Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Aug 2018




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Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
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Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2011 | Month : December | Volume : 5 | Issue : 8 | Page : 1499 - 1501

A Case for Bleeding: Structures at the Risk of Injury during Invasive Procedures of the Cricothyroid Membrane

Ivan James Prithishkumar, Christilda Felicia

1. M.S., Anatomy Institute of Anatomy, Madras Medical College and Research Institute, Chennai 600003, India. 2. M.S., Anatomy Institute of Anatomy, Madras Medical College and Research Institute, Chennai 600003, India.

Correspondence Address :
Ivan James Prithishkumar
Department of Anatomy
Christian Medical College
Vellore - 632002, India.
Phone: +91 416 2284245
Fax: +91 416 2262788
E-mail: drivanjames@gmail.com

Abstract

Background: Transcutaneous puncture of the cricothyroid membrane is a component of several important invasive clinical procedures, including surgical cricothyroidotomy. One of its most feared complications is endolaryngeal haemorrhage that has been fatal at times.

Aim: Our aim was to determine the structures at the risk of injury during procedures which involved puncture of the cricothyroid membrane.

Methods: Anterior neck dissection was done on sixty three cadavers in a tertiary care, university teaching hospital. Results: Several structures were noted to be anterior to the membrane, such as the paired and the median anterior jugular veins, the transverse cricothyroid artery, the median descending artery, the sternohyoid muscle, the pyramidal lobe of the thyroid gland, the thyroidea ima artery and the jugular venous arch. The transverse cricothyroid artery was seen anterior to the upper 1/4th of the membrane in 98% of the cadavers. In most of the cadavers, the right and left transverse cricothyroid arteries joined to form a median descending artery. Both the transverse cricothyroid artery and the median descending artery gave multiple branches that perforated the cricothyroid membrane.

Conclusion: All invasive procedures require a firm grounding in anatomy. Regarding surgical cricothyroidotomy, the authors recommend an initial vertical incision of the skin and the investing layer of the deep cervical fascia, followed by a horizontal incision of the cricothyroid membrane, just above the arch of the cricoids, to avoid the transverse cricothyroid artery. For needle procedures, the authors suggest an anterior midline approach, immediately above the arch of the cricoid.

Keywords

Clinical anatomy, Cricothyroidotomy

INTRODUCTION
Puncture of the cricothyroid membrane or the median cricothyroid ligament (situated between the cricoid and the thyroid cartilage) is a component of several invasive clinical procedures such as surgical cricothyroidotomy for emergency airway access into the subglottic larynx, minitracheotomy for the clearance of excess tracheobronchial secretions, botox injections into the vocal cord for patients with adductor spasmodic dysphonia, scintigraphic measurement of the tracheal mucus velocity in patients with mucociliary dyskinaesia and retrograde intubation of the larynx. One of its most dreaded complications is acute endolaryngeal haemorrhage, which has been reported to be fatal by several clinicians (1),(2),(3),(4),(5). The aim of the present study was to determine the vascular and other soft tissue structures which lie anterior to the cricothyroid membrane and could be at a risk of injury during the puncture of the membrane. An awareness of such anatomical considerations would result in safer surgical procedures.

Material and Methods

Anatomic dissection was done on sixty three cadavers at Madras Medical College and Research Institute in Chennai, India, which is a tertiary care, university teaching hospital. The skin of the infra-hyoidregion of the neck was incised and reflected; the superficial fascia was examined for vascular structures and platysma. The investing layer of the deep cervical fascia was reflected and the infra hyoid group of the strap muscles were retracted. The pre-tracheal fascia was incised, and the vascular and the soft-tissue structures in front of the cricothyroid membrane were identified. All the vascular and soft tissue structures which were anterior to the cricothyroid membrane were noted. Their frequency and their percentage of occurrence were determined.

Results

Various blood vessels and soft tissue structures were encountered anterior to the cricothyroid membrane; their frequency and percentage of occurrence is shown in (Table/Fig 1).

The anterior jugular vein was seen to course vertically downwards in the superficial fascia, in the region which was anterior to the cricothyroid membrane in 21 cases (33%). It was present as one of the following types: a) as a single median jugular vein in 6 cases (10%) (Table/Fig 2) as an unpaired unilateral vein in 4 cases (6%); c) as paired anterior jugular veins in 12 cases (19%) [Table/Fig 2b and d] as triple jugular veins (a median jugular vein in addition to the paired jugular veins in 13 cases (21%). Surprisingly, the anterior jugular venous system was completely absent in 28 cases (44%).

