Radiologic and surgical evidence of pre-tracheal anatomies for safe procedures in older adult oncologic patients: educational implications for elective or emergent tracheotomies among novice practitioners

Introduction

Open surgical tracheostomy (OST) is one of the most commonly employed life-saving procedures for resolving upper airway obstruction, and further provides long-term respiratory support for critically ill patients, especially those with complex trauma, infections or extensive head and neck malignancies (1,2). However, this surgical procedure is not consistently straightforward to perform. According to the literature, the perioperative complications of OST, whether urgent or elective, have an incidence ranging from 0.1% to 31.0%, with bleeding being the most common complication (3,4). OST is generally performed between the second and fourth cartilage rings of the anterior cervical trachea, where unidentified vascular variants in the thyroid isthmus, anterior jugular vein (AJV) or innominate artery (IA) may occasionally overlap or adjoin anatomically (5,6). Another relatively uncommon cause of bleeding is accidental injury to the inferior thyroid vascular plexus (ITVPs) (7). The vast majority of peri-tracheal bleeding cases are thought to result from iatrogenic damage to these structures (6). Apart from the current guidelines and expert consensus publications on tracheostomy (8,9), the literature regarding OST procedures and local vascular locations or identifications is scarce (10). In addition, there is little information on the surgical challenges related to the pre-tracheal vascular structures and thyroid isthmus, in terms of possible age-related changes or anomalies. Moreover, medical residents are often unsure when to use bipolar diathermy or ligation/clip for hemostasis during emergent or elective OSTs and may be unaware which vessels are involved.

In older adult patients, the cervical vascular anatomy may influence the postoperative outcomes of OST procedures, particularly when improvised in emergency situations. Moreover, it has been found that the twisting and kinking of the carotid arteries become more pronounced with increasing age (10,11). Knowledge of these vascular structures’ anatomies may be critically important for the success of impromptu procedures, especially for younger practitioners. Therefore, we sought to characterize the pre-tracheal anatomy on contrast-enhanced computed tomography (CECT) or computed tomography venography (CTV) imaging of both older adult and non-older adult patients. An additional aim was to assess the target vessel morphology and short-term complications by comparing the intraoperative findings in those undergoing elective OSTs for head and neck cancer. We present this article in accordance with the STROBE reporting checklist (available at https://qims.amegroups.com/article/view/10.21037/qims-2025-601/rc).

Methods

This retrospective cohort study was approved by the Ethics Review Committee of the 9th People’s Hospital, Shanghai Jiao Tong University School of Medicine (No. SH9H-2019-T138). Written informed consent was obtained from all participants and/or their legal guardians. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The older adult patient group consisted of those patients aged 65 years and older who had undergone elective OSTs and other head and neck surgeries in 9th People’s Hospital, Shanghai Jiao Tong University School of Medicine from January 2019 to February 2022. Meanwhile, non-older patients (<65 years) were recruited as the control group during the same observation period. The inclusion criteria of patients for this study were as follows: (I) cervical CECT/CTV completed before operation for head and neck cancer; (II) no history of radiation therapy or head and neck surgery (especially thyroid surgical treatment); and (III) with detailed OST records. Participants with massive head and neck vascular malformation or severe cardiac diseases and a history of vascular interventional or surgical treatment were excluded to avoid confounding factors in the analysis of general pre-tracheal anatomies. A representative excluded case is presented in Figure S1.

Image scanning technology

Patients underwent CECT/CTV imaging using a 320-row detector computed tomography (CT) scanner (Aquilion One Vision; Canon Medical Systems Corporation, Otawara, Japan). The scanning parameters were as follows: tube voltage, 120 kVp; tube current, 200 mA; detector collimation, 0.625 mm; and matrix, 512×512. CECT images were obtained at 90 seconds after contrast material administration (Omnipaque, GE Healthcare, Chicago, USA, 2 mL/kg or 300 mg/mL). Subsequently, bolus tracking was performed with the region of interest (ROI) setting on the ascending aorta. Contrast material (5.0 mL/s) was with an 18- or 20-gauge catheter injected into antecubital vein by using a power injector (Dual Shot; Nemoto Kyorindo, Tokyo, Japan). The scanning range was roughly from skull base to the lower edge of aortic arch, in attempt to cover all the interested anatomies. The CECT/CTV images were then reconstructed with Adaptive Iterative Dose Reduction 3D standard software (AIDR 3D, Canon Medical Systems), for reconstruction section thickness and interval of 0.5 mm.

