Clinical Anatomy 9:291-295 (1996)

ORIGINAL COMMUNICATIONS

The Dimensions and Vascular Anatomy of the Cricothyroid Membrane:

Relevance to Emergent Surgical Airway Access
KEVIN DOVER, THOMAS R . HOWIESHELL,
mi) GENE

L. COLBORN

Deportmentr of Anatomy und Surgery, hledirii/ CoDegf of GeorgiSln, Augusta

Following traumatic injury, rapid surgical access to the airway may be required, with surgical cricothyroidostomy the procedure of choice. Immediate complications of cricothyroidostomy include unsuccessful or incorrect site of tube placement and hemorrhage. Subglottic stenosis is the most common late complication. This project was undertaken to better define the dimensions and vasculature of the cricothyroid region. In 15 cadaveric specimens, cervical dissection revealed the average width of the cricothyroid membrane visible between cricothyroid muscles to be 8.2 mm, and the average height 10.4 mm. Latex injection of the carotid artery demonstrated a transverse cricothyroid artery arising from the superior thyroid artery in 93% of cases. The cricothyroid artery crossed the upper one-half of the cricothyroid membrane in all but one specimen. Branches of the cricothyroid artery penetrated the membrane and ascended along the undersurface of the thyroid cartilage. Unilateral superior thyroid artery injection demonstrated anastomoses between right and left cricothyroid arteries. In 54% of specimens, the superior thyroid artery coursed anterior to the sternothyroid muscle and then the lateral edge of the cricothyroid membrane. The membrane was also crossed by venous tributaries to the superior and inferior thyroid veins. To lessen the possibility of complications following cricothyroidostomy, a knowledge of the dimensions, relations, and vasculature of the cricothyroid membrane is of inestimable value. o 1996 Wiley-Liss, h c .

Key words: cricothyroidostomy, airway, cricothyroid membrane, superior thyroid artery

INTRODUCTION
Orotracheal intubation via direct laryngoscopy is the preferred method of initiating general anesthesia for surgical procedures and to establish an airway in nontraumatic cardiopulmonary resuscitation (Ampel et al., 1988). T h e advantages of oral intubation are that it can be performed rapidly under direct vision and accomplished both in awake and apneic patients. In performing airway maneuvers after acute trauma, however, one must always consider the possibility of injury to the cervical spine (Bucholz et al., 1979). T h i s can be an occult dislocation, or an unstable fracture that has yet to produce injury to the spinal cord, or an incomplete spinal cord lesion that can be aggravated by uncontrolled manipulation of the neck. Oral intubation requires some degree of cervical hyperextension for glottic visualization and is to be avoided in victims of blunt trauma until the cervical spine has been evaluated. This route can also be difficult or contraindicated in patients with maxillofacial and mandibular fractures,
0 1996 Wiley-Liss, Inc.

laryngeal fracture, or thermal burn with inhalation injury and associated laryngeal edema. Nasotracheal intubation, popularized by Magill (1930), is a blind technique directed primarily by the sound of the air moving through the endotracheal tube. It has several advantages in trauma, requiring no cervical manipulation or direct laryngoscopy, and it can be performed in the awake patient. Disadvantages include limited success in the presence of apnea, retropharyngeal perforation, and vocal cord disruption. It is contraindicated in maxillofacial trauma with instability of the midface or suspected fracture of the cribriform plate, where a misdirected endotracheal tubc
Rcceivcd for publication June 27, 1995; revised August 8, 1995. Address reprint q u e s t s to 'Thomas R. Howdieshell, hlI), FACS, l'rauma/Surgical Critical Carc, Medical College of Georgia, RA4411, Augusta, GA 30912. Presented a t thc American Association of Clinical Anatomists Annual Meeting, liniversity of 'I'exas Medical 13rdnch, (;atveston,
Texas, J u n e 1994.

