Topographic variations in anatomical structures of the anterior

neck of children
An ultrasonographic study

Rüdiger Emshoff, MD, DMD,a Stefan Bertram, MD, DMD,b and Alfons Kreczy, MD,c Innsbruck,
Austria
UNIVERSITY OF INNSBRUCK

Objective. Tracheostomies in children are frequently used for temporary airway support during surgical procedures. In pedi-
atric patients with congenital craniofacial malformations, preoperative assessment of the delicate anatomy of the airway is
necessary. The purpose of this study was to assess the ultrasonographic anatomy of the anterior neck with regard to the perfor-
mance of tracheostomy.
Study design. Ultrasonographic investigation was done in 50 pediatric patients (age range, 6 to 15 years) to analyze the rela-
tionships among the anatomical structures that are of practical interest with respect to tracheostomy.
Results. The data reveal that information concerning variations in anatomical structures lying in the immediate vicinity of the
tracheostomy site was readily obtainable with the techniques used.
Conclusions. In pediatric patients requiring tracheostomy for surgical treatment of severe congenital craniofacial malforma-
tions, preoperative ultrasonography may be used to diagnose individual anatomical variations at the tracheostomy site.
(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:429-36)

For certain maxillofacial and craniofacial procedures
in children, elective tracheostomy is often required.1,2
A review of the literature shows pediatric tracheostomy
to be a surgical intervention with significant morbidity
and mortality. The most frequent complications
encountered are hemorrhage, pneumothorax, pneumo-
mediastinum, tracheal stenosis, and delayed decannu-
lation.3-7 The complication rates from tracheostomy in
children range from 19% to 49% in the literature,5-9
whereas the incidence of tracheostomy-related
mortality is reported to be between 0% and 3.4%.6,8-12
In view of the fact that many congenital malforma-
tions are associated with structural anomalies of the
upper airway tract and the cardiovascular system, due
emphasis must be given to accurate identification of
the anatomical structures lying in the immediate
vicinity of the tracheostomy site. In children with
tracheal stenosis,13-16 trachiobronchiomegaly,17,18
tracheal bronchus,19,20 and vascular anomalies21,22 in
front of the cervical trachea, correct placement of the
stoma may be of great significance with regard to mini-
mizing complications both operatively and postopera-
tively. In addition, a cervical location for the pleural
domes has been reported to be related to pneumo-
aResident, Department of Oral and Maxillo-Facial Surgery.
bConsultant, Department of Oral and Maxillo-Facial Surgery.
cAssistant Professor, Department of Pathology.
Received for publication July 30, 1998; returned for revision Sept 23,
1998; accepted for publication Nov 12, 1998.
Copyright © 1999 by Mosby, Inc.
1079-2104/99/$8.00 + 0 7/12/95980
thorax, a complication occurring most frequently
among pediatric patients.7,23 To demonstrate the value
of preoperative high-resolution grayscale ultrasonog-
raphy, we used this technique to assess the ultrasono-
graphic anatomy of the anterior neck with regard to the
performance of tracheostomy.
MATERIAL AND METHODS
The subjects in this study were 50 children (28 boys
and 22 girls) between 6 and 15 years of age who were
referred to the Department of Oral and Maxillofacial
Surgery for treatment of odontogenic-related prob-
lems. Informed consent was received from both the
children and their parents. Longitudinal and transverse
scans were carried out with a linear (B-scan) 7.5-MHz
small-part transducer. The transducer was connected to
a Picker (Picker International GmbH, Vienna, Austria)
echocamera (CS 9300); the measurements were made
directly on the screen at the time of scanning, with a
readout of distance to the nearest 0.1 mm. The sono-
grams were performed by a single oral and maxillofa-
cial surgeon experienced in ultrasonography of the
neck. The trials were performed in a darkened room
with the patient in a supine position and the head
slightly hyperextended.
To assess the ultrasonographic anatomy of the larynx
and the subglottic region, we positioned the transducer
against the patient’s neck in a vertical direction; sequen-
tial parallel shifts of transverse scans were performed to
obtain local cross-sectional images perpendicular to the
orientation of the larynx (Fig 1). To evaluate topo-

429
430 Emshoff, Bertram, and Kreczy ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
April 1999

Fig 1. Schematic drawing of superior portion of trachea, including larynx, cricoid cartilage, tracheal rings,
common carotid arteries, and pleural domes.