Data collection and measurement techniques

We collected demographic characteristics, clinicopathological data on primary disease, comorbidities, and treatment status for all participants. The reasons for OST in both groups were summarized through face-to-face interviews with all the relevant surgical operators. Using preoperative CECT/CTV images, two radiologists independently analyzed the morphological relationships of following targets: (I) the AJV; (II) IA; (III) ITVP, including the inferior thyroid vein (ITV) or the lowest thyroid artery; and (IV) the thyroid isthmus. According to the OST procedure (from skin to trachea), the superficial relationship of the AJV was first analyzed for comparisons. Second, the representative radiographic and clinical evidence of the IAs was recorded. Third, the lower edges of thyroid isthmus were measured for possible interruptions of tracheal exposure. Finally, the presence of the ITVs, or the lowest thyroid arteries, which mainly run between the pre-tracheal fascia and the anterior parts of the trachea, were determined. We further classified the pre-tracheal AJVs as single-branch, double-branch, or multi-branch types (Figure 1). According to Sung et al.’s study (12), the IAs were categorized by their morphological characteristics as (I) the low-bifurcation type (the level of the superior border of the IA bifurcation crosses the tracheal anterior from the suprasternal notch at <2 cm); (II) high-bifurcation type (the level of the superior border of the IA bifurcation crosses the tracheal anterior from the suprasternal notch at ≥2 cm); (III) high-platform type (or high-lying IA, in which the upper edge of the platform IA crosses the tracheal anterior midline from the suprasternal notch ≥2 cm); (IV) low-platform type (namely low-lying IA, in which the upper edge of the platform IA passes through the tracheal anterior midline from the suprasternal notch at <2 cm); and (V) variant type. Among these types, the low-bifurcation type was considered the normal IA type, with sufficient space for a safe and routine OST procedure. Admittedly, due to possibly unrecognized discrepancies in CECT, ITVs and the lowest thyroid arteries were combined into a single category of (ITVPs) for ease of analysis. We further classified them based on the presence or absence of trunks (independent or common trunk type) and communicating branches (with or without branches) (Figure 1). For quantitative clinical references, the maximum calibers of these three target vessels, and their shortest horizontal distances towards both skins and the anterior walls of 1st–5th tracheal cartilage rings were radiographically measured in both groups.

Figure 1 Illustrative diagram of imaging MPR classification for three target vessels. (A-C) The imaging MPR of AJV: (A) single-branch type; (B) double-branch type; (C) multi-branch type. (D-H) The MPR of IA: (D) low bifurcation type; (E) high bifurcation type; (F) platform type (low-lying); (G) platform type (high-lying); (H) variant type (the left carotid artery emanates from IA). (I-M) The MPR of ITVPs: (I) a right inferior artery/vein and a left inferior artery/vein; (J) three inferior artery/veins; (K) a common trunk; (L) a right inferior artery/vein and a common trunk; (M) a left inferior artery/vein and a common trunk. Blue arrows: AJV; red arrows: IA; yellow arrows: ITV. AJV, anterior jugular vein; IA, innominate artery; ITV, inferior thyroid vein; ITVP, inferior thyroid vessel plexus; MPR, multiplanar reconstruction.