The jugular venous arch connects the two anterior jugular veins and it is normally situated in the suprasternal space of Burns. In the present study, the jugular venous arch was seen as a rare occurrence opposite the cricothyroid space in one case (1.6%).

The paired sternohyoid muscles lay close to each other on either side of the midline. The medial borders of the muscles touched each other in the midline in 31 cases (49%).

The transverse cricothyroid artery was seen in 62 cases (98%). In all the cases, it was seen to run anterior to the upper 1/4th of the cricothyroid membrane, close to lower border of the thyroid cartilage (Table/Fig 3). In 94% of the cases, it arose as a branch from the main pedicle of the superior thyroid artery, but in 6% of the cases, it arose as a branch from the superior laryngeal artery.

In 92% of the cases, the right and the left transverse cricothyroid arteries joined in the midline to form a median descending artery, which ran downwards to a variable extent, and ended by supplying the isthmus of the thyroid gland, the pyramidal lobe of the thyroid gland, the levator glandulae thyroidea and the strap muscles. The median descending artery anastomosed with the anterior descending branches of the superior thyroid artery, along the upper border of the isthmus of the thyroid in 13 cases (21%). Only in one case (1.6%), the median artery ascended beneath the lower border of the thyroid cartilage.

The transverse cricothyroid arteries and the median descending artery gave branches that perforated the cricothyroid membrane in 46 cases (73%). Multiple small perforations were seen in few cases, and single large perforations were seen in most of the cases (Table/Fig 4). These perforating vessels were thought toanastomose with the endolaryngeal arteries.

In one case (1.6%), the thyroidea ima artery which arose from the arch of the aorta, crossed the cricothyroid membrane to reach up to the level of the hyoid bone.

The levator glandulae thyroideae was seen in 13 cases (21%), to lie anterior to the cricothyroid membrane.

The pyramidal lobe of the thyroid gland was seen in 10 cases (16%), to lie anterior to the cricothyroid membrane (Table/Fig 4).

The tributaries of the superior thyroid vein crossed the cricothyroid membrane only in two cases (3.1 %).

Discussion

There is a crucial role for a sound understanding of the underlying anatomy of any clinical procedure (6).Several vascular and softtissue structures lie anterior to the cricothyroid membrane and are at a risk of injury during these invasive clinical procedures. These structures can often complicate the performance of a cricothyroidotomy.

(1) The anterior jugular vein: Single or paired anterior jugular veins were found to course across the region of the membrane in 21 cases (33%). Brofeldt et al. (1982) reported bleeding from the anterior jugular veins in one patient during a cricothyroidotomy (7). Dover et al. (1996) found the paired anterior jugular veins to cross the membrane in a vertical direction in a majority of his specimens and suggested a midline approach to avoid this structure (8).

(2) The transverse cricothyroid artery: The transverse cricothyroid artery was seen close to the lower border of the thyroid cartilage in 98% of the cadavers. Dover et al. (1996), in their landmark article, reported that the cricothyroid artery coursed across the upper one-third of the membrane in 13 out of 15 specimens (93%) (8). Bennett et al (1996) reported that an artery ran transversely across the cricothyroid membrane in only 8 out of 15 subjects (62%) (9). In the present study, the transverse cricothyroid artery was found to arise as a branch from the main pedicle of the thyroid artery in 94% of the cadavers, and in only 6% of the cadavers, it arose as a branch from the superior laryngeal artery. Dover et al. (1996) found the cricothyroid artery to arise from the superior thyroid artery in 93% of the cases (8). However, Lippert et al (10) and Bergmann et al (11) reported that the cricothyroid artery usually arose from the superior laryngeal branch of the superior thyroid artery.

(3) The median descending artery: The transverse cricothyroid artery and the median descending artery gave smaller branches that perforated the upper part of the cricothyroid membrane in 46 cases (73%). These perforators anastomosed with the endolaryngeal vessels and were implicated in the extra-laryngeal spread of laryngeal cancers. Ortug et al. (2005) studied the vascular anatomy of the cricothyroid space in 50 Turkish cadavers and found the vessels to pass through the foramens in the membrane in 20 cases (40%) (12).

(4) The superior and the inferior thyroid veins: Only in two cases (3%), the tributaries of the superior thyroid vein crossed anterior to the membrane. However, Krausen (13) and Dover et al. (8) found numerous tributaries of the superior and inferior thyroid veins to cross the cricothyroid membrane. This may be a racial variation.

