**3. Conclusion**

life-threatening complication is a tracheo-innominate fistula. These are linked to low-placed tubes and patients with excessive movement of the head. This complication has a 25% mortality rate [27]. If it does occur, manual pressure over the tract or over inflation of the cuff when it is seated in this tract can help tamponade the bleed until the patient can be taken back to the

Tracheostomy placement in the form of an open versus percutaneous approach has been evaluated in many studies, to see if there is an advantage of one approach over the other. A Cochrane analysis of all randomized control and quasi-randomized control studies, evaluated approximately 20 trials that compared percutaneous to open technique [28]. The goal was to evaluate whether there was a higher complication profile amongst one technique over the other. The review looked at studies completed in an ICU over an emergency room setting. Overall, the systematic showed some benefits in terms of effectiveness and safety of the use of percutaneous techniques for tracheostomy, especially in regards to rates of late non-life threatening complications. However there is overall low quality evidence to suggest a difference in postoperative mortality or total mortality from life threatening complications like bleeding, between the two techniques. Generalizability of one technique over the other was

The review concluded that open tracheostomy may still be indicated for selected patients, despite the continuing broader indications for use of percutaneous technique [28]. Again, this review did not evaluate studies that looked at the use of percutaneous tracheostomy in an

The role of the otolaryngologist-head and neck surgeon is to be an important counterpart to the team involved in a difficult airway. O'dell describes the role of the otolaryngologist as involved in the preoperative evaluation of a difficult airway and the comprehensive algorithm in identifying and evaluating the airway prior or during induction of general anesthesia [4]. The fiberoptic laryngoscopy, used in evaluating the airway, is the trademark tool of the otolaryngologist. The technical expertise and familiarity with the upper airway and larynx allows an otolaryngologist to screen a difficult airway [5], as well as provide therapeutic means to fiberoptically intubate at the same time if needed. Nasotracheal intubations done with the use of a fiberoptic laryngoscope is a common practice, and can be done with the patient spontaneously breathing. The availability and expertise with certain equipment allows the otolaryngologist a more invasive approach to the airway, with determination of what branch of the difficult airway algorithm should be taken next based

An otolaryngologist is also equipped to handle the placement of a surgical airway whether it is an awake tracheostomy in a controlled setting for a patient with known upper airway obstruction and difficult intubation [4, 26]. An otolaryngologist is also able to assist in placement of an emergency surgical airway, with most otolaryngologists placing an emergent tra-

operating room for further exploration.

122 Tracheal Intubation

not possible according to the Cochrane review [28].

**2.6. The role of the otolaryngologist-head and neck surgeon**

emergent, difficult airway setting.

upon findings.

cheostomy over a cricothyroidotomy [23, 26].

In conclusion, the definition of a difficult airway is not rigid, nor is it an over-arching diagnosis. A difficult airway can come in all shapes and sizes, keeping in mind that an airway is never stable without ability to oxygenate or ventilate. The importance of a difficult airway algorithm is crucial in organization of steps involved in securing the airway. A difficult airway does not necessarily have to be an emergency, but it does take require a team approach to initiate the appropriate steps in saving a life. Resources such as equipment available to secure a difficult airway, the steps involved in performing a surgical airway, and the pros and cons of a tracheostomy over a cricothyroidotomy, were summarized in this chapter. The goal of this chapter is to allow readers to identify the difficult airway and have a broad understanding of how to provide the appropriate care for these patients. For the otolaryngologist, this chapter aims to serve as a guideline by which to address the airway with the tools and resources available, both in a controlled and emergency situation.
