10.14639/0392-100X-N2192
Objective. Compare long-term outcomes of thyroid-split and standard thyroid-retraction tracheostomy in a large cohort. Methods. The healthcare database of a university-affiliated hospital was searched for past patients over 18 years of age from all of the hospital’s wards on whom an ear, nose, and throat specialist performed a tracheostomy in the operating room between 2010 and 2020. Clinical data were extracted from the hospital and outpatient medical records. Life-threatening and non-life-threatening intra-operative and early and late post-operative adverse events in patients who underwent split-thyroid tracheostomy were compared with those who underwent standard tracheostomy. Results. There was no significant difference in intra-operative and early post-operative complications, hospitalisation length, or early reoperation and death rates between the 140 (28%) thyroid-split tracheostomy patients and the 354 (72%) standard tracheostomy patients, although the thyroid-split group had more non-decannulated patients and a longer operative time. Conclusions. Thyroid-split tracheostomy is safe and feasible. Compared to the standard procedure, it provides better exposure and a similar rate of complications, although its decannulation success rate is lower.
text/xml
1827-675X
2192
en
Esmat Najjar
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
decannulation
Thyroid-split tracheostomy: short- and long-term outcomes
Text.Serial.Journal
https://www.actaitalica.it/
43
Head and neck
2023-04-26
2022-06-23
2023-04-27
2023-04-27
99-107
1
Esmat Najjar
2023/04/26
10.14639/0392-100X-N2192
99
Department of Otorhinolaryngology-Head & Neck Surgery, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
1827-675X
decannulation
en
107
Thyroid-split tracheostomy: short- and long-term outcomes
https://www.actaitalica.it/article/download/2192/954
43
ACTA OTORHINOLARYNGOLOGICA ITALICA 2023;43:99-107; doi: 10.14639/0392-100X-N2192




Head and Neck


Thyroid-split tracheostomy: short- and long-term
outcomes
Tracheotomia con istmectomia tiroidea: risultati a breve e lungo termine
Nir Tsur1,2*, Ella Segal1,2*, Eyal Yosefof1,2, Noam Koch1, Idan Zeeman1,2, Ella Reifen1,2, Ory Wiesel3, Gideon Bachar1,2,
Esmat Najjar1,2
1
 Department of Otorhinolaryngology-Head & Neck Surgery, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel; 2 Sackler
Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; 3 Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Rabin
Medical Center, Beilinson Hospital, Petach Tikva, Israel
*Tsur and Segal equally contributed to this study


SUMMARY
Objective. Compare long-term outcomes of thyroid-split and standard thyroid-retraction
tracheostomy in a large cohort.
Methods. The healthcare database of a university-affiliated hospital was searched for past
patients over 18 years of age from all of the hospital’s wards on whom an ear, nose, and
throat specialist performed a tracheostomy in the operating room between 2010 and 2020.
Clinical data were extracted from the hospital and outpatient medical records. Life-threat-
ening and non-life-threatening intra-operative and early and late post-operative adverse
events in patients who underwent split-thyroid tracheostomy were compared with those
who underwent standard tracheostomy.
Results. There was no significant difference in intra-operative and early post-operative
complications, hospitalisation length, or early reoperation and death rates between the 140
(28%) thyroid-split tracheostomy patients and the 354 (72%) standard tracheostomy pa-
tients, although the thyroid-split group had more non-decannulated patients and a longer
operative time.
Conclusions. Thyroid-split tracheostomy is safe and feasible. Compared to the standard
procedure, it provides better exposure and a similar rate of complications, although its de-    Received: July 5, 2022
cannulation success rate is lower.                                                              Accepted: November 17, 2022

KEY WORDS: tracheostomy, thyroid split, complications, decannulation                            Correspondence
                                                                                                Nir Tsur
RIASSUNTO                                                                                       Department of Otorhinolaryngology-Head & Neck
Obiettivo. Analisi delle complicanze in un’ampia coorte di pazienti sottoposti a tracheoto-     Surgery, Rabin Medical Center - Beilinson Hospi-
                                                                                                tal, 39 Jabotinsky St., Petach Tikva 4941492, Israel
mia chirurgica con e senza istmotomia tiroidea.
                                                                                                Tel. +972 3 937 6457. Fax +972 3 937 6467
Metodi. Un apposito database retrospettivo è stato completato, includendo tutti i pazienti      E-mail: nirtsur19@gmail.com
maggiorenni sottoposti a tracheotomia chirurgica presso il nostro ospedale universitario
nel periodo tra il 2010 e il 2020. È stata condotta un’analisi comparativa degli eventi av-
versi precoci, tardivi, mortali e non, insorti tra i pazienti sottoposti a tracheotomia con e     How to cite this article: Tsur N, Segal E,
senza istmotomia tiroidea.                                                                        Yosefof E, et al. Thyroid-split tracheostomy:
Risultati. Non è stata riscontrata alcuna differenza statisticamente significativa in merito      short- and long-term outcomes. Acta Otorhi-
                                                                                                  nolaryngol Ital 2023;43:99-107. https://doi.
a complicanze intra-operatorie, post-operatorie precoci e tardive, tempo di ospedalizza-
                                                                                                  org/10.14639/0392-100X-N2192
zione e tasso di decessi tra i 140 pazienti (28%) sottoposti a tracheotomia con istmotomia
tiroidea e i 354 (72%) sottoposti a tracheostomia senza istmotomia. Nella prima coorte di
pazienti sono stati riscontrati un tempo operatorio maggiore e un maggior tasso di pazienti     © Società Italiana di Otorinolaringoiatria
non decannulati.                                                                                e Chirurgia Cervico-Facciale
Conclusioni. La tracheotomia con istmotomia tiroidea si conferma una tecnica sicura.
Se paragonata alla tracheotomia senza istmotomia, permette una esposizione migliore                            OPEN ACCESS
dell’asse tracheale e un tasso di complicanze sovrapponibile, nonostante il riscontro di un     This is an open access article distributed in accordance with
minore tasso di decannulazione.                                                                 the CC-BY-NC-ND (Creative Commons Attribution-Non-
                                                                                                Commercial-NoDerivatives 4.0 International) license. The
PAROLE CHIAVE: tracheotomia, istmotomia tiroidea, complicanze, decannulazione                   article can be used by giving appropriate credit and mentio-
                                                                                                ning the license, but only for non-commercial purposes and
                                                                                                only in the original version. For further information: https://
                                                                                                creativecommons.org/licenses/by-nc-nd/4.0/deed.en