(5) The paired sternohyoid muscles: The paired sternohyoid muscles were close to the midline, anterior to the cricothyroid membrane in 45 cases (71%). The muscles being vascular structures, are capable of haemorrhage. The sternohyoid is at a risk of being incised, especially during surgical cricothyroidotomy, when a horizontal stab incision is made above the cricoid cartilage.

(6) The pyramidal lobe of the thyroid gland: The pyramidal lobe was anterior to the cricothyroid membrane in 16% of the cadavers. Boon et al. (2004) stated that the pyramidal lobe may extend as high as the hyoid bone in 40% of the people and that it may be at a risk of injury during a cricothyroidotomy (14).

The frequency of occurrence of the structures such as the median descending cricothyroid artery, the thyroidea ima artery, the jugular venous arch and the levator glandulae thyroidea have not been discussed for want of comparative data in the literature. Allthe vascular and soft tissue structures which were encountered anterior to the cricothyroid membrane must be known to the clinicians, who should anticipate them when they do invasive procedures. The occurrence of uncommon structures is more dangerous.

Conclusion

Postgraduate students and residents are called to perform a variety of invasive procedures during their training. All the clinical procedures, however simple they may seem, require a firm grounding in anatomy. Invasive procedures that fail to achieve their objectives, or that result in complications, are often linked to a lack of understanding or misunderstanding of the anatomy (15). Various structures which are mentioned above can complicate the performance of a cricothyroidotomy. Regarding surgical cricothyroidotomy, the authors suggest a vertical incision of the skin and investing the deep cervical fascia (to avoid the vertically oriented venous structures), followed by a horizontal incision of the cricothyroid membrane (close to the lower border of the membrane, just above the arch of the cricoid) to avoid the transverse cricothyroid artery. For needle cricothyroidotomy, the authors suggest an anterior midline approach which is immediately superior to the arch of the cricoid. The authors believe that the findings of this study would be useful in planning for any invasive procedure of the cricothyroid membrane.

Key Message

Acute endolaryngeal haemorrhage is a dreaded complication, following cricothyroidotomy. There is a crucial role for a sound understanding of its underlying anatomy to ensure a safe performance. This study shows the structures which are at a risk of injury during a cricothyroidotomy.

References

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Safar P, Penninckx J. Cricothyroid membrane puncture by using a special cannula. Anesthesiology 1967; 28:943-48.
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Unger KM, Moser KM. Fatal complications of transtracheal aspiration. Arch Intern Med 1973; 132:437-39.
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Donald PJ, Berstein L. Subglottic hemorrhage following translaryngeal needle aspiration. Report of a case. Arch Otolaryngol 1975; 101:395- 96.
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Schilliaci RF, Lacovani VE, Conte RS. Transtracheal aspiration which was complicated by fatal endobraonchial hemorrhage. New Engl J Med 1976; 295:488-90.
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McGill J, Clinton JE, Ruiz E. Cricothyroidotomy in the emergency department. Ann Emerg Med 1982; 10:387-89.
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American Association of Clinical Anatomists. The Educational Affairs Committee. The clinical anatomy of several invasive procedures. Clin Anat 1999; 12:43-54.
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Brofedlt BT, Panacek EA, Richards JR. An easy cricothyrotomy approach: the rapid four-step technique. Acad Emerg Med 1982; 3:1060-63.
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Dover K, Howdieshell TR, Colborn DL. The dimensions and vascular anatomy of the cricothyroid membrane: relevance to emergent surgical airway access. Clin Anat 1996; 9:291-95.
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Bennett JD, Guha SC, Sankar AB. Cricothyrotomy: the anatomical basis. J R Coll Surg Edinb 1996; 41(1):57-60.
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Lippert H, Pabst R. Arterial variations in man: classification and frequency. Munich: J.F. Bergmann. 1985
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Bergmann RA, Thompson SA, Afifi AK, Saadch FA. Compendium of the human anatomic variation. Baltimore: Urban and Schwarzenberg. 1988; 353-67.
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Ortug G, Ortug C, Gunduz T. Clinical implication of vascular and dimensional aspects of the cricothyroid space in the Turkish population. Saudi Med J 2005; 26(5): 718-22
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Kraussen AS. The inferior thyroid veins--the ultimate guardians of the trachea. Laryngoscope. 1976; 86(12): 1849-55
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Boon JM, Abrahams PH, Mering JH, Welch T. Cricothyroidotomy: A clinical anatomy review. Clin Anat 2004; 17:478-86
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Graney DO. Clinical anatomy. Clin Anat 1996; 9:61

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