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may enter the frontal cranial fossa (Tintinalli and Claffey, 1981). Inability to intubate the trachea is a clear indication for creating a surgical airway. With few exceptions, tracheostomy is a poor choice for emergent airway access in the trauma victim. T h e trachea resides deeper in the neck than is commonly appreciated; it is surrounded by numerous veins capable of alarming hemorrhage, and the location for recommended tracheal incision is frequently obscured by the isthmus of the thyroid gland (Skaggs and Cogbill, 1969). Also, the necessary light, instruments, and assistance for tracheostomy are rarely available a t the emergency site. For these reasons, technical misadventures may result in complications, including hemorrhage, hypoxemia, injury to the recurrent laryngeal nerve, pneumothorax, or esophageal perforation (McClelland, 1965). Surgical cricothyroidostomy is the procedure of choice in circumstances in which emergency surgical airway access is indicated (Walls, 1988).T h e procedure requires elementary technical skills, a few basic instruments, and can be performed rapidly. T h e subcutaneous cricothyroid membrane is identified by palpation, the larynx stabilized, and a short transverse incision made through skin, subcutaneous tissue, and membrane. The incision is dilated with an instrument or the tip of a gloved finger, and a tracheostomy tube or endotracheal tube is inserted into the tracheal lumen (Phillips, 1991). Reported complication rates vary from 6% to 40%, with complications including incorrect site of tube insertion, damage to cricoid and thyroid cartilages, stoma1 or endobronchial hemorrhage, and subglottic stenosis. T h e cricothyroid membrane, o r ligament, is seen initially as a trapezoidal, tough band of tissue extending in the midline from the cricoid cartilage below to the thyroid cartilage above. It should be referred to more specifically as t h e median cricothyroid ligament, for it is the superficial, thickened, and antcromedial part of the conus elasticus which lies beneath the laryngeal mucosa. This membrane arises from the arch of the cricoid cartilage and attaches superiorly to the thyroid and arytenoid cartilages. Its free superior margin forms the focal ligament or cord. 7he cricothyroid artery is mentioned briefly in most classic anatomic reference texts. Ihe British edition of Grays Anatomy (Williams et a]., 1989) states that the artery crosses the superior portion of the median cricothyroid ligament. The cricothyroid artery usually arises from the superior laryngeal branch of the superior thyroid artery and commonly has rich anastomoses with the superior laryngeal artery deep to the thyroid lamina (Lippert c t al., 1985; Bergmann et al., 1988). In approximately 5% of cases, the cricothyroid artery may

totally replace the superior laryngeal artery. Occasionally, two enlarged cricothyroid arteries anastomose in the midline, giving origin to a median descending artery supplying a pyramidal thyroid lobe. T h e purpose of this paper is to provide data concerning the dimensions and vascular relations of the cricothyroid membrane. This information may help the clinician avoid, or at least manage, the complications following cricothyroidostomy.

MATERIAL AND METHODS

In this study, 15 cadaveric specimens were examined. Nine of the specimens were male (60%) and six were female (40%), with ages ranging from 70 to 92 years. Red arterial latex was injected in nine cadavers via the right common carotid artery a t the time of embalming. Six embalmed cadavers were dissected without latex injection. Selective latex injection of the superior thyroid artery was performed in three of the six cadavers not previously injected to evaluate the collateral circulation across the cricothyroid region. Neck dissection was performed via a collar incision beginning at the level of the clavicles and suprasternal notch. T h e skin, subcutaneous tissue, and platysma were elevated as a flap to the level of the mandible. T h e sternohyoid and omohyoid muscles were detached from their origins and elevated cephalad to expose the cricothyroid membrane region for dimensional measurements and identification of vasculature. Only that part of the membrane seen clinically was measured; that is, the area between the cricothyroid muscles laterally, the thyroid cartilage superiorly, and the cricoid cartilage inferiorly. Because the exposed portion of membrane is actually trapezoidal in shape, wider above than below, measurements included the width at three levels and the height.

RESULTS
T h e dimensions of the exposed portion of cricothyroid membrane were measured with calipers following careful dissection of the pretracheal fascia and associated loose areolar tissue. T h e width (three levels) and height for males, females, and the total group are shown in Figure 1. The average width and height of the cricothyroid membrane were consistently smaller in fcmales. In 13 of the 15 cadavers (87%), the superior thyroid artery originated from the external carotid artery. In two cadavers, both male, the superior thyroid artery originated from the common carotid artery. A transverse cricothyroid artery was identified in 14 cadavers (93%), originating from the superior thyroid artery.

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Fig. 1. Dimensions of cricothyroid membrane. Range and (mean) values reported in millimeters.