                                                                                                                                                          99
N. Tsur et al.




Introduction                                                        hospital’s wards, including the ICU, aged over 18 years on
                                                                    whom an ear, nose, and throat specialist (ENT) performed
Tracheostomy was first performed in 100 BC, making it
                                                                    a tracheostomy for any indication in the OR between 2010
among the oldest surgical procedures 1. Although translaryn-
                                                                    and 2020. Possible tracheostomy indications are prolonged
geal intubation is the preferred initial artificial airway in me-
                                                                    intubation, protective tracheostomy, airway obstruction by
chanically ventilated patients, early tracheostomy accelerates
                                                                    a tumour or oedema, bilateral vocal cord paralysis, glottis
the weaning process and reduces aspiration and ventilator-
                                                                    or subglottis stenosis, and trauma (Tab. I). Patients were
acquired pneumonia 2. Thus, tracheostomy is one of the most
                                                                    divided into two groups according to the type of tracheos-
commonly performed surgical procedures in critically-ill pa-
                                                                    tomy they underwent: thyroid-split or standard.
tients who require airway protection or long-term mechanical
ventilation 3,4. Tracheostomy also has established benefits for
                                                                    Data collection
patients who need prolonged invasive mechanical ventilation,
                                                                    Clinical data were extracted from hospital and outpatient
including weaning from relaxation and sedation drugs, facili-
                                                                    medical records. The patient data included demographics,
tating pulmonary hygiene, decreasing dead space, enhancing
                                                                    clinical history, laboratory tests and date of death, and were
weaning from mechanical ventilation, decreasing subglottic
                                                                    collected from each patient’s computerised medical records.
stenosis and shortening the intensive care unit (ICU) stay 5.
                                                                    Hospitalisation data included antibiotic treatment, length of
The indications for tracheostomy, the complex underlying
                                                                    hospitalisation, and short-term post-operative complications
conditions of the patients, and the involvement of the airway
                                                                    (within 30 days after surgery) and were collected from the
increase the tendency for complications. Early complications
                                                                    patient’s computerised admission-transfer-discharge (ATD)
occurring within 30 days of tracheostomy include bleeding,
                                                                    records. The tracheostomy data included the method, date,
stomal infection, injuries to nearby structures, subcutaneous
                                                                    intra-operative complications and operative time obtained
emphysema, pneumothorax, tracheostomy tube obstruction
                                                                    from surgical reports. Patients were followed until death or
and tube dislodgement. Late complications, occurring after
30 days, include tracheal stenosis or malacia, followed by          the end of the research period (June 2021). Follow-up data,
trachea-oesophageal fistula, trachea-innominate fistula and         including long-term complications (occurring more than 30
tracheocutaneous fistula (TCF) 6. Complication rates report-        days after surgery) and cause of death, were obtained from
ed in the literature range from 6% to 66% depending on the          follow-up meeting reports or computerised medical records.
study design, duration of follow-up and specific definition of
complications, with mortality rates up to 5% 1,7,8. However,        Surgical approach
more recent studies have reported infrequent complications,         After evaluating the clinical course and prognosis, critical
ranging from minor to life-threatening 9.                           care consultants and ENT surgeons decided to perform a tra-
Traditionally, tracheostomy has been performed as an open           cheostomy jointly. The choices of technique, operator, and
surgical procedure in the operating room (OR). However, per-        equipment were based primarily on local resources and ex-
cutaneous tracheostomy has become more common in recent             pertise, but patient factors, including body habitus, adequacy
decades, primarily performed at bedside in the ICU. As a re-        of neck extension and laryngoscopy grade, were also con-
sult, many different methods have arisen over time, although        sidered. A senior otorhinolaryngologist and an ENT resident
their superiority in terms of complication rates and outcomes       performed the tracheostomy by either retraction or thyroid
remains unclear 10. One controversy involves the approach to        split. The intra-operative haemostasis technique involved
the thyroid isthmus, which can be preserved by retracting it        high-energy electrocautery with the LigaSureTM (Valleylab,
superiorly (standard tracheostomy) or splitting it for better       Boulder, CO) or Rex® Harmonic Scalpel System (Ethicon
exposure of the trachea 11. Studies comparing the two have re-      EndoSurgery, Cincinnati, OH). The Bjork flap or tracheal
ported similar complication rates 11,12, but included only small    flap technique is not common in our institution. Finally, the
patient cohorts with a short follow-up of six months.               cannula flanges were fixed with stitches to the skin in each
This study compared the outcomes of thyroid-split and               procedure. The tracheostomy multidisciplinary team man-
standard thyroid-retraction tracheostomy in a large cohort          aged de-cannulation and performed it in the ENT ward.
over a long period of follow-up.
                                                                    Outcomes
                                                                    The study’s primary outcomes were intra-operative and di-
Materials and methods                                               rect post-operative life-threatening adverse events (AEs).
Design and setting                                                  Intra-operative life-threatening AEs were defined as sig-
The healthcare database of a university-affiliated hospital         nificant vascular injuries or excessive bleeding (determined
was retrospectively searched for patients from all of the           by the need for blood transfusion or referred to in the surgi-



