Emergency front-of-neck access: cricothyroidotomy and tracheostomy

What it is

Front-of-neck access means opening the airway through the skin of the neck. In an emergency the route is the cricothyroid membrane, which is shallow, has few vessels and is easy to find: this is cricothyroidotomy, done by an emergency physician, anaesthetist or surgeon in the emergency room or theatre. A tracheostomy goes through the anterior wall of the trachea below the cricoid; it is a planned operation by ENT or a surgeon in theatre or at the ICU bedside. This page is an educational overview, not a guide to performing the procedure.

Indications and contraindications

• Cricothyroidotomy: cannot intubate and cannot oxygenate despite optimal attempts; massive facial trauma or upper airway obstruction that prevents intubation.
• Relative contraindications: young children (use the needle technique), laryngeal fracture or tracheal transection, a mass over the membrane.
• Tracheostomy: prolonged mechanical ventilation, obstruction above the larynx or at the glottis, airway protection and access for suction, planned head and neck surgery.
• An awake tracheostomy under local anaesthesia is chosen when the airway is threatened but the patient still breathes on their own.

How it is done

1. Recognise failure early: failed intubation, failed supraglottic device and falling saturation mean it is time for front-of-neck access.
2. The neck is extended and the larynx is held between thumb and fingers to find the cricothyroid membrane (laryngeal handshake).
3. Scalpel technique: a transverse stab incision through the membrane, a bougie into the trachea and a small cuffed tube over it.
4. If the membrane cannot be felt, a vertical midline skin incision and blunt dissection reveal the landmarks.
5. Tube position is confirmed with continuous waveform capnography and bilateral chest movement.
6. In young children, a cannula through the membrane gives temporary oxygenation until a definitive airway is made.
7. Formal tracheostomy: done in theatre or ICU, through the trachea below the cricoid, open or percutaneous.

Complications

• Bleeding from the anterior jugular veins, the thyroid isthmus or its vessels.
• False passage in front of the trachea, with subcutaneous emphysema and failed ventilation.
• Injury to the posterior tracheal wall or the oesophagus.
• Pneumothorax and pneumomediastinum.
• Late: subglottic stenosis, voice change, infection and tube displacement.

Next step / Initial management

• Confirm the airway with waveform capnography; then chest X-ray for tube position and pneumothorax.
• After the emergency, plan conversion of a cricothyroidotomy to a tracheostomy or to oral intubation by an airway team.
• Refer to ENT or a head and neck surgeon urgently, the same day, for any surgical airway made in an emergency and for formal tracheostomy planning.
• Record what was done and which tube was placed; make sure spare tubes and the tracheostomy emergency plan are at the bedside.

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Educational content; it does not replace a medical assessment and is not a clinical instruction. For a real case, follow current guidelines and specialist advice.

Sources: Cricothyroidotomy (StatPearls) (StatPearls Publishing, NCBI Bookshelf, 2025); Tracheostomy (StatPearls) (StatPearls Publishing, NCBI Bookshelf, 2026).

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Representative model, for educational purposes only.