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Fiberoptic view of the arytenoid cartilage on the seventh day after cardiac operation. Severe anterior dislocation of the right arytenoid cartilage is apparent. Just under the right arytenoid, a small hematoma (arrow) is visible. This trauma may indicate the point at which an upward-lifting force was applied under the arytenoid cartilage. Φ denotes left arytenoid cartilage.
Source publication
Occurring most usually as complications of upper aerodigestive tract instrumentation during endotracheal intubation or extubation, arytenoid cartilage dislocation and arytenoid subluxation are uncommon laryngeal injuries. Their precise cause, however, is usually difficult to determine. We encountered arytenoid dislocation following cardiac surgery...
Contexts in source publication
Context 1
... the ICU, the tracheal tube was smoothly removed on the following morning, whereupon the patient complained of severe hoarseness and sore- ness; symptoms of dysphagia and odynophagia were not present. On post-operative day 7, severe anterior dislocation of the right arytenoid cartilage was observed during fiberoptic laryngoscopy (Fig. 1). Computed tomography of the neck and X-ray tomo- graphy at the time of exhalation and inspiration were also performed. Upward dislocation of the vocal fold on the right side was visible. This imaging further clarified the laryngoscopic observation. An otorhino- laryngologist diagnosed a highly dislocated aryte- noid cartilage that ...
Context 2
... and lifted in an anterior direction (Fig. 2A). Arytenoid displacement may also ensue if the tip of an endotracheal tube or stylet exerts similar pressures (Fig. 2B). In our patient, the cause of anterior dislocation was not absolutely certain. Seven days after surgery, a small hematoma was detected just under the right arytenoid cartilage (Fig. 1). During and after surgery, the patient received anticoagulants, and so the healing of wounds would have been delayed. The hematoma appears to be the site of force trauma, and therefore it is considered very likely that external pressure at this location dislocated the arytenoid cartilage. In this case, laryn- goscopy was unlikely to ...
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Background:
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Citations
... Additionally, subluxation may occur when extubation is performed without sufficient deflation of the balloon of the endotracheal tube [6]. Conversely, anteromedial displacement of the arytenoid cartilage can occur when the blade of the laryngoscope is inserted to the pyriform sinus and lifted forward, and also when the tip of the endotracheal tube presses the arytenoid cartilage in the forward direction [8]. In our case, the left arytenoid cartilage was detected to have been dis- www.e-arm.org ...
Arytenoid cartilage dislocation is one of the most common mechanical causes of vocal fold immobility. The most common etiologies are intubation and external trauma, but its incidence is lower than 0.1%. Its symptoms include dysphonia, vocal fatigue, loss of vocal control, breathiness, odynophagia, dysphagia, dyspnea, and cough. Although there are some reports of arytenoid cartilage dislocation in adults, there are only few reports on its occurrence in children. It is particularly difficult to detect the symptoms of arytenoid cartilage dislocation in uncooperative pediatric patients with brain lesions without verbal output or voluntary expression. We report a case of arytenoid cartilage dislocation with incidental findings in a videofluoroscopic swallowing study performed to evaluate the swallowing function.
... The incidence of AD after general anesthesia has been reported to be approximately 0. 01-0.1% [2]. The cause of AD may be inadvertent trauma to the cricoarytenoid joint from the insertion of airway tools into the larynx [3][4][5]. To our knowledge, no systematic investigations of AD associated with tracheal intubation have been reported. ...
Backgrounds:
Arytenoid dislocation (AD) is a rare but severe complication after general anesthesia with endotracheal intubation. We conducted a case-control study at Peking Union Medical College Hospital to identify risk factors associated with AD, including the use of an intubation stylet.
Methods:
Patients who experienced AD were matched 1:3 with controls based on gender, age and type of surgery. Multiple conditional logistic regression was performed to determine associations between potential risk factors and AD.
Results:
Twenty-six AD cases were retrospectively identified from 2004 through 2016. On average, arytenoid dislocation occurred in 2 cases per year, with an incidence of 0.904/100,000 (approximately 0.01%). The 26 patients who experienced AD and 78 matched control patients were enrolled in this study. All enrolled patients underwent endotracheal intubation, and a stylet was used for intubation for 38.5% (10/26) of the AD patients and 64.1% (50/78) of the controls (OR = 0.23, 0.07-0.74). A higher incidence of AD was significantly associated with longer duration of operation (OR = 1.74, 1.23-2.47).