100
                                                                                                              Thyroid-split tracheostomy: a safe alternative




Table I. Characteristics of patients treated by tracheostomy, by type.
 Characteristics                                       Thyroid-split                        Standard                      Total                P-value
                                                         (n = 140)                          (n = 354)                   (n = 494)
 Age (yr), median (Q1, Q3)                                        67.5                        65.2                        66                    0.061
                                                               (51.6, 76.7)                (56.7, 79.0)               (56.0, 78.3)
 Gender, female, n (%)                                         61 (43.6%)                  164 (46.3%)                225 (45.5%)               0.579
 Smoking, n (%)                                                                                                                                 0.123
    Active smoker                                              34 (26%)                     92 (27.7%)               126 (27.2%)
    Past smoker                                               32 (24.4%)                    54 (16.3%)                86 (18.6%)
    Pack years, median (Q1, Q3)                                 0 (0, 30)                     0 (0, 25)                0 (0, 28.5)              0.209
    Body mass index, median (Q1, Q3)                      25.97 (22.45, 30.25)          25.7 (21.95, 30.57)        25.7 (22.15, 30.4)           0.762
 Comorbidities, n (%)
    Diabetes mellitus                                          52 (37.4%)                  118 (33.7%)                170 (34.8%)               0.439
    COPD                                                       14 (10.1%)                   81 (23.1%)                 95 (19.4%)               0.001
 Malignancy                                                                                                                                     0.170
    No                                                         52 (38.0%)                  165 (49.7%)                217 (46.3%)
    Glottic                                                    25 (18.2%)                   37 (11.1%)                62 (13.2%)
    Thyroid                                                     7 (5.1%)                     28 (8.4%)                 35 (7.5%)
    Oral cavity                                                30 (21.9%)                   58 (17.5%)                 88 (18.8%)
    Lymphoma                                                    2 (1.5%)                      8 (2.4%)                  10 (2.1%)
    Breast                                                      6 (4.4%)                      8 (2.4%)                   14 (3%)
    GI tract                                                    5 (3.6%)                      8 (2.4%)                  13 (2.8%)
    Lung                                                        2 (1.5%)                      5 (1.5%)                  7 (1.5%)
    Other                                                       8 (5.8%)                     15 (4.5%)                  23 (4.9%)
 Irradiation                                                   57 (42.2%)                  122 (37.7%)                 179 (39%)                0.361
    Irradiation dose (Gy), median (Q1, Q3)                      0 (0, 69)                    60 (0, 70)                 60 (9, 28)              0.135
 Indication, n (%)                                                                                                                              0.002
    Prolonged intubation                                       39 (28.3%)                  159 (47.5%)                198 (41.9%)               0.001
    Protective                                                 37 (26.8%)                   52 (15.5%)                 89 (18.8%)               0.002
    Airway obstruction by tumour                               16 (11.6%)                    47 (14%)                  63 (13.3%)                0.57
    Airway obstruction by oedema                               22 (15.9%)                    33 (9.9%)                 55 (11.6%)                0.04
    Bilateral V. C. paresis                                     11 (8%)                      16 (4.8%)                  27 (5.7%)                0.14
    Stenosis exacerbation                                       8 (5.8%)                     16 (4.8%)                  24 (5.1%)                0.46
    Trauma                                                      5 (3.6%)                     12 (3.6%)                  17 (3.6%)                0.92
COPD: chronic obstructive pulmonary disease; GI: gastrointestinal; VC: vocal cord.

cal report as severe intra-operative bleeding) or a misplaced                        redness and secretions), tracheal and oesophageal damage
airway (paratracheal insertion of the tracheostomy tube).                            as evaluated by either endoscopy or imaging, and aspiration
Direct post-operative severe, life-threatening AEs were                              during the post-operative hospitalisation. The late non-LTEs
defined as excessive bleeding (determined by the need for                            were tracheal stenosis, tracheal malacia, TCF, granuloma
blood transfusion or an additional surgical procedure) and/                          development, re-operation within a month of the surgery
or cannula dislodgement. Premature mortality was defined                             and hypothyroidism [the first thyroid-stimulating hormone
as death within 30 days of the tracheostomy.                                         (TSH) test after the tracheostomy]. Our 7-day survival anal-
The secondary outcomes of this study were: (i) intra-oper-                           ysis was based on all-cause mortality.
ative, post-operative and late non-life-threatening events
(non-LTEs); (ii) duration of the procedure; and (iii) 7-day                          Post-operative complications based on the Clavien-Dindo
survival. Intra-operative non-LTEs were defined as transient                         Classification System
hypotension or technical difficulties. Among the direct post-                        Post-operative complications were further categorised us-
operative non-LTEs were peristomal infection (defined as a                           ing the Clavien-Dindo Classification System (Appendix
body temperature above 38°C or local peristomal swelling,                            1) 13. Two authors (NT and ES) independently assigned a



