Anatomical particularities and difficulties in tracheostomy: three case reports.

Three tracheostomies conducted using Fantoni's translaryngeal technique (TLT) are described in patients with particular anatomical conditions of the trachea and neck. The first case is of a patient with tracheal stenosis, which is known to be problematic with regard to gaining adequate endoscopic control, assuring effective ventilation during maneuvers and ensuring the safety of the walls of the trachea. The second case is with regard to a patient with a voluminous thyroid goiter that displaced the trachea to the right, making it difficult to appreciate the tracheal lumen during needle introduction. The third case is of a patient with spastic tetraparesis due to asphyxia neonatorum and kyphoscoliorachitis, which made ventilation and access to the trachea difficult. The peculiarity of the technique and the constitutive elements of the TLT kit were invaluable for the resolution of the problems that occurred during the procedure. In particular, the tracheoscope with a rigid optical lens inside allowed for better protection of the trachea by offering optimal endoscopic vision. The three tracheostomies were performed without intraprocedural or long term complications.

[Evaluation of preoperative activity in a research and teaching hospital]. / Valutazione dell'attività di prericovero in un ospedale di ricerca e di insegnamento.

To shorten the length of stay before the surgical intervention and to increase the performance of the elective surgery, the Ospedale Maggiore di Milano decided to open a preadmission service working as a day hospital setting. This service has to evaluate patients eligible for surgery both from the surgical than for the anesthesiological point of view. The study wants to state the efficacy, the performance, the quality of this service with particular attention on the elaboration of diagnostic protocols. In this study were investigated more than 8.000 accesses registered in two years (2003-2004) from 9 units of surgery. The evaluation wants to improve the level of quality of this structure in order to better identify the anesthesiological patient risk, the diagnostic protocols and the coordination with all the ancillary services in the hospital.

An unusual aspect of tracheal stenosis. Case report.

lnjury of the tracheal mucosa at the decubitus site of the endotracheal tube cuff during prolonged endotracheal intubation and resulting fibrin deposits may predispose for the development of tracheal stenosis. Frequent endoscopic control examinations, following the increased use of dilation tracheostomy techniques, have revealed a considerable number of these once misrecognized complications in laryngeal and tracheal structures alike. The case reported here appears to confirm this sequence of events. Timely operative endoscopy using a pair of pincers mounted on a rigid endoscope permitted the removal of the fibrin membrane causing the tracheal lumen stenosis and allowed us to achieve complete and definitive recalibration of the trachea, with restoration of spontaneous breathing. Cortisone therapy prolonged for 5 days probably prevented recurrence of the stenosis. Follow-up was carried out in 3 phases. The 1(st) phase included early control using tracheal endoscopy; 2(nd) comprised neck CT scan to examine the tracheal lumen 15 days after endoscopic control, and the 3rd phase involved medical examination after about 3 months and neck radiography in 2 projections.

[Translaryngeal tracheostomy. A new era?]. / Tracheostomia translaringea. Nuova era?

OBJECTIVE: Presentation of a new technique of dilation tracheostomy projected to offer a minimum risk of complication and tissue trauma. DESIGN: Prospective study carried out between July 1993 and December 1995, to evaluate the feasibility of the procedure, its possible advantages over other methods, and possible complications. SETTING: General ICU with a Paediatrics Section. PATIENTS: Uninterrupted series of 84 adults and 12 children with multifactorial respiratory insufficiency. INTERVENTION: Through a needle inserted in the trachea, a guide wire is retrogradely pushed out of the mouth and attached to a special device formed by a flexible plastic cone with pointed metal tip joined to an armoured tracheal cannula. This device is then pulled back through the oral cavity, larynx, trachea-hence the definition: TransLaryngeal Tracheostomy (TLT)- and outwards across the neck wall by applying traction on the wire with one hand and counterpressure on the neck wall with the fingers of the operator's other hand. When the cone and part of the cannula have emerged, the cone is separated from the cannula. The cannula is further extracted until its inside portion can be turned downwards to its final placement. RESULTS: A precise localisation of the stoma placement and the needle introduction are facilitated by the rigid tracheoscope and protrusion. Thanks to the very pointed cone, the piercing resistances are lowered. At the same time, every degree of traction power is allowed through the counterpressure practised by the fingers. The channel is very regular with a strong adherence to the cannula that secures a virtual lack of bleeding and local inflammation. We observed this in the fifty cases, in which the final version of our technique was applied. Trachea CT scan and endoscopic control did not show late lesions of the airway. CONCLUSIONS: TLT is characterised by highest inherent safety and lowest tissue traumatism, that it can also be performed in patients who would risk complications from any other tracheostomy techniques.