Conclusions:
The use of an intubation stylet for endotracheal intubation appears to protect against AD. Prolonged operation time increases the risk of AD. These factors should be considered when assessing the risks of AD associated with endotracheal intubation and in efforts to avoid this complication.
... Other causes of arytenoid cartilage dislocation include the use of a laryngeal mask airway [11] or the insertion of a transesophageal echocardiography probe. [12] Cases of arytenoid cartilage dislocation in patients with apparently uneventful tracheal intubation, [13,14] or after a bout of coughing, have also been reported. [15] No rigid device, such as a lighted stylet, double lumen tube, or transesophageal echocardiography probe, which might press the arytenoid cartilage downward and outward, was used in our patient during the procedure. ...
Rationale
Arytenoid dislocation is very rare and may be misdiagnosed as vocal cord paralysis or a self-limiting sore throat.
Patient Concerns
A 70-year-old male (70 kg, 156 cm) was scheduled for transurethral resection of bladder tumors. A McGrath videolaryngoscope, with a basic cuffed Mallinckrodt oral tracheal tube of 7.5 mm internal diameter, was used to successfully intubate his trachea. The duration of surgery was 25 minutes. In the recovery room, he complained of sore throat and dyspnea with inspiratory stridor, which were not resolved after intravenous injection of 10 mg of dexamethasone.
Diagnoses
The otolaryngological examination revealed midline fixation of the bilateral vocal folds, suggestive of bilateral arytenoid dislocation or bilateral vocal cord palsy. The latter was ruled out because there was no evidence of recurrent laryngeal nerve injury.
Interventions
Under general anesthesia, a closed reduction was performed using laryngoscopic forceps to apply posterolateral pressure on the arytenoid joints on both sides. Only the dislocation of the left cricoarytenoid joint could be easily reduced, whereas reduction of the right joint was not possible.
Outcomes
On postoperative day 7, examination with a rigid laryngoscope showed a medially fixed right vocal fold, with full compensation by the left vocal fold. Computed tomography of the neck showed no pathologic findings. Six weeks after surgery, the patient had regained his normal voice with no complications.
Lessons
Although arytenoid dislocation is a rare complication, it should be considered even in patients with uncomplicated tracheal intubation. Early diagnosis and the optimal therapeutic approach are critical for restoration of the patient's original vocal cord function.
... So far, definite evidence demonstrating the relationship between a probe of TEE and the complication has not been reported although one previous case report suggested the possible involvement of TEE in the complication after intubation. [5] Another previous study by Rousou et al. [6] reported that the odd of dysphagia for TEE patients was 7.8 times greater than for non-TEE patients after cardiac operations. Considering that dysphagia as well as hoarseness is included in major symptoms of arytenoids dislocation/subluxation, [7] we speculate that dysphagia following TEE might be in part due to arytenoid dislocation/subluxation. ...
Background
Arytenoid cartilage dislocation/subluxation is one of the rare complications following tracheal intubation, and there have been no reports about risk factors leading this complication. From our clinical experience, we have an impression that patients undergoing cardiovascular operations tend to be associated with this complication.
Aims
We designed a large retrospective study to reveal the incidence and risk factors predicting the occurrence and to examine whether our impression is true.
Settings and Designs
This was a retrospective study.
Methods
We retrospectively studied 19,437 adult patients who were intubated by an anesthesiologist in our operation theater from 2002 to 2008. The tracheal intubation was performed by a resident anesthesiologist managing the patients. Only patients whose postoperative voice was disturbed more than 7 days were referred to the Department of Otorhinolaryngology-Head and Neck Surgery and examined using laryngostroboscopy by a laryngologist to diagnose arytenoid cartilage dislocation/subluxation. We evaluated age, sex, weight, height, duration of intubation, difficult intubation, and major cardiovascular operation as risk factors to lead this complication.
Statistical Analysis
The data were analyzed by logistic regression analysis to assess factors for arytenoid cartilage dislocation/subluxation after univariate analyses using logistic regression analysis.