                                                                                                                                                      101
N. Tsur et al.




Clavien-Dindo grade to each post-operative complication.         Complications
Any disagreements were deliberated and decided jointly.          Nine (2%) emergent tracheal dislodgements occurred: six in
Complication grade frequency was defined as the number           the thyroid-split group and three in the standard-tracheosto-
of times the complication grade occurred divided by the          my group. The mean time of occurrence of these dislodge-
sum of the post-operative complications. In this analysis,       ments from surgery was on post-operative Day 5, between 3
each patient could have multiple complications. However,         p.m. and 7 a.m. Six cannulas were relocated to the patient’s
only the highest complication grade for each patient was         bedside, and one went into the OR. Two patients with trache-
considered when comparing post-operative complication            al dislodgment could not be relocated and died due to airway
grades between tracheostomy techniques.                          obstruction and hypoxaemia. Of them, one had undergone
                                                                 a thyroid-split tracheostomy and the other had undergone a
Statistical analysis                                             standard tracheostomy.
Statistical analyses were performed using SPSS version 25        The early and late complications are shown in Tables III
(IBM Corp. Armonk, NY). Continuous variables with a nor-         and IV, respectively. The rates of early post-operative com-
mal distribution are presented as means and standard devia-      plications of bleeding, pneumothorax, infection, canula
tions and compared between groups with t-tests. Continuous       dislocation, aspiration, tracheal damage and oesophageal
variables with a non-normal distribution are presented as me-    damage did not differ between groups. However, the op-
dians and ranges and analysed using the Mann-Whitney and         erative time of the thyroid-split tracheostomy group was
Wilcoxon signed-rank tests for dependent samples. Categori-      significantly longer than that of the standard-tracheostomy
cal variables are presented as percentages and analysed using    group (median, 54 min vs 40 min, respectively, p < 0.001).
the chi-square or Fisher’s exact test. Multiple comparisons      The late complications of tracheal stenosis, tracheomalacia,
were adjusted using the Bonferroni correction. Survival was      TCF, granuloma formation, and all-cause mortality (41% in
calculated from the surgery date to the date of death or last    thyroid slit group vs 48.9% in standard method group) did
follow-up. Univariable survival models and curves were gen-      not differ between groups. However, the percentage of pa-
erated using the Kaplan-Meier method and compared using a        tients who were not decannulated was higher in the thyroid-
log-rank test. All the tests were two-sided, and the threshold   split tracheostomy group (57.1% vs 44.4%, p = 0.039).
for statistical significance was set at a p-value of < 0.05.
                                                                 The Clavien-Dindo Classification System
                                                                 for post-operative complications
Results                                                          According to the Clavien-Dindo Classification System (Ap-
Study population and demographics                                pendix 1), one or more post-operative complications occurred
The cohort consisted of 494 patients, of whom 140 (28%)          in 285 (57.7%) patients, 40.78% of which were classified
had thyroid-split tracheostomy and 354 (72%) had stand-          as Grade 1; 20.61%, Grade 2; 11.06%, Grade 3a; 24.95%,
ard tracheostomy. Their characteristics are shown in Table       Grade 3b; and 2.6%, Grade 5. No complication was classi-
I. There were no significant differences in demographics
and comorbidities except for a higher prevalence of chronic      Table II. Prolonged intubation indication (subanalysis).
obstructive pulmonary disease in the standard-tracheosto-                                   Thyroid    Standard        Total     P-value*
my group (23.1% vs 10.1%, p < 0.001). However, indica-                                        split    (n = 159)     (n = 198)
tions for tracheostomy differed between the groups. The                                     (n = 39)
standard-tracheostomy group had higher rates of prolonged         Respiratory failure     14 (35.9%)   72 (45.3%) 86 (43.4%)      0.289
                                                                  (n, %)
intubation (47.5% vs 28.3%, p = 0.001), and the thyroid-
                                                                  Airway                    3 (7.7%)   11 (6.9%)     14 (7.1%)    0.856
split tracheostomy group had higher rates of the protective       compromise (n, %)
airway (26.8% vs 15.5%, p = 0.002) and airway obstruc-            Reduced                 13 (33.3%)   16 (10.1%) 29 (14.6%)     < 0.001
tion by oedema (15.9% vs 9.9%, p = 0.04). Furthermore,            consciousness
we performed a subanalysis of 198 patients who under-             (n, %)
went tracheostomy due to prolonged intubation to assess           Sepsis (n, %)             1 (2.6%)   10 (6.3%)     11 (5.6%)    0.362
differences in the indications between the groups (Tab. II).      Surgical                  3 (7.7%)   13 (8.2%)     16 (8.1%)    0.920
A significant difference was shown in the indications for         emergency (n, %)
prolonged intubation (p = 0.042), with a higher prevalence        Circulatory failure       1 (2.6%)   12 (7.5%)     13 (6.6%)    0.260
of reduced consciousness in the thyroid-split group (33.3%        (n, %)
vs 10.1%, p < 0.001).                                            *Bonferroni-adjusted p-value.




