Johnny Argent fell down the stairs, suffered a brain injury and was in a coma. An emergency cricothyroidotomy was performed in order to place a tube that could be connected to a ventilator and breathe for him. The surgeon wanted to avoid stretching his neck, which could occur during a standard intubation, in case he had a cervical spinal cord injury. While most surgeons place a tracheostomy tube through the trachea a few rings below the larynx, Johnny’s breathing tube was placed through the larynx between the cricoid and the thyroid cartilages, perhaps because it was an easier opening to find.
However, this tube was left in place for two weeks, a long time to expose the cartilage of the larynx to the air and the bacteria from the skin edges. When he recovered from his coma, the cricothyroidotomy tube was removed and the opening healed over a few days. However, his voice remained soft and hoarse. He now would like to return to singing the blues, but his upper vocal range is severely restricted. His uppermost pitch is A3, a note which is typically the top of a male’s vocal chest range. He has no falsetto.
On endoscopic examination, he cannot stretch his vocal cords, no matter how high a pitch he attempts to make, and I can see that he is putting in a lot of effort. A CAT scan of his larynx shows that bone has formed between his cricoid and thyroid cartilage. It is located at the edge of where the tracheostomy tube was placed and bridges the gap between the cricoid and thyroid cartilage. He can no longer contract the cricothyroid muscle since the two cartilages are fixed in place by this bridge of bone. The cricothyroid muscle is the one that puts us into falsetto — and since he cannot move the cricothyroid joint, he has no falsetto. We also tighten this joint when we yell, so he cannot yell as loud either.
Most surgeons would avoid placing a cricothyroidotomy or, if they needed to in an emergency, would change it to a regular tracheostomy at the earliest opportunity to avoid this type of later complication.
He elected to have a surgery where the bridge of bone was removed and the cricothyroid joint was mobilized. After surgery, he had restoration of a small portion of his falsetto. He could get louder. However, the joint could not move as well as it did before his cricothyroidotomy.
What you learned
- A cricothyroidotomy places the airway tube directly through the cricothyroid space — the same joint used by the cricothyroid muscle to lengthen the vocal cords for falsetto and yelling.
- Leaving a cricothyroidotomy tube in place for more than a few days exposes the cartilages to bacteria and inflammation, risking heterotopic bone formation that fuses the joint.
- When the cricothyroid joint is fused, the patient loses falsetto entirely (the CT muscle cannot lengthen the cords) and volume is reduced (the joint cannot be tightened when yelling).
- Emergency cricothyroidotomies should be converted to a standard tracheostomy (below the larynx) as soon as safely possible to protect the cricothyroid joint.
- Surgical removal of the bony bridge can partially restore falsetto but rarely returns the joint to full normal mobility.