Table I. Ultrasonographic local cross-sectional dimensions between anatomical structures of the anterior neck (n = 50)
Local cross-sectional dimension (mm)
Males (n = 28) Females (n = 22) 6-10 y (n = 31) 11-15 y (n = 19)
Distance M SD M SD M SD M SD s(i)
Cricoid cartilage–2nd tracheal ring 6.9 1.79 7.0 1.90 5.9* 0.93 8.7 1.61 0.16
2nd tracheal ring–4th tracheal ring 7.7 1.72 7.7 1.74 6.6* 1.08 9.5 0.95 0.28
2nd tracheal ring–common carotid artery 8.3 2.20 8.2 2.10 6.9* 0.88 10.5 1.52 0.29
4th tracheal ring–common carotid artery 7.5 3.26 7.5 1.38 5.5* 1.71 10.9 2.24 0.41
M, Mean; SD, standard deviation; s(i), method error.
*P < .001 (data analyzed by independent samples t test)

graphic variations in the linear arrangement of tracheal
rings in a first series of measurements, we positioned
the transducer against the patient’s neck in a horizontal
direction overlying the trachea; the transducer was then
tilted until optimal longitudinal scan planes of the
trachea were obtained. Unilateral images were recorded
to assess local cross-sectional dimensions (LCSDs) for
the distance from the caudal border of the cricoid to the
second tracheal ring (LCSDC-R2) and the distance from
the second tracheal ring to the fourth tracheal ring
(LCSDR2-R4 ; Fig 1).
In the second series of the study, the topographic
variations in the course of the trachea to the common
carotid artery were evaluated. The transducer was posi-
tioned against the patient’s neck in a vertical direction,
and the scan planes were orientated perpendicular to
the long axis of the trachea at the height of the second
and fourth tracheal rings until optimal transverse cross
sections were obtained. Sequential unilateral images
were recorded for the sake of assessing the LCSDs for
the distances from the lateral border of the second
tracheal ring to the ipsilateral common carotid artery
(LCSDR2-CC) and from the lateral border of the fourth
tracheal ring to the ipsilateral common carotid artery
(LCSDR4-CC; Fig 1).
To evaluate the feasibility of ultrasonography in
assessment of the occurrence of cervical location for
the pleural domes, we used a technique that involved
positioning the transducer against the patient’s neck in
a vertical direction, using scan planes orientated
perpendicularly to the long axis of the trachea at the
height of the fourth tracheal ring (Fig 1). The patient
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
Volume 87, Number 4
Fig 2. Ultrasound image of larynx (arrows) produced with
transverse scan. L, Larynx.
Fig 4. Relative frequency distribution regarding distances from caudal border of cricoid cartilage to second
tracheal ring.
was diagnosed with cervical location of the pleural
domes when the right and/or left apex of the pleural
dome became visible on the respective transverse cross
sections during maximum inspiration.
Method error (s[i]), defined as
s(i) = √∑d2/2n,
where d is the difference between the second and first
recordings and n is the number of double measure-
ments within a session, was evaluated in 10 randomly
Emshoff, Bertram, and Kreczy 431
Fig 3. Ultrasound image of superior portion of trachea
produced with sagittal scan. Electronic calipers used for
establishing reference points for linear measurements indicate
transverse diameter of trachea at height of first (D1) and
second (D2) tracheal rings. C, Cricoid cartilage; R2, second
tracheal ring; R4, fourth tracheal ring.
selected patients who did not participate in this study.
The outcomes are shown in Table I. An independent-
samples t test was performed to test for age-related and
gender-related differences in LCSDs. Significance was
set at P < .05. For all statistical analyses, the SPSS×
package (SPSS Inc) was used.
RESULTS
Through use of the techniques of sequential parallel
transverse scanning, the larynx is sonographically visu-
432 Emshoff, Bertram, and Kreczy
Fig 5. Relative frequency distribution regarding distances from second tracheal ring to fourth tracheal ring.
Fig 6. Ultrasound image of superior portion of trachea
produced with transverse scan at height of second tracheal
ring. Pulsed Doppler techniques reveal location of common
carotid arteries and other adjacent vessels. Electronic calipers
were used for establishing reference points for linear measure-
ments. D2, Measured distance between second tracheal ring
(R2) and common carotid artery (arrows); D1, transverse
diameter of trachea at height of second tracheal ring.
alized as a leaf-shaped structure, with a hypogenic
center that corresponds to the various muscular and
ligamentous portions and a hypergenic contour formed
by the respective cartilaginous architecture (Fig 2).
Following the course of the larynx from cranial to
caudal, the subglottic region may be distinguished by
its semicircular shape as it forms the anterior cartilagi-
nous and posterior muscular-ligamentous relations.
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
April 1999
When the patient swallows, the mobility of the struc-
tures can be recorded and investigated in real time.
There were no failures with respect to imaging and
assessment of the various LCSDs. In sagittal scans,
ultrasonography produced a well-defined depiction of
the cricoid cartilage and the various tracheal rings, with
distinct dense echoes forming the typical linear
arrangement (Fig 3). The relative frequency distribu-