In order to further clarify the pre-tracheal anatomical structures, the radiologic distances between the upper edge of the suprasternal notch and the isthmus of the thyroid gland (suprasternal-isthmus) or the cricoid cartilage ring (suprasternal-cricoid) were recorded for both groups. For comparison with the radiologic findings, we collected the intraoperative data of both groups, including the presence or abnormality of the majority of the targeted vessels (but not all) and the possible presence of a hypertrophic thyroid isthmus. Finally, the tracheotomy-related short-term (7 days) complications (including bleeding, subcutaneous/mediastinal emphysema, pneumothorax, recurrent laryngeal nerve injury and tracheoesophageal fistula) were summarized to clarify the clinical implications of the preoperative anatomical evidence.

Statistical analysis

SPSS 26.0 software (IBM Corp., Armonk, NY, USA) was used for statistical analysis in this study. Qualitative data were analyzed via the Chi-squared test. Parameters with normal distribution and uniform variance are expressed as the mean ± standard deviation and were analyzed via the independent-samples t-test. Parameters that were not normally distributed are expressed as medians and interquartile ranges and were analyzed via nonparametric tests. Multivariate correlation analyses were used to assess the covariate effects of multiple parameters [coefficient of contingency (rn)]. Scatter plots were employed to display the numerical distribution of variables and visualize the relations and correlations [correlation coefficient (r)].

Results

A total of 201 patients (115 males and 86 females) who underwent preoperative cervical CECT/CTV were included in the study. Among these, 127 (127/201, 63.2%) who were aged 65 years or older were enrolled in the older adult group and had mean age of 72.0 years (age range, 65–87 years). Meanwhile, 74 (74/201, 36.8%) patients who were not-older adults (under 65 years of age) were enrolled as the control group and had mean age of 46.5 years (age range, 12–59 years) (Table 1). The majority of cases were diagnosed with oral cancers (129/201, 64.2%), while the proportion of patients with sarcoma or adenoid cystic carcinoma in the non-older adult group (14.9% and 13.5%, respectively) was larger than that of the older adult group (5.5% and 4.7%, respectively).

As for the comorbidities, the proportion of patients with hypertension (43/127, 33.9%) and diabetes mellitus (13/127, 10.2%) was higher in the older adult group (P<0.001). Furthermore, 34 (26.8%) patients in the older adult group had more than three types of comorbidities, indicative of their serious general conditions. The univariate analysis (t-test) showed no significant difference in body mass index (BMI) between the two groups (P=0.678); meanwhile, the multivariate regression analysis, with adjustments for age, gender, hypertension and diabetes, indicated that the non-older adult group had a higher mean BMI than did the older adult group, although this difference was also not statistically significant (P=0.088). The primary reason for elective OSTs in both groups were direct disease involvement (oral: 129 cases, oropharyngeal: 40 cases) (Table 1).

In terms of radiographic parameters, AJVs were not visible in the pre-tracheal region in 2 (2/201, 1%) patients. The distribution of classification among the remaining patients (n=199) was as follows: (I) 10.4% had the single-branch type (21/199); (II) 80.1% had the double-branch type; and (III) 8.5% had the multibranch type. There was no statistically significant difference in the AJVs types between the older adult and the non-older adult groups (P>0.05; Table 2). The median shortest distance to the midline of the lower neck was 3.6 mm (range, 0–15.3 mm). Moreover, the CECT/CTV parameters for the single-branch type only were compared, and there was a significant difference in the maximum pipe caliber (P<0.05, Table 3). In addition, the proportion of double-branch type in the non-older adult group is slightly lower than that in the older adult counterpart. The median distance between the double branches of AJVs in the non-older adult and the older adult groups was 12.8±6.1 mm (range, 2.4–28.7 mm) and 14.3±6.0 mm (range, 3.0–31.4 mm), respectively, while the median of the shortest distance to the midline of the neck in the two groups was 3.0 mm (range, 0–14.1 mm) and 3.5 mm (range, 0–15.3 mm), respectively, indicating a high probability of encountering AJVs or their branches in both groups during OSTs. Additionally, by means of univariate correlation analysis, we found that comorbidities were not statistically associated with our AJV classification (P=0.701) in the overall cohort (201 cases). However, after covariates (diabetes and hypertension) were incorporated, the multivariate analysis showed a significant difference in this regard (P<0.01; Table S1), suggesting that these two comorbidities influence the variations in the AJVs. As shown in Table 2, the majority of cases in the older adult and non-older adult groups had a low-bifurcation IAs (104/201, 51.7%), while other variant types were less common. There were strong correlations found between age and IA types (P=0.004) with a much higher proportion of platform IAs in the older adult group (47/127, 37%) than in the non-older adult group (10/74, 13.6%), indicating an age-related change in IA locations in the pre-tracheal region. A further examination of the overall cohort revealed that the median age of the five IA types were 66.5 (range, 12–87), 58.0 (range, 21–84), 67.0 (range, 33–87), 69.0 (range, 28–84) and 65.0 (range, 50–73) years. within whom the high-platform one (directly interfering with the OST) had the highest median age (69.0 years, P=0.042). Regarding tracheostomy, the tracheal-to-IA and skin-to-IA distances for the first four IA types are shown in Table 3. In the multivariate analysis, diabetes and hypertension were also found to be statistically associated with pre-tracheal IA classifications (P=0.008; Table S1).