T h e cricothyroid artery coursed across the upper onethird of the cricothyroid membrane in 13 specimens (93%), and across the lower portion of the membrane in one cadaver (Fig. 2). In nine specimens (60%), the superior thyroid artery branched prior to reaching the upper pole of the thyroid lobe. O n e branch coursed

posterior to the sternothyroid muscle to supply the posterior aspect of the thyroid lobe. T h e other branch passed anterior to the sternothyroid muscle to supply the anterior aspect of the thyroid lobe and isthmus. In these nine cadavers, the cricothyroid artery arose from the anterior division of the superior thyroid artery. In six cadavers (40%), the superior thyroid artery failed to branch prior to reaching the upper pole of the thyroid gland. In these cadavers, the cricothyroid artery arose from the intrathyroid portion of the superior thyroid artery and coursed posterior to the sternothyroid muscle to reach the cricothyroid membrane. [Jnikiteral superior thyroid artery latex injection demonstrated communications between the right and left superior thyroid artery. Collateral anastomoses were noted both at the level of the cricothyroid membrane via the cricothyroid artery, and at the level of the thyroid isthmus. Several branches of the cricothyroid artery supplied the strap muscles, while others penetrated the cricothyroid membrane and ascended along the undersurface of the thyroid cartilage to supply the laryngeal mucosa and anastomose with branches of the superior laryngeal artery (Fig. 3). Numerous veins were also identified in the cricothyroid region. In the ~ i i b c u t a n e o u tissue, ~ paired anterior jugular veins crossed the membrane in a vertical direction in the majority of specimens. Deep to the sternohyoid muscles, venous tributaries of superior and in-

Fig. 2. Cricothyroid artery (arrow) travcrsing upper portion of membrane.

Fig. 3. Branches of cricothyroid artery supplying strap muscles (large arrows) and penetrating cricothyroid membrane (small arrows). C = cricothyroid muscles, S = strap muscle.

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ferior thyroid veins were found crossing the cricothymid membrane. In 12 of the specimens (80%), small veins from the region of the thyroid isthmus traversed the cricothyroid membrane, followed the cricothyroid and superior thyroid arteries, and drained into the internal jugular vein.

DISCUSSION
Jackson's (1921) landmark study proposed the seeond to fourth tracheal rings as the only acceptable locations for establishment of a surgical airway. Citing unacceptable complication rates at higher laryngotrachcal levels, the Jacksonian dictum received no serious challenge for over 50years. 'I'horacic surgeons Brantigan and Grow (1976), wishing to maximize the distance between clean median sternotomy wounds and colonized trdcheostomy stomal sites, reported a series of 655 elective cricothyroidostomies with lower morbidity than that reported in series of tracheostomies. This report stimulated renewed interest in cricothyroidostomy, to include its use as an emergency airway access procedure. Subsequent reports (Boyd et al., 1979; Cole and Aguilar, 1988) of emergency cricothyroidostomy documented complication rates of 6.8-32%. Immediate complications included incorrect site of tube placement, subcutaneous emphysema, pneumomediastinum, and hemorrhage. Late complications included hoarseness or voice change, vocal fold paresis, laryngeal fracture with permanent dysphonia, and subglottic stenosis. Inappropriate placement of the skin incision can increase the risk of complications, including incorrect site of tube placement and stomal hemorrhage. Cervical hematoma, edema, or subcutaneous emphysema may make palpation of topographic landmarks, such as t h e thyroid and cricoid cartilages, difficult or impossible. T h e placement of a horizontal skin incision too cephalad or caudad may lead to inadvertent thyrohyoid membrane or tracheal insertion of the airway. ( h e s of stomal or surface hemorrhage requiring vessel ligation have been reported following horizontal skin incisions (McGill et al., 1982). From our investigation, it is easy to imagine injuries to the anterior jugular veins or anterior branch of the superior thyroid artery as causes of wound bleeding following horizontal skin incision. Fatal airway hemorrhage has also been reported following transtracheal needle aspiration and cricothyroidostomy (1Jnger and Moser, 1973; Schillaci et al., 1976; Safar and Penninckx, 1967). T h e cricothyroid artery was lacerated with its freely bleeding transected ends forced into the lumen of the airway resulting in endobronchial hemorrhage and asphyxia. As illustrated in our dissections, injury to t h e transverse cricothyroid artery or an-