tion of the LCSDs for the distance between the caudal
border of the cricoid cartilage and the second tracheal
ring and the distance between the second tracheal ring
and the fourth tracheal ring are presented in Figs 4 and
5. With a mean distance of 6.96 mm, the second
tracheal ring was found to be located between 4.3 and
8.3 mm from the caudal border of the cricoid cartilage
in 84% of the subjects, whereas in the other 16% the
distance was between 8.3 and 12.3 mm. The distance
from the second to the fourth tracheal ring was between
3.3 and 4.1 mm in 4% of the subjects, between 5.7 and
9.7 mm in 86%, and between 10.5 and 11.3 mm in 10%
(mean, 7.71 mm). For the ultrasound measurements
there was a significant age-related difference in the
mean LCSDs between the 6-to-10–years age group and
the 11-to-15–years age group for LCSDC-R2 (5.8 mm
vs 8.6 mm; P < .001) and LCSDR2-R4 (6.6 mm vs 9.4
mm; P < .001), whereas no gender-related difference
was found between the respective LCSDs (Table I).
On transverse scans, a sectional view reveals the
trachea and the left and right common carotid arteries as
anechoic circles with a solid circumference. The
mobility of the trachea may be demonstrated in real
time by having the patient breathe; use of pulsed
Doppler techniques may reveal the location of the
common carotid arteries and other adjacent vessels (Fig
6). The height of the second tracheal ring was found to
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
Volume 87, Number 4
Fig 7. Relative frequency distribution regarding distances from second tracheal ring to common carotid artery.
Fig 8. Relative frequency distribution regarding distances from fourth tracheal ring to common carotid artery.
be less than 7.4 mm from the common carotid artery in
44% of the subjects (Fig 7), whereas the fourth tracheal
ring was less than 7.4 mm from the common carotid
artery in 54% of the subjects (Fig 8). When the age-
related and gender-related LCSDs were analyzed, a
significant difference in the mean LCSDs was observed
between the 6-to-10–years and 11-to-15–years age
groups for LCSDR2-CC (6.7 mm vs. 10.6 mm; P < .001)
and LCSDR4-CC (5.5 mm vs. 11.1 mm; P < .001),
whereas no significant difference was found between
the respective gender-related LCSDs (Table I).
Fig 9, the result of a transverse scan made at the
height of the fourth tracheal ring, shows detailed visu-
alization of the trachea, the common carotid arteries,
and the pleural domes. With regard to the occurrence
of cervical location of the pleural domes, the respec-
tive diagnosis was a common finding in the 6-to-
10–years age group, whereas in the 11-to-15–years
Emshoff, Bertram, and Kreczy 433
age group visualization of the apices was difficult in
most instances.
DISCUSSION
The purpose of this study was to evaluate the feasi-
bility of preoperative ultrasonography as a method of
visualizing anatomical structures, variations of which
may cause complications during elective tracheostomy.
The most common acquired lesion of the larynx
described in the literature is subglottic stenosis related to
trauma from endotracheal tubes used in association with
mechanical ventilation24,25; in addition, a number of
congenital anomaly syndromes were found to be associ-
ated with functional laryngomalacia or with structural
malformations of the larynx.13,26 Laryngotracheal
stenosis and consequent decannulation difficulties have
been reported to be a result of subglottic damage occur-
ring during tracheostomy and affecting the cricoid carti-
434 Emshoff, Bertram, and Kreczy
Fig 9. Ultrasound image of superior portion of trachea
produced with transverse scan at height of fourth tracheal ring.
Electronic calipers were used for establishing reference points
for linear measurements. Arrow indicates location of apices of
pleural domes. D2, Measured distance between fourth tracheal
ring (R4) and common carotid artery (arrows); D1, transverse
diameter of trachea at height of fourth tracheal ring.
lage and first tracheal ring.3,4 In this study, it was
possible to visualize the larynx and the subglottic region
in all of the subjects. The second tracheal ring was
shown to be located between 4.3 and 8.3 mm from the
cricoid cartilage in 74% of patients. With regard to the
anatomical variations, preoperative ultrasonography is
of value in verifying the precise tracheostomy position
and thereby preventing subglottic damage of the cricoid
cartilage and the first tracheal ring.
Although malformations of the trachea are commonly
associated with recurrent pneumonia, stridor, and respi-
ratory distress, there are rare cases of congenital tracheal
malformation that remain undiagnosed during infancy
and early childhood. Complete tracheal cartilage rings14
and cartilage plate deficiencies13 have been related to the
occurrence of tracheal stenosis, most forms of which are
described as generalized, funnellike, or segmental.13-16
In tracheobronchiomegaly there is an outpouching of the
tracheal lumen between tracheal cartilage rings that
produces multiple diverticula.17,18 With regard to our
finding that a detailed visualization of the cartilaginous
architecture of the trachea was readily obtainable with
the techniques used, ultrasonography may be beneficial
in the effort to identify the presence, site, and dimen-
sions of trachea-related malformations.
