Arytenoid dislocation while using a McCoy laryngoscope

2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway

The American Society of Anesthesiologists; All India Difficult Airway Association; European Airway Management Society; European Society of Anaesthesiology and Intensive Care; Italian Society of Anesthesiology, Analgesia, Resuscitation and Intensive Care; Learning, Teaching and Investigation Difficult Airway Group; Society for Airway Management; Society for Ambulatory Anesthesia; Society for Head and Neck Anesthesia; Society for Pediatric Anesthesia; Society of Critical Care Anesthesiologists; and the Trauma Anesthesiology Society present an updated report of the Practice Guidelines for Management of the Difficult Airway.

Clinical characteristics of arytenoid dislocation in patients undergoing bariatric/metabolic surgery: A STROBE-complaint retrospective study

Tracheal intubation and the use of a large-bore calibrating orogastric (OG) tube have been reported to increase the incidence of arytenoid dislocation (AD) in patients undergoing bariatric/metabolic surgery. This study aimed at identifying the clinical characteristics of this patient subgroup.We retrospectively examined the clinical characteristics of 14 patients with AD (study group) who received tracheal intubation and OG insertion for bariatric/metabolic surgery between 2011 and 2016. For comparison, another group of 19 patients with postoperative AD collected from published literature and 3 patients from the authors' institute served as controls in whom only tracheal intubation was performed. Information on patient characteristics, anesthetic time, symptoms, time of symptom onset, intervention, and postinterventional impact on vocalization of the 2 groups were collected and compared.Patients in the study group were younger than those in the control group (38 [25-60] vs 54.5 [19-88] years, P = .03). Compared with the control group, anesthetic time (282.5 [155-360] vs 225 [25-480] minutes, P = .041) was longer and symptom onset (1.0 [0-6] vs 1.0 [0-6] days, P = .018) was more delayed in the study group. After closed reduction, the frequency of voice recovery was comparable in both groups in a time interval of 12 weeks (84.6% vs 92.9%, P = .59).Our report demonstrates that the clinical characteristics of patients with AD who received tracheal intubation and OG insertion for bariatric/metabolic surgery were different from those with postoperative AD receiving only tracheal intubation, highlighting the importance of implementing individualized strategies for AD prevention in this patient population.

Indications for endotracheal intubation and ventilation

The ability of the emergency physician to recognize and manage a patient with a compromised airway is probably the most important aspect of an individual’s care in the emergency department. Endotracheal intubation in a critically ill patient is a potentially hazardous procedure because of the technical difficulties that can be encountered during emergency airway management and the profound pathophy siological changes that the institution of mechanical ventilation can cause. This review article sets out to illustrate when invasive airway management should be considered and the potential consequences of attempts to perform endotracheal intubation and mechanical ventilation.

Nomenclature proposal to describe vocal fold motion impairment

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.

Arytenoid dislocation: An analysis of the contemporary literature

OBJECTIVES/HYPOTHESIS

To discuss the incidence, diagnosis, laryngeal findings, and management of arytenoid dislocation as a separate entity from vocal fold paralysis.

STUDY DESIGN

Literature review.

METHODS

A contemporary review of the literature was performed by searching the terms arytenoid cartilage dislocation and subluxation in various combinations. Articles were analyzed and selected based on relevance and content.

RESULTS

Arytenoid dislocation is described as an uncommon laryngeal finding associated with intubation or blunt laryngeal trauma. The majority of recent publications are case reports or small case series. Diagnosis of arytenoid dislocation with flexible laryngoscopy, helical computed tomography, videostroboscopy, and laryngeal electromyography is recommended. In most reported cases, diagnosis has been made based on the position of the arytenoid at laryngoscopy. Reduction and repositioning of the arytenoid cartilage is reported with limited success noted with delayed diagnosis. Speech therapy may also be a beneficial treatment option.

CONCLUSIONS

Although arytenoid dislocation is reported in the literature, the body of available evidence fails to sufficiently differentiate it as a separate entity from unilateral vocal fold paralysis. Flexible laryngoscopy is inadequate as a standalone procedure to distinguish arytenoid dislocation from laryngeal nerve injury.