As for the ITVPs, only 2 patients did not have ITVPs on CECT/CTV; meanwhile, there were 77 (77/199, 38.7%) patients with a common trunk, and 32 (32/72, 44.4%) with large-diameter (≥2 mm) communicating branches (Figure 1). Univariate analysis of variance indicated that in terms of ITVPs, whether grouped by trunk (P=0.623) or communicating branch (P=0.117) types, the difference between the older adult and the non-older adult group did not reach statistical significance (Table 2). However, Significant differences could be discerned in the shortest distance to the trachea of the independent trunk type by comparing the CECT/CTV parameters between these two groups (P<0.05, Table 3). Among these patients, 60 (60/74, 81.1%) in the non-older adult group and 45 (36.0%, 45/125) in the older adult group had one or more branches of the ITVP running through the lower border of the thyroid isthmus.

Apart from data on vascular information, we also collected data on the body surface localization of the lowest edges of the thyroid isthmus. The mean suprasternal-isthmus distance in the older adult and non-older adult groups was measured as 21.6±10.1 and 28.8±10.5 mm, respectively; meanwhile, the suprasternal-cricoid distance was 4.22±1.35 cm and 54.0±13.5 mm, respectively; neither of these distances were different between the two groups (P>0.05, Table S2).

The maximum diameter of the thyroid gland (coronal view) in the older adult group was 44.0±10.3 mm, and that in the non-older adult group was 46.2±8.9 mm, and these were not significantly different (P=0.028). The incidence of thyroid nodules/diffuse lesions in the older adult group (38/125, 30.4%) was higher than that in the non-older adult group (12/74, 16.2%), especially among female patients in the older adult group (23/57, 40.3%).

According to our intraoperative data, possible high-platform IAs were found or exposed in 20 (20/127, 15.7%) cases in the older adult group and 7 (7/74, 9.5%) cases in the non-older adult group. Owing to vascular anatomical variations of the IA, we detected prominent vascular pulsations in the cervical tracheotomy field during the physical examination performed as part of the tracheotomy procedure (Videos S1,S2). Thyroid-level tracheotomy (i.e., thyroid anatomy and higher-than-usual tracheal incision) was applied to ensure the safety of these patients. In addition, we compared the intraoperative exposure of the pre-tracheal vessels in the older adult patient group, which corroborated the image findings of the CECT/CTV analysis (Table 4 and Figure 2). The types of AJV, IA, and ITVP communicating branch were related to the location of the tracheal incision in the older adult group (r_n=0.28, r_n=0.59, and r_n=0.267, all P<0.01; Table 4 and Tables S3,S4). All the single-branch and multi-branch AJVs in both groups were exposed in the second to fourth tracheal cartilage region, namely the so-called the OSTs’ common zone.