The results of our study showed the distance between
the second tracheal ring and the fourth tracheal ring to
range from 3.3 to 11.3 mm. This finding suggests that
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
April 1999
Fig 10. Anatomical situation of upper airway in pediatric
patient; topographic relationship of adjacent common
carotid arteries and pleural domes is shown. C, Common
carotid arteries.
preoperative knowledge of the topographic position of
the various cartilage rings may be important for the sake
of avoiding inadvertent placement of the stoma, espe-
cially in children with congenital malformations and
particularly in instances where hyperextension may
cause several tracheal rings to move far up into the neck.
Immediate and delayed bleeding, the most severe
complication associated with tracheostomy, can be due
to erosion of the innominate artery; the major factor is
tracheostomy at the fourth tracheal ring or lower.27,28
Vascular malformations situated suprasternally in front
of the cervical trachea have been described and related
to the onset of fatal hemorrhages both operatively and
postoperatively.29,30 Abnormally placed or abnormally
large blood vessels, such as branches of the vascular
ring passing anteriorly to the trachea and an anomalous
left carotid or innominate artery, may be present in the
immediate vicinity of the tracheotomy site.22 Although
no major vascular anomalies were observed in this
study, the data on anatomical variations with respect to
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
Volume 87, Number 4
the relation of the common carotid artery to the second
and fourth tracheal ring may indicate the possibility of
irregular vessel courses.
Several authors5-9 have reported tracheostomy in chil-
dren to be associated with considerably higher morbidity
than tracheostomy in adults, the major factor being the
particularly higher incidences of pneumothorax and
pneumomediastinum in children. However, only a few
studies are available that describe complications in rela-
tion to specific pediatric age groups. In the study of
Oliver,31 which included tracheostomies performed on
children less than 18 years of age, all operative compli-
cations and 85% of postoperative complications
occurred in children not yet 5 years old, whereas
McClelland32 found the 0-to-9–years age group to be
associated with significant higher incidences of periop-
erative complications than the 10-to-19–years age
group. The data of our study suggest that age may have
a significant effect on variations of the anatomical struc-
tures lying in the immediate vicinity of the tracheostomy
site. With the most prominent finding of significant
lower LCSDs associated with the 6-to-10–years age
group in comparison with the 11-to-15–years age group,
further prospective studies may be warranted to assess
whether age-related topographic variations may be an
important factor in determining the incidence rate of
specific tracheostomy-related complications.
Ultrasonographic investigation in this study was
done with the subject in a supine position and the head
slightly hyperextended. In children in whom
tracheostomy is performed with the neck hyperex-
tended, vascular structures that normally occupy the
superior mediastinum may come to lie in this upward
extension in the neck and therefore lie in front of the
cervical trachea (Fig 10).27,33 Because these positional
changes must be considered a major factor in the
pathogenesis of operative profuse hemorrhage in chil-
dren, further studies are indicated to evaluate the effect
of hyperextension on the position of vascular structures
lying in the vicinity of the tracheostomy site.
The lateral structure most frequently injured during
tracheostomy is the pleura, damage to which produces
pneumothorax, which has been reported in as many as
5% of cases.34 Rabuzzi35 reported pneumothorax in
17% of 46 tracheostomies performed in children under
the age of 12 years. In numerous articles, pneumo-
thorax and pneumomediastinum have been said to be
the most common immediate complications.9,36 The
high incidence rates of pneumothorax described in
pediatric series are considered to be due to the fact that
the pleural domes in children lie higher in the neck and
are thus more prone to inadvertent injury during
tracheostomy. Although the findings of our study
suggest the occurrence of cervically located pleural
Emshoff, Bertram, and Kreczy 435
domes to be more prominent in the 6-to-10–years age
group than in the 11-to-15–years age group, ongoing
studies using more favorable ultrasonic imaging tech-
niques may be warranted to assess the effect of age on
the topographic variations of pleural domes relevant to
the performance of tracheostomy in children.
CONCLUSION
Pediatric patients with congenital craniofacial
malformations may require tracheostomy; however,
tracheostomy in children is associated with operative and
postoperative difficulties. Real-time ultrasonography, a
noninvasive, rapid, and reliable method by which struc-
tures of the infrahyoid region can be visualized, may
become useful in verifying precise tracheostomy posi-
tions and avoiding inadvertent injuries.
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Reprint requests:
Rüdiger Emshoff, MD, DMD
Höhenstraβe 5
A-6020 Innsbruck
Austria

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