpated, attempts were made to manually displace the bone in the throat. In this case, the foreign body is fixed with forceps and at the same time conducting traction with additional pushing from the side of the wound, the foreign body is removed together with the tube of the esophagoscope. The need for esophagotomy has disappeared. Subsequently, a tracheotomy was performed. A nasogastric tube for probe feeding was delivered. The postoperative period without complications. Tracheotomy tube removed on day 4, nasogastric tube after 7 days. As a result of the treatment, the patient was discharged home on day 10 with recovery. The clinical case indicates that the diagnosis and treatment of foreign bodies of the esophagus is a complex problem of otolaryngology and complex manipulations and surgical interventions are used to remove the latter.

Tracheastomal myiasis in ventilator dependant patient: case report and review of literature

A 51 year old severe morbidly obese female 1 week s/p tracheotomy with fenestration and PEG complicated by IDDM, ARF, CHF, COPD, OSA, and HVS was readmitted to hospital for tracheostomy wound myiasis and cellulitis. The patient had been admitted to a local long term assisted care facilty where the infection was noted. The patient was taken back to the OR where the tracheotomy tube was removed and oral ETT was placed. Wound debridement along with larvae removal was performed. Airway endoscopy was done to rule out presence of intra-luminary larvae. It was noted that the Bjork flap had become devitalized with the infection, leaving a 2 ring defect. The wound was packed with Dakin's Solution and daily wound care was done until no further larvae or necrotic tissue was seen. The patient was then taken back to OR where an anterior tracheal wall reconstruction was performed and replacement of trachostomy tube with removal of oral ETT. She was then transferred back to the ICU and long-term assisted care living.

Complication of tracheotomy: A case of fatal pneumomediastinum in spontaneous ventilation

Pneumomediastinum is defined as the presence of free air in the mediastinal space. It is classically defined as either spontaneous or secondary pneumomediastinum, depending on whether a cause can be recognised (e.g. trauma, intrathoracic infections or medical procedures such as dental or facial surgery and tracheotomy). It can be associated with pneumothorax and subcutaneous emphysema of the cervico-facial area because of the ascent of the air from the mediastinum towards the neck. To our knowledge, only one case of death from pneumomediastinum due to tracheotomy has previously been recorded. We report a case of death due to pneumomediastinum, which occurred in a patient with a tracheotomy during spontaneous ventilation. The 65-year-old man underwent surgical mandibular reconstruction with a custom-made titanium plate for osteonecrosis with temporary tracheotomy. The patient received mechanical ventilation only during surgery. On day 3, when the tracheotomy was closed, the patient experienced a rapid deterioration of lung ventilation with initial development of subcutaneous cervical emphysema. Although a tracheotomy tube was promptly inserted, the patient developed massive subcutaneous cervico-facial emphysema with a drop in oxygen capillary saturation. The man died after half an hour of resuscitation due to a massive pneumomediastinum. In this paper, we discuss the epidemiology, aetiology, physiopathology, complications and necropsy findings in pneumomediastinum, focusing on the aspects of our case compared to the only other case reported.

Glottic Stenosis: An Anatomic Analysis and New Treatment With a Self-Retaining Interarytenoid Spring

Introduction: Endotracheal (ET) intubation is a common cause of acquired glottic stenosis. Severe cases often require an irreversible arytenoidectomy/cordectomy, which typically results in poor voice quality. Adult human cadaver larynges were studied to gain insights about ET tube–induced posterior glottic injuries, hoping to create a less invasive remedy. Study Design: Human cadaver investigation and case reports. Methods: Microlaryngeal assessments were done on 10 human cadaver larynges (5 men, 5 women) with and without ET tubes. After supracricoid soft tissue resection, measurements were obtained, including the distance between the outer diameter of the ET tube and the medial aspect of the cricoarytenoid joint facet. Additionally, measurements of the circumferential arc of differently sized ET tubes were made alongside both cricoarytenoid joint capsules. This information was used to design a silastic stent that would function as a self-retaining interarytenoid spring to treat posterior glottic stenosis in 5 patients. Four of 5 patients included in the clinical study were tracheotomy dependent, primarily because of glottic stenosis. The human surgical technique is described in detail. Results: The shortest distance between the outer diameter of the ET tube to the medial cricoid facet averaged 5.02 mm in men and 3.62 mm in women. On the basis of the diameter of the intralaryngeal component of the initially round stent, and the position of the cricoarytenoid joint facets, the interarytenoid spring would have a subtended arc between 110° and 175°. These data helped fashion parameters for modifying a conventional T-tube to form a new self-retaining silastic interarytenoid spring. The first 5 human cases have been successful, allowing effective tracheotomy tube decannulation and excellent voice quality. Conclusions: The anatomic investigation herein provided key insights into ET tube–induced glottic stenosis and facilitated a new straightforward procedure to surgically improve the airway yet preserve excellent vocal function in patients with acquired glottic stenosis. Level of Evidence: NA