Figure 2 Intraoperative examples of three targeted vessels during elective tracheotomies. (A,B) An example of tracheotomy in a 70-year-old woman with oral cancer. (A) The double-branch type AJVs are exposed at the tracheal incision. (B) The coronal reconstruction of CT image-based imaging shows the double-branch type AJVs. (C,D) An example of tracheotomy in a 65-year-old woman with oral cancer. (C) There is a common trunk of ITV that exposed at the tracheal incision. (D) The coronal reconstruction of CT image-based imaging shows that the common trunk of ITV oblique downward on trachea incision. (E,F) An example of tracheotomy in a 69-year-old man with oral cancer. (E) There is no ITV that exposed at the tracheal incision. (F) The coronal reconstruction of CT image-based imaging shows that a right inferior ITV and a left inferior ITV are injected into the common jugular veins on both sides along the nearly horizontal direction. Blue arrows: AJV; yellow arrows: ITV. AJV, anterior jugular vein; CT, computed tomography; IA, innominate artery; ITV, inferior thyroid vein.

The incidences of all the post-OST complications were not statistically different (P=0.441) between the two groups. After the OST procedure, 7 patients (5.5%) in the older adult group and 3 patients (4.1%) in the non-older adult group were reported for minor bleeding after OST, which had been resolved by conservative measures. Three patients (2.4%) in the older adult group and 1 patient (1.4%) in the non-older adult group encountered active bleeding complications requiring reoperations for hemostasis. According to the reoperation medical records, the main unattended vessels/structures (causes for active bleeding) were AJVs (1 in the older adult group and 1 in the non-older adult group), ITVP (1 in the older adult group) and thyroid isthmus (1 in the older adult group). Though the rate of bleeding-related complications, on the whole, were not statistically different between the two groups (P=0.901), there is still an increasing likelihood of post-OST bleeding in the older adult group (10/127, 7.9%) when compared with that in the non-older adult counterpart (4/74, 5.4%). Given that most tracheotomies in this study were elective rather than emergency/impromptu, no recurrent laryngeal nerve injury or tracheoesophageal fistula occurred in this study. However, severe post-OST subcutaneous emphysema and pneumothorax were only reported in 2 and 1 patients in the older adult group, respectively (Video S3 and Figures S2,S3). We used scatter plots to visualize the numerical distribution of variables and quantify the correlation, with coefficients of determination r² values of 0.190, 0.459, and 0.451 respectively. The distance from the upper edge of IA to the upper edge of the sternal stem notch was moderately correlated with the commonly used incision position (r=0.436). The correlation coefficient of the older adult group (r=0.313) was smaller than that of the non-older adult group (r=0.651). The distance from the midpoint of the second to fourth tracheal ring to the lower edge of thyroid isthmus and the distance from the lower edge of thyroid isthmus to the upper edge of the sternal stem notch were interpreted as having a strong correlation with the commonly used incision position (r=0.677 and r=0.672, respectively); the correlation coefficient of the older adult group (r=0.665 and r=0.668, respectively) was greater than that of the non-older adult group (r=0.560 and r=0.661, respectively) (Figure 3).

Figure 3 Scatter plots are used to discover relationships and correlations of the numerical distribution of variables. (A) The distance from the upper edge of IA to the upper edge of the sternal stem notch was be treated as “moderate” correlation to commonly-used incision position (r²=0.190, r=0.436). (B) The correlation coefficient of the elderly group (r=0.313) was smaller than that of the non-elderly group (r=0.651). (C,E) The distance from the midpoint of the 2nd–4th tracheal ring to the lower edge of thyroid isthmus and the distance from the lower edge of thyroid isthmus to the upper edge of the sternal stem notch were interpreted as “good” correlation to commonly-used incision position (r²=0.459, 0.451, r=0.677, 0.672). (D,F) The correlation coefficient of the elderly group (r=0.665, 0.668) was greater than that of the non-elderly group (r=0.560, 0.661). Group 1, the elderly group; Group 2, the non-elderly group. IA, innominate artery.

