Question 1

Outline the anatomical relations of the cervical trachea relevant to performing a percutaneous tracheostomy.

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College Answer

•    Trachea is attached superiorly to the cricoid cartilage, by the cricotracheal membrane
•    Trachea is covered anteriorly by skin, superficial fascia, strap muscles
(sternohyoid, sternothyroid), and deep (pretracheal) fascia.
•    2nd to 4th rings of the trachea are covered by isthmus of the thyroid anteriorly.
•    Branches of the superior thyroid artery run along the superior aspect of the thyroid isthmus, anterior to the trachea.
•    Lateral lobes of the thyroid lie between the trachea and the carotid sheath and its contents.
•    Oesophagus lies posterior to the trachea.
•    Carotid sheath containing carotid artery, jugular vein, and vagus nerve lie posterolateral to the trachea.
•    Recurrent laryngeal nerves lie posterolaterally in the grove between the trachea and the oesophagus.
•    Anterior jugular veins are often connected by a vein that runs superficially across the lower neck.
•    Inferior thyroid veins lie anterior to the lower part of the cervical trachea, posterior to the strap muscles.


A picture is worth a thousand words. Instant Anatomy does it best.  However, if words are called for... has an excellent tutorial on this technique. ANZICS also has a position statement for percutaneous tracheostomy.

In short:

  • Anterior to the second and third rings of the trachea, is merely skin, subcutaneous tissue, sternothyroid and sternohyoid muscles, and pretracheal fascia.
  • Sometimes, there is an anterior communicating jugular vein which also travels through this space.
  • Posteriorly lies the oesophagus.
  • Posterolaterally, on either side of the oeseophagus lie the recurrent laryngeal nerves
  • Laterally, on both sides there are the vagus nerves, carotid arteries and the jugular veins, covered by the carotid sheath
  • Superiorly is the cricoid cartilage and the cricothyroid membrane
  • Inferiorly lies the isthmus of thyroid and the inferior thyroid veins


Superficial anatomy of the neck for percutaneous tracheostomy


Muhammad, Joseph Kamal, Edward Major, and David William Patton. "Evaluating the neck for percutaneous dilatational tracheostomy." Journal of Cranio-Maxillofacial Surgery 28.6 (2000): 336-342.

Epstein, Scott K. "Anatomy and physiology of tracheostomy." Respiratory care 50.4 (2005): 476-482.