Cricotracheostomy is a useful surgical procedure for opening the airway in cases where conventional tracheotomy is difficult. This is a safe and easy technique involving removal of the anterior portion of the cricoid cartilage. Herein, we report the case of a patient with difficulty in neck extension due to severe kyphosis, who underwent cricotracheostomy. A 65-year-old woman developed dyspnea and was transported to our hospital. SpO2 was 60% (room air) and endotracheal intubation was performed. She was managed on ventilator. However, weaning off the ventilator was difficult, and endotracheal intubation was prolonged. Subsequently, the patient was referred to us for a tracheostomy. The patient was unable to maintain the supine position due to severe kyphosis, and computed tomography revealed that the brachiocephalic artery was running just below the thyroid gland. Therefore, conventional tracheostomy was difficult to perform, and we performed cricotracheostomy instead. After the cricotracheostomy, there were no tracheal problems, such as tracheal stenosis and stomal hemorrhage. Cricotracheostomy can be performed in cases where multiple anatomical difficulties may be faced in the tracheostomy site, as in this case. Furthermore, cricotracheostomy is beneficial for long-term airway management because it causes fewer complications compared to conventional tracheotomy.

Postoperative saliva leakage associated with wound dehiscence is one of the serious postoperative complications of major head and neck oncological surgery. Usually, a pharyngocutaneous fistula has to be formed for appropriate drainage of the infectious saliva to protect cervical vital structures, including the carotid artery. After the microvascular circulation around the fistula becomes stable, the fistula can be closed safely using a hinge flap and local rotation or a free island flap. Conventionally, the pharyngocutaneous fistula is maintained by plugging it with ointment gauze and covering it tightly with dry gauze and adhesive tapes ; the tracheal stoma has to be managed with a cuffed cannula to prevent aspiration of saliva. However, this conventional method is associated with heavy distress to the patient, such as skin damage and pain due to frequent replacement of gauze and tapes, and increased cough and sputum induced by the 日耳鼻 松居・他＝咽頭皮膚瘻のパウチ管理 125-277 tracheal cannula insertion. In recent years, various alternative methods have been reported for mitigating the patients' burden associated with fistula management. However, these methods cannot solve the pharyngocutaneous fistula-specific problems which are attributed to the three-dimensional structure and mobility of the neck. Therefore, we developed a new management method for fistula using a combination of a urine collection bag or a stoma pouch and a clay-like skin protecting agent, which enabled us to flexibly manage various cases by adjusting the attachment-plate area of the pouch and shaping a wall with clay-like skin protectant. As a result, we could reduce the frequency of fistula coverage replacement from daily to once every 3 to 4 days, which resulted in decreased skin damage and pain, and avoidance of tracheal cannulation. Furthermore, the daily material cost was also greatly reduced. In conclusion, we believe that this new method can overcome the disadvantages of the conventional method, reduce the burden on the patients, and reduce the cost, yielding medical economic benefit. In addition, the cooperation of the patients themselves and a certified nurse familiar with handling the pouch materials appears to be helpful for successful management.