Discussion

Patients with head, neck cancers, especially those of older ages and impaired regional functions, account for a large proportion of the cases which require OST due to airway concerns. Patients with respiratory distress may also need invasive tracheal mechanical ventilation, especially those elderlies with severe underlying medical conditions (13,14). According to Knewitz et al., OST is one among them more commonly performed surgical procedures in the United States, with over 100,000 cases each year, either elective or emergent. Despite ongoing efforts to reduce OST-related complications, perioperative tracheotomy-related complications are reported to occur in 4.3–40% of cases, with most reports including subcutaneous emphysema, bleeding, pneumothorax, pneumonia and tracheoesophageal fistula. Among these complications, some may become life-threatening when unattended or mishandled (3,4,8,15,16). Although several consensuses have been published recently on perioperative management, there is little guidance regarding intraoperative difficulties encountered in the older adult during OST procedures (17-19). Thus, complications of bleeding after tracheostomy, whether emergent or elective, remain between 2% and 31%, partly due to the use of anticoagulants or failure to ligate the thyroid isthmus (20-22), and the lack of a comprehensive characterization of the pre-tracheal vascular space, morphology, and variation (12,23,24). In our study, CECT/CTV examinations provided a detailed view of the anterior tracheal structures, including the thyroid isthmus, arteries, and veins. Our analyses also provided a general overview of the likely anatomical features and several important surgical key points relevant to elective and emergent OSTs.

As part of the superficial venous drainage system of the head and neck, AJVs are typically the first and most superficial vessels encountered in OSTs. AJVs often present mostly in pairs, namely the double-branch type. In the literature, the variant AJVs is purported to replace the AJV variant with a grid of smaller venous vessels (25). However, this type of variant was only found in 3 older adult patients in our study. To our knowledge, the most common AJV variant is the single-branch type, also known as the “median vein” (25), which was present 11.9% of the patients in our older adult group. When AJVs are found during tracheostomy, efforts should be made to avoid (preserve) these vessels. Ligation should also be prepared to stop the hemostasis in some cases with AJV variants (26). The calibers of the single-branch AJVs in the non-older adult group were generally larger than those in the older adult counterparts, which is partly consistent with other vascular studies (6,10,25). In encountering large-caliber AJVs during OSTs, attention should be paid to avoiding improper handling of these variants, which may result in air embolism or bleeding (25).

The IA is one of the three major branches of the aorta, and its location around the trachea depends primarily on its morphology, neck length, and inspiratory/expiratory status. We found that the proportion of platform-type IAs in the older adult group (37%) was much higher than that in the non-older adult group (13.6%). This finding validates the claim that the IA and carotid twisting and kinking become more pronounced as age increases (11). Therefore, during emergent OSTs for older adult patients, caution should be paid to the possibility of high-platform IA variants. In some rare cases, the IA may reach or even exceed the level of the thyroid isthmus (extreme high-platform type), largely interfering with routine OST incisions. From our perspective, the high position of IA, with its partial segment extending above the second to fourth tracheal ring, may also involve a considerable risk of fatal iatrogenic bleeding during OST procedures (11,12,26-32). Accidental life-threating injury of the IA has even been attributed to the existence of such uncommon variants (11,26-30,32). For older adult patients with strong pre-tracheal vessel palpation signs, CECT or CTA could be possibly arranged for analysis of IA and OST-related issues. In addition, under these IA circumstances, nasal intubation or higher elective or emergent tracheal incision should be attempted to avoid severe OST complications.

Unlike IAs, ITVPs, including the ITVs and the lowest thyroid artery, mostly run between the pre-tracheal fascia and the anterior part of the trachea. Within our study, we observed large differences in the numbers, locations, and calibers of ITVPs between the two groups. Our results regarding the ITVPs slightly differ from those of other previous studies obtained via autopsy or venography (33-35). In the OST area, there may be large-caliber ITVs, common trunks and communicating branches in front of the trachea, posing a higher risk for postoperative bleeding. Thus, attention should be paid to these ITVPs for possible ligation or cauterization during OSTs.