102
                                                                                                    Thyroid-split tracheostomy: a safe alternative




Table III. Early complications (within 30 days) of tracheostomy by type.
 Complication                                               Thyroid split       Standard               Total                    P-value
                                                             (n = 140)          (n = 354)            (n = 494)
 Intra-operative, n (%)
    Bleeding                                                 5 (3.8%)            9 (2.7%)             14 (3%)                    0.553
    Paratracheal insertion                                    0 (0%)              0 (0%)               0 (0%)
    Technical difficulties                                  14 (10.1%)           20 (6%)             34 (7.2%)                   0.122
    Hypotension                                              2 (1.4%)            8 (2.4%)            10 (2.1%)                   0.730
 Early post-operative, n (%)
    Bleeding                                                 6 (4.4%)           27 (7.9%)            33 (6.9%)                   0.170
    Pneumothorax                                             3 (2.2%)           15 (4.4%)            18 (3.8%)                   0.251
    Infection                                                12 (8.8%)          23 (6.7%)            35 (7.3%)                   0.440
    Dislocation                                              7 (5.1%)           25 (7.3%)            32 (6.7%)                   0.387
    Aspiration                                               6 (4.5%)           21 (6.2%)            27 (5.7%)                   0.476
    Tracheal damage                                          1 (0.8%)            3 (0.9%)             4 (0.9%)                   1.000
    Oesophageal damage                                        0 (0%)             1 (0.3%)             1 (0.2%)                   1.000
    Duration of surgery (min), median (Q1, Q3)              54 (39, 176)       40 (22, 112)         46 (26, 120)                < 0.001
    Length of hospitalisation (days), median (Q1, Q3)       15 (10, 28)         15 (9, 28)           15 (9, 28)                  0.987
    Reoperation within 30 days, n (%)                        7 (5.1%)           27 (7.8%)            34 (7.1%)                   0.293
    Death within 30 days, n (%)                             18 (12.9%)         49 (13.9%)           67 (13.6%)                   0.778


fied as Grade 4. According to the Clavien-Dindo Classifica-                 102 obese patients (BMI > 30). However, in the subanalysis
tion, the severity of complications did not differ significantly            on indications for tracheostomy, among the 82 patients who
between groups (p = 0.340), as shown in Table V. Likewise,                  underwent the procedure because of prolonged intubation
when complications were classified into low or high grades                  and on whom data on planned elective de-cannulation was
(defined as Grade 3 and above), there was no difference be-                 available, those who had a thyroid-split tracheostomy had
tween the tracheostomy technique groups (p = 0.059).                        a lower de-cannulation rate than those who had a standard
                                                                            tracheostomy (57.6% vs 87%, respectively, p = 0.018).
Survival
Our 7-day survival evaluation showed a significant differ-
                                                                            Discussion
ence between groups (Fig. 1). The thyroid-split group had
a survival rate of 98.6% after 9 days compared to 94.6% in                  This single-centre retrospective cohort study compared
the standard-tracheostomy group (p = 0.05).                                 standard and thyroid-split tracheostomy in 494 patients
                                                                            (Fig. 2). To our knowledge, few studies have compared
Subpopulations                                                              these techniques even though they are performed daily in
We performed subpopulation analyses to determine if specif-                 many ENT surgical procedures. Despite decades of experi-
ic patient groups were more prone to tracheostomy compli-                   ence, the preferred tracheostomy technique in critically-ill
cations. The complication rates and lengths of hospitalisation              patients is still debatable, and newer, less invasive proce-
of the 254 patients older than 65 years did not differ sig-                 dures that often do not require an OR are presented yearly
nificantly according to the type of tracheostomy performed.                 at intensive care symposia, with potential differences in
These findings were similar to those in the subanalysis of                  outcomes, complication rates and costs 5,14. Furthermore,

Table IV. Late complications (more than 30 days) of tracheostomy by type.
                                                          Thyroid split      Standard method           Total                    P-value
                                                           (n = 140)             (n = 354)           (n = 494)
 Tracheal stenosis (n, %)                                    6 (4.4%)            24 (7%)            30 (6.3%)                    0.286
 Tracheomalacia (n, %)                                       1 (0.7%)             7 (2%)             8 (1.7%)                    0.450
 Tracheocutaneous fistula (n, %)                            10 (7.4%)          42 (12.3%)           52 (10.9%)                   0.116
 Granuloma (n, %)                                            12 (8.6%)          15 (4.2%)            27 (5.5%)                   0.056
 Successful de-cannulation (n, %)                           39 (42.9%)         129 (55.6%)          168 (52%)                    0.039




                                                                                                                                            103
N. Tsur et al.




Figure 1. 7-day survival (Kaplan-Meier).


in this study, participants were seemingly homogenous in                        analysis by differentiating early and late post-operative
terms of demographics, medical history and overall mortal-                      complications and including many different and specific
ity, allowing for comparison of the effects of standard vs                      difficulties. We also analysed both life-threatening and
thyroid-split tracheotomy.                                                      non-life-threatening complications. Overall, the complica-
In a prospective tracheostomy study, Calhoun et al. 12 com-                     tion profile was similar for the thyroid-split and standard
pared electrocautery division to clamp-and-tie. They found                      techniques, consistent with earlier studies.
that the former had a shorter operative time and the same                       Cannula dislodgement is a life-threatening tracheostomy
complication rate. However, in a more extensive study                           complication associated with 50% of airway-related deaths 16.
of 1,143 patients by Janik et al. 11 that compared isthmus                      Its rates in the literature range from 0.35% to 15% 17,18. Vari-
preservation with suture ligation of the thyroid isthmus,                       ous methods of decreasing the rate of emergency cannula
no significant difference in complication rates between the                     dislodgement have been described, including sutured neck-
two groups was reported. Our study refined the outcome                          ties 19, using specific fresh tracheostomy guidelines 20, and

Table V. Post-operative complications* according to the Clavien-Dindo classification.
                                                          Thyroid split            Standard method          Total                P-value
                                                            (n = 140)                  (n = 354)          (n = 494)
 Grade 1 (n, %)                                                    38 (27.1%)      61 (17.2%)             99 (19.6%)
 Grade 2 (n, %)                                                    16 (11.4%)      42 (11.9%)             58 (11.5%)
 Grade 3a (n, %)                                                    6 (4.3%)        21 (5.9%)              27 (5.4%)              0.340
 Grade 3b (n, %)                                                   20 (14.3%)      69 (19.5%)             89 (17.7%)
 Grade 4a (n, %)                                                        0               0
 Grade 4b (n, %)                                                        0               0
 Grade 5 (n, %)                                                     2 (1.4%)        10 (2.8%)             12 (2.4%)
 Grade ≥ 3                                                          28 (20%)       100 (28.2%)           128 (25.9%)              0.059
The most severe complication per patient was used for assigning a grade.