Results
Our analysis indicated that difficult intubation (odds ratio: 12.1, P = 0.018) and cardiovascular operation (odds ratio: 9.9, P < 0.001) were significant risk factors of arytenoid cartilage dislocation/subluxation.
Conclusion
The present study demonstrated that major cardiovascular operation is one of the significant risk factors leading this complication.
... These can include dislocation/subluxation vs. fixation of the CA joint. These alterations of the CA joint may be related to trauma (both internal and external), neoplastic infiltration, extrinsic compression from large tumors, or inflammatory processes (such as CA joint arthritis/synovitis) [10][11][12][13][14][15][16][17]. Another cause of mechanical vocal fold motion impairment is scarring of the inter-arytenoid region (i.e., the soft tissue around the CA joint and the posterior commissure of the larynx [18]. ...
The terms used to describe vocal fold motion impairment are confusing and not standardized. This results in a failure to communicate accurately and to major limitations of interpreting research studies involving vocal fold impairment. We propose standard nomenclature for reporting vocal fold impairment. Overarching terms of vocal fold immobility and hypomobility are rigorously defined. This includes assessment techniques and inclusion and exclusion criteria for determining vocal fold immobility and hypomobility. In addition, criteria for use of the following terms have been outlined in detail: vocal fold paralysis, vocal fold paresis, vocal fold immobility/hypomobility associated with mechanical impairment of the crico-arytenoid joint and vocal fold immobility/hypomobility related to laryngeal malignant disease. This represents the first rigorously defined vocal fold motion impairment nomenclature system. This provides detailed definitions to the terms vocal fold paralysis and vocal fold paresis.
... The literature contains references to injuries to the cricoarytenoid as a result of traumatic intubation and arytenoid cartilage dislocation after cardiac surgery or blunt trauma however there are no references to fixation of laryngeal tissues to osteosynthetic materials. [1][2][3] Injuries to the esophagus, trachea and larynx are discussed as extremely rare complications at the time informed consent is obtained at our neurosurgical department. These however are largely consequences of the ventral approach, and are not expected to be caused by the osteosynthesis material itself. ...
We report on a 70-year-old patient who underwent ventral fusion of the cervical spine (C3/4 and C4/5) for spinal canal stenosis performed by the neurosurgery department. The patient suffered an exceedingly rare complication of the surgery - laryngeal dislocation. Had the deformed laryngeal structures been overlooked and the patient extubated as usual after surgery, reintubation would have been impossible due to the associated swelling, which might have had disastrous consequences. Leftward dislocation of the larynx became apparent post-operatively, but prior to extubation. Extubation was therefore postponed and a subsequent computed tomography (CT) scan revealed entrapment of laryngeal structures within the osteosynthesis. A trial of repositioning using microlaryngoscopy performed by otolaryngology (ears, nose and throat) specialists failed, making open surgical revision necessary. At surgery, the entrapped laryngeal tissue was successfully mobilised. Laryngeal oedema developed despite prompt repositioning; thus, necessitating tracheotomy and long-term ventilation. Laryngeal dislocation may be an unusual cause of post-operative neck swelling after anterior cervical spine surgery and should be considered in the differential diagnosis if surgical site haematoma and other causes have been ruled out. Imaging studies including CT of the neck may be needed before extubation to confirm the suspicion and should be promptly obtained to facilitate specific treatment.
... 4,5 However, insertion of any instruments, such as a transesophageal endocardiography probe, into the upper aerodigestive tract predisposes the patient to possible arytenoid injury. 12 Several theories have been postulated regarding the mechanism of dislocation associated with intubation. Posterior lateral dislocation of the left arytenoid can result from direct pressure from the endotracheal tube. ...
Study Design Case series of two arytenoid dislocations after anterior cervical discectomy.
Objective To recognize arytenoid dislocation as a possible cause of prolonged hoarseness in patients after anterior cervical discectomies.
Summary of Background Data Prolonged hoarseness is a common postoperative complication after anterior cervical spine surgery. The etiology of prolonged postoperative hoarseness is usually related to a paresis of the recurrent laryngeal nerve. However, other causes of postoperative hoarseness may be overlooked in this clinical scenario. Other possible etiologies include pharyngeal and laryngeal trauma, hematoma and edema, injury of the superior laryngeal nerve, as well as arytenoid cartilage dislocation. Arytenoid dislocation is often misdiagnosed as vocal fold paresis due to recurrent or laryngeal nerve injury.
