Cricothyrotomy (also cricothyroidectomy or coniotomy) is the insertion of a tracheal tube through an incision in the cricothyroid membrane (CTM) in order to establish a rapid, definitive airway. Although discouraged in the early part of the 20th century because of complications, chiefly subglottic stenosis, cricothyrotomy was reestablished as a safe technique for airway management after publication of the work by Brantigan and Grow. They documented an acceptable complication rate of 6.1%, among a series of 655 procedures.¹ This compares well to the published rate of tracheostomy complication of 6.6% for bleeding and 5.7% for surgical site infection; these were comparable for both a percutaneous and surgical technique.²

Cricothyrotomy is most commonly used when both intubation and ventilation fail; in situations such as foreign-body obstruction; superior laryngeal trauma; inhalation, thermal, or caustic injury to the upper airway; angioneurotic edema; upper airway bleeding; epiglottitis and croup. Its use has also been advocated for patients with anatomy that would otherwise complicate tracheostomy, such as increased cervical girth, an abundance of pendulous, submental fat, or an entirely intrathoracic trachea in a patient with restricted cervical range of motion; a small case series of such patients did not reveal any complications.³

The classic technique involves a vertical midline incision over the thyroid and cricoid cartilages to expose the CTM, followed by a transverse incision through the CTM. The medial portion of the CTM is commonly referred to as the cricothyroid ligament, whereas the underlying and wider membrane is known as the conus elasticus.⁴ The vertical incision allows the operator to extend the incision in order to obtain appropriate exposure while minimizing the risk of vascular injury. Neck veins may course within 1 cm of midline in 30% of patients (Fig. 36-1), whereas midline arteries occur in less than 5% of patients.⁵ Cricothyrotomy may also be carried out with a single transverse incision through skin and CTM, if the interval is readily palpable.¹,⁶ The incision is placed across the lower third of the CTM to avoid the cricothyroid artery, which transverses the internal aspect of the upper third of the membrane and may cause unrecognized bleeding and aspiration.⁷

Cricothyrotomy is not recommended in children under 8 years of age due to multiple anatomic differences when compared with the adult airway, including a hyoid bone that is more prominent than the thyroid cartilage, cephalad CTM displacement, and a smaller CTM. Specifically, the dimensions of the neonate’s CTM is only 2.6 × 3.0 mm, making the passage of even a neonatal endotracheal tube (ETT) difficult, without causing cartilaginous injury, edema, or hemorrhage in the airway.⁸

Cricothyrotomy is effective for establishing an emergency airway1 but does carry a risk of acute and chronic complications. Bleeding, failure to secure the airway, and pneumothorax may complicate this procedure, which is typically carried out rapidly and often under duress. Because of its invasive and emergent nature, cricothyrotomy is not subject to randomization in trials of airway management, and most evidence is in the form of case series. Recent data suggest that, even in the emergency department, where major trauma and other emergent indications for surgical airways are likely to be higher than in other settings, the incidence of surgical airways approximates only 1% of all intubations.⁹,¹⁰,¹¹ This is likely due to the success of rapid sequence intubation with direct laryngoscopy as the preferred means of managing the airway,⁹ the improved training of emergency medicine residents in airway management, and the lower frequency of resuscitation of blunt trauma victims with no detectable vital signs.¹² In the face of falling rates of cricothyrotomy, it has become difficult to maintain proficiency in, and to teach, this essential skill.¹³

Success rates are quite high in skilled hands, usually above 90%, though these may be considerably lower when carried out by inexperienced personnel.¹⁴,¹⁵,¹⁶ Reported acute complication rates for emergent cricothyrotomy are between 6% and 40%.¹,¹⁴,¹⁵,¹⁶ In Brantigan and Grow’s¹ landmark study, chronic subglottic stenosis did not occur
after any of their 655 procedures, but in a meta-analysis of reports from 1978 to 2008, there was a reported rate of chronic subglottic stenosis of 2.2% after cricothyrotomy.¹⁷