104
                                                                                                                   Thyroid-split tracheostomy: a safe alternative




 A                                                                                B




Figure 2. Thyroid split tracheostomy technique showing (A) before the thyroid split and (B) after the thyroid split, exposing the trachea above and below the car-
tilage window location (From De Leyn, et al., 2007, mod. Prof. Dr. P. De Leyn has permitted the author to use the figure in date January 20, 2023) 15.


establishing airway rapid response teams 21. In our study,                         intra-operative haemostasis technique during thyroid-split.
dislodgement rates did not significantly differ between the                        Second, during thyroid split, exposing the medial margins
thyroid-split and standard tracheostomy groups. Moreover,                          of the thyroid to an unsterilised environment near the stoma
we evaluated several variables, including anoxic brain dam-                        may increase the peri-operative infection rate 10. However,
age, dislodgement-related death and bedside recannulation.                         we did not observe an increased post-operative infection
However, dislodgement is fortunately rare, with only 0.2%                          rate in the thyroid-split group compared to the standard-
of our cohort experiencing it. Given the devastating potential                     tracheostomy group. This finding may be explained by a
of this complication, however, thyroid split can offer poten-                      shift in both thyroid lobes posteriorly during the procedure,
tial advantages over the standard tracheostomy technique, as                       away from the stoma, thereby lessening the potential for
it allows for a better view of the stoma and easier insertion.                     respiratory pathogen contamination. Moreover, the high-
In our cohort, surgeons chose the thyroid-split technique                          energy split technique could also have contributed to the
over the standard-tracheostomy technique for patients when                         local sterilisation of thyroid tissue and decreased bacterial
short-term de-cannulation was not anticipated, but the prog-                       biofilm degradation, as demonstrated in a previous study 23.
nosis was deemed favourable, such as decreased conscious-                          When we evaluated planned de-cannulation, we assumed
ness (33% vs 10%, p < 0.001). The surgeons’ choice of the                          that an intact thyroid lobe, together with subcutaneous tissue
thyroid-split over standard technique in this study can be at-                     and strap muscles, can serve as a soft-tissue barrier between
tributed to the potential advantage of the thyroid-split tech-                     the trachea and the skin, which could lead to a higher likeli-
nique due to its more stable tract for potential dislodgements.                    hood of de-cannulation success and a decreased risk of a per-
The devastating potential of emergent dislodgement and the                         manent TCF. Furthermore, in our study, the de-cannulation
rarity of this phenomenon require evaluation in further stud-                      success rate was 42.9% in the thyroid-split group and 55.6%
ies using a caregiver-based survey that will assess the ease of                    in the standard-tracheostomy group (p = 0.039). Known pre-
recannulation in different tracheostomy techniques.                                dictors of elective tracheostomy de-cannulation include old-
At the same time, the thyroid-split technique has several                          er age, BMI < 22 kg/m2, respiratory indication for tracheos-
theoretical disadvantages. First, manipulating the highly                          tomy and neurologic disease 24-28. However, no evidence has
vascularised thyroid gland may cause intra-operative bleed-                        been reported that the location of the thyroid isthmus relative
ing, requiring more extensive exposure and blood trans-                            to the location of the stoma is a predictor of de-cannulation
fusion with an overall prolonged operative procedure 22.                           success. Therefore, we assumed that the factors contribut-
However, our study showed no increase in intra-operative                           ing to the lower de-cannulation rates were, first, the indica-
or post-operative bleeding, probably due to our meticulous                         tions for tracheostomy, which showed that the thyroid split