Thyroid isthmus may run in front of the same region where OST incisions are performed. A hypertrophic thyroid isthmus may span over more tracheal rings, resulting in unexpected injury during OST. Ajish and Jayakumar reported that the volume of the thyroid gland may undergo changes with aging, primarily due to the progressive fibrosis and atrophy of the gland, resulting in the reduction of thyroid volume (36). In line with this, the thyroid maximum diameter (coronal views) in most older adults in our study were smaller than that of their non-older adult counterparts (P=0.028). However, another study found that older adult patients with comorbidities (autoimmune thyroid diseases) tended to have larger thyroid volumes (37). Thus, surgeons should be aware of the possibility of large thyroid isthmus during emergent tracheotomy as reflected in our study.

Regarding the influence of comorbidities on OSTs, we found that hypertension and diabetes may have certain effects on the location and geographic changes of the pre-tracheal blood vessels. These changes have also been reported in other studies, which found that hypertension can increase the likelihood of both carotid calcifications and cardiovascular stiffness (38,39), while gradual vessel position (geometry) changes may ensue uncontrolled hypertension over the long term (40). Such hypertension-related alterations in vascular location were also reported in a retrospective study by Sagiv et al., which were consistent with the results of ours (41). Thus, in the education of young practitioners for OSTs in older adult patients, possible anatomical landmark or position changes should be emphasized, especially in those with chronic conditions of hypertension or diabetes.

This study involved inherent limitations due to its retrospective design. Moreover, given the inclusion and exclusion criteria, our candidates had no prior irradiation or head and neck operations. Thus, the implications of this study may not be applied to patients receiving such treatment. Admittedly, our findings also need to be viewed with caution pending a larger multi-institutional study, but the data can help to guide OST surgical procedures for young practitioners.

Conclusions

In emergent settings, residents and novice surgeons often struggle with inadvertent or unrealized damage to these anatomic structures, causing either prolonged OSTs with fatal anoxic consequences, or iatrogenic complications, such as bleeding or pneumothorax. Moreover, the current guidelines for tracheotomy-related care or practice are primarily centered on the timing of OST and the indications and post-OST treatment for complications (pneumonia); however, there is no emphasis for the need of practitioners to comprehensively understand the normal and age-related variants of pre-tracheal changes during OST procedures. Therefore, our comprehensive overview of these pre-tracheal vessels and thyroid status may reduce the incidence of these OST-related hemorrhage complications, especially in more frail older adult patients. In addition, our image-based assessment of pre-tracheal anatomies and risk stratifications may also serve as an educational resource and aid the young practitioners in OST preparations and decisions.

Acknowledgments

We gave our sincere gratitude to Prof. Yue He for his help and guide during the revision of the manuscript.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://qims.amegroups.com/article/view/10.21037/qims-2025-601/rc

Data Sharing Statement: Available at https://qims.amegroups.com/article/view/10.21037/qims-2025-601/dss

Funding: This work was supported by the Fundamental Research Funds for the Central Universities (No. YG2022QN060); Science and Technology Commission of Shanghai Municipality (No. 19ZR1430000); Hospital Innovation Project (No. CK2019004); Hospital Cross-Multidisciplinary Project (No. JYJC201911); National Natural Science Foundation (No. 82271038); Hainan Provincial Natural Science Foundation of China (No. 824MS153); and Interdisciplinary Innovation Fund of Shanghai 9th People’s Hospital, Shanghai Jiao Tong University School of Medicine (No. JYJC202414).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-2025-601/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This retrospective cohort study was approved by the Ethics Review Committee of the 9th People’s Hospital, Shanghai Jiao Tong University School of Medicine (No. SH9H-2019-T138). Written informed consent was obtained from all participants and/or their legal guardians. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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