CHAPTER 29 • OTORHINOLARYNGOLOGY 169

are the same as that for laryngeal spasm; however,

there is associated subcutaneous crepitus, loss of thy-

roid cartilage contour, and cyanosis from damage to

the airway. It is of the upmost importance to establish

an airway, protect it, then transport the athlete to the

nearest health care facility. If there is an associated

facial injury, it may be impossible to place an orotra-

cheal tube or a nasotracheal tube. In these cases the

surgical airway of choice is the cricothyroidotomy.

CRICOTHYROIDOTOMY

• Percutaneous transtracheal ventilation or needle
  cricothyroidotomy is placement of a catheter through
  the cricothyroid membrane to establish an airway.
  This surgical airway may be used as a temporizing
  airway when oral and nasal intubation is not possible.
  This is done by first identifying the anatomy. The
  cricothyroid membrane is located between the thyroid
  cartilage and the cricoid cartilage. The first landmark
  to find is the thyroid cartilage (Adam’s apple), then
  move inferiorly to the groove below the thyroid carti-
  lage. The cricothyroid membrane is in the space
  between the thyroid cartilage and the crycoid cartilage
  located as the next hard ring of tissue inferior to the
  thyroid cartilage. If time permits the neck should be
  prepped with alcohol or povidone-iodine and the skin
  anesthetized locally before the first incision is made.
  The initial incision is made vertically thought the skin
  (3–4 cm) over the cricothyroid membrane. The next
  step is to identify the cricothyroid membrane immedi-
  ately inferior to the thyroid cartilage. Once it is iden-
  tified, a 1–2-cm horizontal incision is made. Insert a
  tracheostomy tube or a 5–6-mm endotracheal tube
  (3 mmfor a child) and secure the tube with tape.


• If there is not enough time to perform the surgical pro-
  cedure a needle cricothyroidotomy may be performed
  by locating the cricothyroid membrane as above and
  inserting a 12–16 gauge over the needle catheter that
  is attached to a syringe can be utilized. This allows the
  syringe to be connected to a pressurized oxygen source
  or a 3.0 endotracheal tube for ventilation while trans-
  port is taking place. There are prepackaged cricothy-
  roidotomy kits available commercially. These kits will

come prepackaged for either the blind percutaneous

method or the insertion through the skin incision. The

contents for a sideline cricothyroidotomy kit are out-

lined in Table 29-1. The complications to this proce-

dure should be weighed against the risk of death in the

athlete prior to availability of definitive care. The

complications as well as the contraindications are

listed in Table 29-2 (Blanda and Gallo, 2003; Norris

and Peterson, 2001a; 2001b; Roberts, 2000).

CONCLUSION

• Ear, nose, and throat injuries are among the most
  common injuries seen on the sidelines and can be
  quite serious in nature. The team physician must
  have a thorough knowledge of the anatomy in order
  to provide adequate care to the injured athlete. These
  injuries can range from cosmetic (wrestler’s ear), to
  the severely life threatening (laryngeal fracture).
  Essential equipment and training for the team physi-
  cian can mean the difference between life and death.

REFERENCES

Blanda M, Gallo UE: Emergency airway management.Emerg

Med Clin North Am21:1, 2003.

Douglass AB, Douglass JM: Common dental emergencies.Am

Fam Phys67(3):511, 2003.

Hart LE: Full facial protection reduces injuries in elite young

hockey players.Clin J Sport Med 12(6):406, 2002.

Luke A, Micheli L: Sports injuries: Emergency assessment and

field side care.Pediatr Rev 20(9):291, 1999.

Norris RL, Peterson J: Airway management for the sports physi-

cian part 1: Basic techniques.Phys Sportsmed29(10), 2001a.

Norris RL, Peterson J: Airway management for the sports physician

part 2: Advanced techniques.Phys Sportsmed29(11), 2001b.

TABLE 29-1 Sideline Cricothyroidotomy Kit

Alcohol pads Povidone-iodine pads or swabs

11 Scalpel 3- or 5-cc syringe

25-gauge needle 1% or 2% lidocaine with or without
epinephrine
4-in. hemostat 5- to 6-mm endotracheal tube or
tracheostomy tube
3-mm endotracheal tube 12–16 guage catheter over needle

TABLE 29-2 Risks and Contraindications

for Surgical Airway

CONTRAINDICATIONS

RISKS ABSOLUTE RELATIVE

Hemorrhage Ability to place Coagulopathy

Laceration to another type Overlying tumor

surrounding structures of airway Hematoma

Subcutaneous emphysema Age less than 10 years

Hypoxia Indistinct landmarks

Aspiration Previous intubation

Infection longer than 3 days

Tracheal stenosis

Vocal cord damage