                                                                                                                                                            105
N. Tsur et al.




was performed for patients as a protective measure against        have influenced the results. In this study, data on the surgical
airway obstruction. Thus, physicians may be reluctant to          duration and the intra-operative complications were limited
try early de-cannulation due to airway compromise and opt         due to gaps in the surgical reports of the different members
to practice a more conservative de-cannulation approach.          of the anesthesia and surgical teams. Finally, as stated earlier,
Moreover, the thyroid isthmus can be a vascularised flap be-      tracheostomy is one of the most common surgical techniques
tween the trachea and the skin after de-cannulation, offering     and has a high safety profile and a low complication rate 5,9,16.
better wound healing and successful de-cannulation.               Therefore, even in our relatively large cohort, a low rate of
Thyroid split was associated with a longer surgical duration      complications could be expected, with low power for statisti-
than standard tracheostomy (median of 54 vs 40 min). This         cal analysis. A multicentre study can overcome this problem.
can be attributed to the need to expose the thyroid isthmus,
split it by electrocautery and maintain meticulous haemo-         Conclusions
stasis. Moreover, in our tertiary centre, residents mostly
perform thyroid split to increase tracheal visibility and thus    Thyroid split is a safe and feasible tracheostomy technique.
improve manual and surgical manipulation of the thyroid           Its rate of complications is similar to that of the standard
gland (for future surgeries). However, this habit might in-       procedure. It was the surgeon’s technique of choice for tra-
crease surgical time.                                             cheostomy to address imminent airway obstruction, prob-
Overall, our results are consistent with those in previous        ably due to the better tracheal exposure associated with it.
publications, suggesting that thyroid-split tracheostomy is       The abovementioned advantages should outweigh the dis-
as safe as standard thyroid-retraction tracheostomy and can       advantages of thyroid-split tracheostomy of longer opera-
be applied according to the surgeon’s preference and need         tional length and decreased elective de-cannulation rates.
for better exposure. Indeed, when addressing the thyroid-
split tracheostomy indications, our study showed that sur-        Conflict of interest statement
geons choose the thyroid-split technique when addressing          The authors declare no conflict of interest.
protective and airway obstruction (Tab. I), with the prob-
able advantage of easier tracheal exposure in emergency           Funding
cannula dislodgement in patients with complicated orotra-         This research did not receive any specific grant from funding
cheal intubation. Finally, the potential disadvantage of the      agencies in the public, commercial, or not-for-profit sectors.
thyroid-split technique was prolonged surgical time and
decreased elective de-cannulation.                                Author contributions
Due to the study’s retrospective design, we did not have          NT, EN: conceptualisation; NT, ES, EY: methodology; NT:
information regarding other factors that might influence the      project administration; NT, ES: writing – original draft; NT,
decision on tracheostomy technique, such as thyroid gland         ES, EY, NK, IZ, ER, OW, GB, EN: writing – review and
volume or neck circumference. However, further prospec-           editing; ES, NK, IZ: data curation; ES: statistical analysis;
tive studies evaluating both anthropometric measures and          GB, EN: supervision.
gland volume may shed light on the potential advantages
of the thyroid-split technique for specific subpopulations,       Ethical consideration
including patients with a short neck, increased neck cir-         This study was approved by th Institutional Ethics Board
cumference and large retrosternal thyroid gland.                  (protocol number RMC 0651-2020).
This study has several limitations. Its retrospective design      The Institutional Review Board, waived the need for informed
with manual data extraction from medical records is inher-        consent due to the retrospective nature of this research.
ently subject to selection and information bias. However, we
focused on a large cohort, detailed early and late complica-      References
tion profiles, and extended the follow-up period. Further-        1
                                                                      Johnson-Obaseki S, Veljkovic A, et al. Complication rates of open sur-
more, our choice of patients suitable for tracheostomy might          gical versus percutaneous tracheostomy in critically ill patients. La-
have been influenced by the patient’s medical history, demo-          ryngoscope 2016;126:2459-2467. https://doi.org/10.1002/lary.26019
graphics and indications. It is noteworthy that patients hospi-   2
                                                                      Adly A, Youssef TA, El-Begermy MM, et al. Timing of tracheosto-
talised in the ICU and undergoing tracheostomy have a high            my in patients with prolonged endotracheal intubation: a systematic
                                                                      review. Eur Arch Otorhinolaryngol 2018;275:679-690. https://doi.
mortality rate due to their primary condition, regardless of          org/10.1007/s00405-017-4838-7
the tracheostomy procedure itself. Thus, their follow-up du-      3
                                                                      Wood DE. Tracheostomy. Chest Surg Clin N Am 1996;6:749-764.
ration may be shorter, and the frequency of long-term post-       4
                                                                      Freeman BD, Kennedy C, Robertson TE, et al. Tracheosto-
operative complications is lower. Missing data could also             my protocol: Experience with development and potential util-




106
                                                                                                                      Thyroid-split tracheostomy: a safe alternative




