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STUDENTS CORNER
Year : 2017  |  Volume : 7  |  Issue : 2  |  Page : 43-45

Arytenoid dislocation subsequent to difficult intubation


Department of ENT, D. Y. Patil Hospital and Research Centre, Mumbai, Maharashtra, India

Date of Web Publication26-Sep-2018

Correspondence Address:
Dr. Anjali Venugopal
701-A Wing, Apsara Building, Plot No. 51, Sector-17, Vashi, Navi Mumbai - 400 703, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jlv.JLV_8_18

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   Abstract 


Dislocation of arytenoid cartilage from the crico-arytenoid joint is an uncommon complication due to intubation of larynx. In many cases, it is frequently mistaken as vocal cord paresis, laryngospasm, or laryngeal edema. Early diagnosis of the arytenoid dislocation and prompt treatment with reduction is crucial to avoid the need for more invasive methods and for a better prognosis of the condition. We report the case of a 50-year-old male with arytenoid dislocation following an uneventful coronary artery bypass graft surgery. He complained of persistent hoarseness following 15 days of the surgery. On fiber-optic laryngoscopic examination, the right vocal cord was immobile with minimal movement of arytenoid. A surgical reduction was performed by the otolaryngologist. The patient was relieved of the symptom postreduction.

Keywords: Arytenoid dislocation, endotracheal intubation, postoperative hoarseness


How to cite this article:
Venugopal A, Dabholkar YG, Saberwal AA. Arytenoid dislocation subsequent to difficult intubation. J Laryngol Voice 2017;7:43-5

How to cite this URL:
Venugopal A, Dabholkar YG, Saberwal AA. Arytenoid dislocation subsequent to difficult intubation. J Laryngol Voice [serial online] 2017 [cited 2019 Sep 17];7:43-5. Available from: http://www.laryngologyandvoice.org/text.asp?2017/7/2/43/242241




   Introduction Top


Arytenoid dislocation is one of the complications encountered during laryngeal and esophageal procedures such as endotracheal intubation, laryngeal mask airway insertion, gastrointestinal endoscopy, and transesophageal endoscopy probe placement. Traumatic insertion of laryngoscope blade, prolonged and/or difficult intubation, overzealous use of lighted stylet intubation, or extubation with partially deflated cuff were reported as the causes of arytenoid dislocation.[1] Endotracheal intubation is a common cause of arytenoid dislocation and it results in hoarseness, aphonia, and dysphagia.[2] Early identification and treatment leads to arytenoid motion restoration and improvement in voice.[3],[4] Treatment varies between spontaneous resolution, speech therapy, and closed reduction through direct/indirect laryngoscopy.[5]


   Case Report Top


A 50-year-old male (175 cm and 75 kg), a known hypertensive, was scheduled for coronary artery bypass graft surgery. He had no history of pharyngeal or laryngeal disorders and had not undergone general anesthesia in the past. Physical examination and laboratory investigations were insignificant. Preoperative physical status classification of the patient according to the American Society of Anesthesiologists (ASA) was ASA Grade II. Assessment of airway showed modified Mallampati Class I, and his mouth opening and thyromental distance were normal.

After securing intravenous access and beginning standard monitoring, agents such as thiopentone, fentanyl, and atracurium were used for induction. Following sufficient depth of anesthesia and complete muscle relaxation, direct Laryngoscope (using Macintosh Blade 3) was introduced and it revealed an anteriorly placed epiglottis. After three unsuccessful attempts, an 8.0-mm plain endotracheal tube was inserted and fixed on the left lip corner and secured with a tube holder. The patient did not move or cough during intubation. Nasogastric (NG) tube and esophageal stethoscope were inserted on surgeon's request without any difficulty.

During the 5-h surgery, anesthesia was maintained with atracurium, inhalational agents such as isoflurane, nitrous oxide, and oxygen. Surgery was uneventful, and the patient was shifted to the cardiac Intensive Care Unit (CICU) with endotracheal tube in situ. The patient suffered cardiac arrest while in the CICU and was revived with cardiopulmonary cerebral resuscitation. Six hours postprocedure, the endotracheal cuff was deflated and removed without any difficulty, coughing, or vomiting. Immediately after extubation, he did not have any symptoms. However, the next day, he complained of hoarseness. The physician expected the symptom to resolve spontaneously, but the patient complained of persistent hoarseness even after 7 days of surgery, for which an otorhinolaryngology referral was done.

A fiber-optic laryngoscopy was performed by the otorhinolaryngologist and the right vocal cord was found to be fixed in the paramedian position along with minimal movement of the arytenoids during phonation. The right arytenoid was displaced to the anteromedial side. In addition, a difference in the level between the two vocal cords was observed. This led to a diagnosis of arytenoid dislocation [Figure 1]. The patient was scheduled for surgical reduction of arytenoid dislocation using direct laryngoscope under 10% topical lignocaine, superior laryngeal nerve block, and sedation.
Figure 1: Right arytenoid dislocation on laryngoscopic examination

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Reduction was attempted repeatedly by applying force on the right arytenoid cartilage toward the posterolateral side using pressure with a blunt surgical instrument [Figure 2]. After reduction, movement of both the vocal cords was confirmed under direct laryngoscopic view (Macintosh blade 3) [Figure 3]a and [Figure 3]b. The patient's voice improved immediately postreduction and he was advised voice rest and speech therapy. Three weeks following the reduction, the vocal quality of the patient significantly improved, with the vocal cords in normal position as confirmed on fiber-optic laryngoscopy.
Figure 2: Right arytenoid reduction using instrument

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Figure 3: ( a and b) Postreduction of right arytenoid