Methods We report two cases of arytenoid dislocation and review the literature on this pathology.
Results Two patients treated with anterior cervical discectomy and fusion experienced prolonged postoperative hoarseness. Arytenoid dislocation was confirmed by flexible fiber-optic laryngoscopy in both cases. The dislocations experienced spontaneous reduction at 6 weeks and 3 months postsurgery.
Conclusions Arytenoid dislocation must be considered in the differential diagnosis of prolonged postoperative hoarseness and evaluated for using direct laryngoscopy, computed tomography, or a laryngeal electromyography. Upon diagnosis, treatment must be considered immediately. Slight dislocations can reduce spontaneously without surgical intervention; however, operative intervention may be required at times.
... It had been recognized that the arytenoid cartilage dislocation may be caused by medical instrumentation used with the larynx and esophagus, and external neck trauma such as whiplash injury [1][2][3]. Medical instrumentation such as endotracheal intubation, laryngeal airway mask intubation [3], upper gastrointestinal endoscopy [4] and transesophageal echocardiography probe [5] may be responsible for complications. Difficult endotracheal intubation, over-zealous use of lighted stylet for the tracheal intubation, traumatic insertion of laryngoscope blade, prolonged endotracheal intubation, or extubation with a partially deflated cuff were reported as the causes of arytenoid cartilage dislocation [6,7]. ...
Incidence of arytenoid cartilage dislocation for patients treated or examined under general anesthesia with tracheal intubaion in one hospital had not been reported. And true incidence and mechanism of arytenoid cartilage dislocation after tracheal intubation are not investigated yet. Here, we examined retrospectively the incidence of arytenoid cartilage dislocation for patients after general anesthesia with tracheal intubaion in the Central Surgical Center of Nippon Medical School Main Hospital for two years from 2004 until 2005. The incidence of arytenoid cartilage dislocation for patients after general anesthesia with tracheal intubaion was 0.2%, and patients received cardiovasucular surgeries were the most common. The mean age of the patients with arytenoid cartilage dislocation was 70 years. It could be considered that additional medical instrumentation of the esophagus including transesophageal echocaridiography probe or upper gastrointestinal endoscopy, and prolonged tracheal intubation for more than two days should be the risk factors causing arytenoid cartilage dislocation. And calcification of the laryngeal cartilage and morphological changes of the cervical vertebrae along with aging might also contribute to dislocate the arytenoid cartilage.
... tion include hoarseness, breathiness, vocal fatigue, aphonia, as well as dysphagia. Diabetes mellitus and renal failure can weaken the arytenoid joint [1], and use of airway tools such as a misplaced laryngoscope, laryngeal mask airways [2] and transesophageal echocardiography (TEE) probe [3] has also resulted in arytenoid dislocations. In the present case, the initial insertion of the gastroscope was not carried out under direct visualization, thus resulting in traumatic arytenoid dislocation. ...
... The use of a LMA 9 , lighted stylet 7 , McCoy laryngoscope 10 and double lumen tube 11 , as well as cases of difficult intubation 3,12 , have been reported to be associated with arytenoid subluxation. In addition, blind instrumentation of the oesophagus with a rigid nasogastric tube and transoesophageal echocardiogram probe have also been implicated as potential factors 13 . Although no disease process or anatomic abnormality has been linked definitively with an increased risk of arytenoid subluxation, there are several case reports involving patients with laryngomalacia 14 , diabetes mellitus 3 , chronic renal failure 3 , acromegaly 4 and chronic steroid use 4 . ...
Arytenoid subluxation is a rare laryngeal injury that may follow instrumentation of the airway and present as hoarseness, vocal fatigue, stridor, dysphagia, odynophagia and sore throat. We report the case of an 88-year-old man with type 2 diabetes mellitus who developed this complication during a difficult intubation where a Macintosh laryngoscope and gum elastic bougie were used to facilitate intubation. Previously considered to play a minor role in treatment, voice therapy was used successfully in this patient to correct subluxation of the arytenoid, with prompt resolution of his symptoms.