      ity. Crit Care Med 2008;36:1742-1748. https://doi.org/10.1097/                 17
                                                                                          Friedman Y, Fildes J, Mizock B, et al. Comparison of percutaneous
      CCM.0b013e318174d9f6                                                                and surgical tracheostomies. Chest 1996;110:480-485.
5
      Cheung NH, Napolitano LM. Tracheostomy: epidemiology, indica-                  18
                                                                                          Halum SL, Ting JY, Plowman EK, et al. A multi-institutional analy-
      tions, timing, technique, and outcomes. Respir Care 2014;59:895-                    sis of tracheotomy complications. Laryngoscope 2012;122:38-45.
      915; discussion 916-919. https://doi.org/10.4187/respcare.02971                     https://doi.org/10.1002/lary.22364
6
      Fernandez-Bussy S, Mahajan B, Folch E, et al. Tracheostomy tube                19
                                                                                          Fine KE, Wi MS, Kovalev V, et al. Comparing the tracheostomy dis-
      placement. J Bronchol Interv Pulmonol 2015;22:357-364. https://doi.                 lodgement and complication rate of non-sutured neck tie to skin su-
      org/10.1097/LBR.0000000000000177                                                    tured neck tie fixation. Am J Otolaryngol 2021;42:102791. https://doi.
7
      Chew JY, Cantrell RW. Tracheostomy: complications and their man-                    org/10.1016/j.amjoto.2020.102791
      agement. Arch Otolaryngol 1972;96:538-545.                                     20
                                                                                          Hood K, Lewis B, Bowens DC. Reducing fresh tracheostomy decan-
8
      Hazard PB, Garrett HE, Adams JW, et al. Bedside percutaneous tra-                   nulations following implementation of a fresh tracheostomy guide-
      cheostomy: experience with 55 elective procedures. Ann Thorac Surg                  line. Crit Care Nurs Clin North Am 201;29:131-141. https://doi.
      1988;46:63-67.                                                                      org/10.1016/j.cnc.2017.01.001
9
      Bathula SS, Srikantha L, Patrick T, et al. Immediate post-operative
                                                                                     21
                                                                                          Rassekh CH, Zhao J, Martin ND, et al. Tracheostomy complications
      complications in adult tracheostomy. Cureus 2020;12:E12228. htt-                    as a trigger for an airway rapid response: analysis and quality improve-
      ps://doi.org/10.7759/cureus.12228                                                   ment considerations. Otolaryngol Head Neck Surg 2015;153:921-
                                                                                          926. https://doi.org/10.1177/0194599815612759
10
      Brass P, Hellmich M, Ladra A, et al. Percutaneous techniques versus
      surgical techniques for tracheostomy. Cochrane Database Syst Rev               22
                                                                                          Bontempo LJ, Manning SL. Tracheostomy emergencies. Emerg
      2016;7:CD008045.          https://doi.org/10.1002/14651858.CD008045.                Med Clin North Am 2019;37:109-119. https://doi.org/10.1016/j.
      pub2                                                                                emc.2018.09.010
11
      Janik S, Kliman J, Hacker P, et al. Preserving the thyroidal isthmus           23
                                                                                          Xiao B, Zou Z, Bhandari J, et al. Exposure to diode laser (810nm)
      during low tracheostomy with creation of a Björk flap. Laryngoscope                 affects the bacterial adherence and biofilm formation in a E. faeca-
      2018;128:2783-2789. https://doi.org/10.1002/lary.27310                              lis biofilm model. Photodiagnosis Photodyn Ther 2020;31:101772.
12
      Calhoun KH, Weiss RL, Scott B, et al. Management of the thy-                        https://doi.org/10.1016/j.pdpdt.2020.101772
      roid isthmus in tracheostomy: a prospective and retrospective                  24
                                                                                          Park C, Ko RE, Jung J, et al. Prediction of successful de-cannulation
      study. Otolaryngol Head Neck Surg 1994;111:450-452. https://doi.                    of tracheostomised patients in medical intensive care units. Respir
      org/10.1177/019459989411100410                                                      Res 2021;22:131. https://doi.org/10.1186/s12931-021-01732-w
13
      Dindo D, Demartines N, Clavien PA. Classification of surgical com-             25
                                                                                          Cankar Dal H. Difficult airway management and emergency tracheos-
      plications: A new proposal with evaluation in a cohort of 6336 pa-                  tomy in a patient with giant goiter presenting with respiratory arrest:
      tients and results of a survey. Ann Surg 2004;240:205-213. https://doi.             a case report. Exp Ther Med 2022;24:499. https://doi.org/10.3892/
      org/10.1097/01.sla.0000133083.54934.ae                                              etm.2022.11426
14
      Divisi D, Stati G, De Vico A, et al. Is percutaneous tracheostomy the          26
                                                                                          Osinaike B, Ogunsiji A, Joseph O. Challenging airway management
      best method in the management of patients with prolonged mechani-                   in a patient with retrosternal goiter presenting in respiratory distress.
      cal ventilation? Respir Med Case Rep 2015;16:69-70. https://doi.                    Niger J Surg 2021;27:66-70. https://doi.org/10.4103/njs.NJS_58_19
      org/10.1016/j.rmcr.2015.07.008                                                 27
                                                                                          Kim SM, Kim HJ. Successful advancement of endotrache-
15
      De Leyn P, Bedert L, Delcroix M, et al. Tracheotomy: clinical review                al tube with combined fiberoptic bronchoscopy and vide-
      and guidelines. Eur J Cardiothorac Surg 2007;32:412-421. https://doi.               olaryngoscopy in a patient with a huge goiter. SAGE Open
      org/10.1016/j.ejcts.2007.05.018                                                     Med       Case      Rep     2020;8:2050313X20923232.          https://doi.
16
      McGrath BA, Bates L, Atkinson D, et al. Multidisciplinary guide-                    org/10.1177/2050313X20923232
      lines for the management of tracheostomy and laryngectomy air-                 28
                                                                                          Omokanye HK, Dunmade AD, Segun-Busari S, et al. Accidental de-
      way emergencies. Anaesthesia 2012;67:1025-1041. https://doi.                        cannulation of tracheostomy tubes - Case Series. J West Afr Coll Surg
      org/10.1111/j.1365-2044.2012.07217.x                                                6:108-118.



Appendix 1. Clavien-Dindo classification system for surgical complications (from Dindo et al., 2004, mod.) 13.
 Grade                                                                           Definition
                     Any deviation from the normal post-operative course without the need for pharmacological treatment or a surgical, endoscopic, or
    Grade I          radiological intervention. Allowed therapeutic regimens are drugs such as antiemetics, antipyretics, analgesics, diuretics, electrolytes, and
                     physiotherapy. This grade also includes wound infections opened at the bedside
                     Require pharmacological treatment with drugs other than those allowed for Grade I complications. Blood transfusions and total parenteral
    Grade II
                     nutrition are included
    Grade III        Require a surgical, endoscopic, or radiological intervention
         IIIa        Intervention not under general anesthesia
         IIIb        Intervention under general anesthesia
    Grade IV         Life-threatening complications (including central nervous system complications) requiring intermediate care or intensive care unit management
         IVa         Single organ dysfunction (including dialysis)
         IVb         Multiorgan dysfunction
    Grade V          Death of the patient




                                                                                                                                                              107