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   Discussion Top


Arytenoid dislocation is a rare complication encountered following intubation. The estimated incidence of arytenoid dislocation is 0.02%–0.1%, although the overall incidence of this clinical entity is probably higher than reported. This is because the cricoarytenoid joint which is prone to dislocation/subluxation is an anatomically synovial-lined diarthrodial joint.[1],[2],[5] Intubation trauma is the most common etiology. Incomplete neuromuscular blockage or motor reactions leading to laryngeal muscle contractions during intubation are implicated. Apart from the use of McCoy laryngoscope and double-lumen tube, laryngeal mask airway, lighted stylet, difficult intubation, and blind instrumentation of the esophagus with a rigid NG tube or transesophageal echocardiogram probe are also associated with arytenoid dislocation.[2],[3],[5]

Upon presentation, the most common symptoms of this disorder are hoarseness, “breathy” voice quality, voice fatigue, and decreased voice volume. Due to its infrequency, arytenoid dislocation may be easily mistaken for other similar presenting disorders such as recurrent laryngeal nerve paralysis, laryngospasm, and laryngeal edema. Hoarseness occurs in almost half of the patients on the day of operation, but hoarseness more than 1 week is unusual.[2],[3] Diagnosis is made through a thorough history and physical examination. The history should explain patient symptoms and any recent intubation or external trauma to the neck.[4],[5],[6] Clinical diagnosis is made by fiber-optic laryngoscopy. Neck computed tomography and electromyography can be helpful in distinguishing arytenoid dislocation from other disorders; however, these are no tools for definitive diagnosis. A high index of suspicion based on circumstances and clinical findings is crucial to the diagnosis of arytenoid cartilage dislocation.[3],[5]

Physical findings that suggest this clinical entity include arytenoid edema, reduced vocal cord mobility, and asymmetry of arytenoid. The arytenoid may be dislocated either anteriorly or posteriorly with respect to cricoid. Anterior dislocation results in anteromedial displacement of the arytenoid cartilage with an inferiorly located foreshortened and dysfunctional vocal cord. In contrast, posterior dislocation is often associated with posterolateral displacement of the arytenoid cartilage and superiorly positioned vocal cord.[7] There are many factors contributing to this condition. A misdirected endotracheal tube tip or stylet knocking into the arytenoids for glottic opening could be a factor.[2],[5] In order to avoid anterior dislocation, a good visualization of the laryngeal inlet is important prior to instrumentation of the airway. Laryngeal morbidity increases and the quality of endotracheal intubation increases with incomplete muscle relaxation. NG tube or esophageal stethoscope should be carefully and gently inserted in anesthetized patients as arytenoid cartilage is one of the most common sites of resistance while introducing these tubes.[8] As the patient is intubated, any movement or improperly secured position of the endotracheal tube can cause arytenoid dislocation. The intubation/extubation conditions and intraoperative factors can influence the pH and thus long duration of intubation may lead to vocal cord sequelae by mucosal damage, submucosal hemorrhage, and change in pH.[8]

The treatment of choice once arytenoid dislocation is diagnosed is immediate surgical reduction. Early intervention increases the likelihood of successful reduction and good functional outcome.[4] The other modalities of treatment include speech therapy, chemical splinting, and invasive surgical procedures such as Type 1 thyroplasty and open reduction of arytenoids. Recovery from this disorder becomes difficult if the treatment is delayed. In order to prevent fibrotic ankylosis of the joint and favorable clinical outcome, the average time interval between the injury and closed reduction is 21 days. A timely diagnosis of this disorder helps in successful reduction and re-establishment of normal voice.[3],[5]


   Conclusion Top


In case of persistent hoarseness after endotracheal intubation, clinicians should suspect arytenoid cartilage subluxation/dislocation as a complication of intubation. Closed reduction is a safe and effective treatment method for arytenoid dislocation. To optimize the probability of effective reduction and restoration of normal voice, prompt diagnosis of this clinical entity is necessary.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

We would like to acknowledge the doctors and nursing staff in our department who participated in the treatment of this patient.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Prasertwanitch Y, Schwarz JJ, Vandam LD. Arytenoid cartilage dislocation following prolonged endotracheal intubation. Anesthesiology 1974;41:516-7.  Back to cited text no. 1
    
2.
Yamanaka H, Hayashi Y, Watanabe Y, Uematu H, Mashimo T. Prolonged hoarseness and arytenoid cartilage dislocation after tracheal intubation. Br J Anaesth 2009;103:452-5.  Back to cited text no. 2
    
3.
Rubin AD, Hawkshaw MJ, Moyer CA, Dean CM, Sataloff RT. Arytenoid cartilage dislocation: A 20-year experience. J Voice 2005;19:687-701.  Back to cited text no. 3
    
4.
Sataloff RT. Arytenoid dislocation: Techniques of surgical reduction. Oper Technol Otolaryngol Head Neck Surg 1998;9:196-202.  Back to cited text no. 4
    
5.
Sataloff RT, Bough ID Jr., Spiegel JR. Arytenoid dislocation: Diagnosis and treatment. Laryngoscope 1994;104:1353-61.  Back to cited text no. 5
    
6.
Norris BK, Schweinfurth JM. Arytenoid dislocation: An analysis of the contemporary literature. Laryngoscope 2011;121:142-6.  Back to cited text no. 6
    
7.
Alexander AE Jr., Lyons GD, Fazekas-May MA, Rigby PL, Nuss DW, David L, et al. Utility of helical computed tomography in the study of arytenoid dislocation and arytenoid subluxation. Ann Otol Rhinol Laryngol 1997;106:1020-3.  Back to cited text no. 7
    
8.
Mencke T, Echternach M, Kleinschmidt S, Lux P, Barth V, Plinkert PK, et al. Laryngeal morbidity and quality of tracheal intubation: A randomized controlled trial. Anesthesiology 2003;98:1049-56.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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