terior branches of the superior thyroid artery, with their rich collateral flow and systemic pressure, might result in serious endobronchial or wound bleeding. I,atc complications, including voice change, vocal cord injury, laryngeal fracture, and subglottic stenosis have been associated with forceful placement of oversized tracheostomy tubes through the cricothyroid membrane (McGill eta]., 1982). In our study, measurements of the exposed portion of the cricothyroid membrane demonstrated the average size of the space to be 6.9 mm by 9.5 mm in females and 8.8 mm by 10.9 mm in males. T u b e s frequently utilized for tracheostomy, #8 and #10 Shiley tracheostomy tubes with outer diameters of 12 mm and 13 mm respectively, could cause laryngeal injury when used for cricothyroidostomy.

CONCLUSIONS
Based on our results, we suggest a vertical skin incision, as it provides maximal flexibility for exposure while minimizing the chance of soft tissue hemorrhage from vertically oriented anterior jugular veins or anterior branches of the superior thyroid artery located superficial to the strap muscles. Palpation of the cricothyroid membrane should be repeated after the skin incision is made to confirm the correct position of the membrane. A transverse stab incision of the membrane near its lower border adjacent to the cricoid cartilage is recommended to avoid injury to the cricothyroid artery. If bleeding occurs, bilateral ligation of the anterior branches of the superior thyroid artery may be necessary to control hemorrhage, due to the extensive collateral blood supply involving the cricothyroid region. Consideration of limiting airway tube size, particularly in females, to no greater than 9-10 mm outer diameter may decrease the incidence of laryngeal injury. When rapid surgical access to the airway is required following traumatic injury, cricothyroidostomy is the procedure of choice. '1'0 avoid or manage complications following surgical cricothyroidostomy, a knowledge of the dimensions, relations, and vasculature of the cricothyroid membrane is imperative.

REFERENCES
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Phillips, T.1:. 1991 Airway management. In Trauma. R.E. Rrantigan, C.O. and J.R. Grow Sr. 1976 (:ricothyroidotomy: Moore, K.1,. blattox and I1.V. Feliciano (eds.) Xorwalk: Elective use in respiratory problems requiring tracheotomy. J. Thorac. Cardiovasc. Surg. 7/:72-81. Appleton and Lange, pp. 127-142. Bucholz, K.W., W.Z. Burkhead, W. (haham and C. Petty 1979 Safar, 1. and J. Penninckx 1967 Cricothyroid membrane puncOccult cervical spine injuries in fatal traffic accidents. ture with special cannula. Anesthesiology 28:943-948. J. Trauma 19768-771. Schillaci, K.F., V.E. Iacovoni and R.S. Conte 1976 Transtracheal Cole, K.R. and E.A. Aguilar 111 1988 Cricothyroidotomy versus traaspiration complicated by fatal endotracheal hemorrhage. cheostomy: An otolaryngologists perspective. 1,aryngoscope N e w Engl. J. Med. 29.5:488-490. 98:131-1 Skaggs, J.A. and (:.I,. Cogbill 1969 Tracheostomy: hlanageJackson, C. 1921 High tracheostomy and other errors the chief ment, mortality, complications. Am. Surg causes of chronic laryngeal stenosis. Surg. Gynecol. Obstet. Iintinalli, J.E. and J. Claffey 1981 Complications of nasotra.?2:392-398. tippert, 11. and K. Pahst 1985 Arterial Variations in Man: (XIS- cheal intubation. Ann. Emerg. bled. /0:142-144. Ilnger, K.M. and K.1LI. Moser 1973 1;atal complication of sitication and Frequency. Munich: J.F. Hergman, pp. 83-84. transtracheal aspiration. Arch. Intern. hled. /.?2:437-439. Magill, I.W. 1930 Iechnique in endotracheal anaesthesia. Hr. Walls, R.M. 1988 <:ricothyroidotomy. Emerg. bled. (:lin, North. hled. J. 2817-819. Am. 6725-736. blc(:lelland, K.M. 1965 (hmplications of tracheostomy. Rr. Williams, P.L., K. Warwick, M. Dyson and L.H. Bannister (eds.) bled. J. 2567-569. 1989 Grays Anatomy. N e w York: Churchill Livingstone, McGill, J . , J.E. Clinton and E. Kuiz 1982 Cricothyrotomy in the emergency department. Ann. Emerg. bled. //:361-364. pp. 1253-1 254.