Arytenoid subluxation after a difficult intubation treated successfully with voice therapy

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.

Arytenoid dislocation after cardiac surgery

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 requiring the use of transesophageal echocardiography (TEE). This case prompted us to review some of the mechanisms of injury to the cricoarytenoid joint. We conclude that even very subtle force may dislocate the arytenoid cartilage. We speculate that careless insertion of a TEE probe is mechanically capable of causing arytenoid dislocation and arytenoid subluxation. As ideal tools for intra-operative cardiovascular monitoring, TEE probes are increasingly being used routinely during cardiovascular surgery. So far, arytenoid cartilage dislocation and subluxation following TEE probe insertion have been reported rarely, but complications caused by TEE may increase in the near future. We wish to emphasize the pathophysiological risks of TEE monitoring and other procedures associated with anesthesia, and the need for a proper explanation to achieve informed consent before carrying out TEE monitoring during cardiac surgeries.

Arytenoid cartilage dislocation caused by a double-lumen endobronchial tube

Following surgery requiring the use of a double-lumen endobronchial tube, a patient immediately complained of persistent severe hoarseness. On the third day after the operation, fibreoptic laryngoscopy revealed posterolateral dislocation of the left arytenoid cartilage. By the sixth day of the operation, a slight improvement was observed in the hoarseness without treatment and a spontaneous recovery of arytenoid cartilage dislocation was expected. The patient did not consent to surgical treatment, and therefore a conservative therapy was selected. Ten weeks after the operation, it was found that the dislocated left arytenoid cartilage had spontaneously repositioned and the patient regained his normal voice. The causes and treatment options are discussed.

[Lesions to lips, oral and nasal cavities, pharynx, larynx, trachea and esophagus due to endotracheal intubation and its alternatives]

Dysphagia of greater than 48 h duration is an indication for indirect laryngoscopy and when odynophagia and otalgia occur simultaneously, the possibility of subluxation of the arytenoids demands an urgent ENT assessment. The potential seriousness of laryngeal lesions following intubation obliges us to use the smallest compatible endotracheal tube. The occurrence of pain cervical surgical emphysema and fever suggests a pharyngeal lesion necessitating the suspension of oral feeding and the initiation of antibiotic therapy with anaerobic activity, while awaiting possible surgical intervention. There is no argument to use a tooth-guard for each intubation, but tooth fragility must be researched. The incidence of nasal fossa trauma is reduced with the use of nasal packs impregnated with local anaesthetic containing a vasoconstrictor. This allows the introduction of a small flexible lubricated tube. Laryngeal mask-induced sore throat is more common than the more serious injuries. The classical technique of introducing a laryngeal mask of appropriate size (4 for women, 5 for men) in which the cuff is inflated to a leak pressure of 20 cm H(2)O reduces this frequency. The facial mask may cause injuries especially with prolonged use. The incidence of pulmonary aspiration, linked to the action of drugs, raised intra-abdominal pressure; an emergent situation or difficult intubation is decreased with the performance of the Sellick maneuver at intubation, rapid induction and the neutralization of gastric acidity. A meticulous technique of insertion of the, individualized anaesthesia, particular vigilance at the time of decurarisation and position changes and a calm awakening assure its optimal use, unless the Proseal laryngeal mask modifies this point of view.

Traumatic complications of airway management

Safe and effective airway management techniques have become a hallmark of modern anesthesiology practice, but even such overwhelmingly successful and life-saving practices come with a cost. This cost is morbidity and mortality secondary to the techniques themselves. Closed claims analysis has shown that adverse outcomes secondary to respiratory events constitute the single largest source of injury to patients (75%). Airway management complications are a significant subset of these outcomes. Difficult intubation was shown to be a factor in only slightly more that one third (38%) of these claims. Six percent of closed claims were for airway trauma. These data indicate that injury frequently occurs without initial difficulty in management of the airway, may occur throughout the perioperative period, and can be unexpected when it occurs. Thorough knowledge of the mechanisms of airway injury associated with different airway management techniques may allow for better patient outcomes. This chapter reviews complications of airway management involving the placement of endotracheal tubes. In addition, because laryngeal mask airways (LMAs) have gained increasing prominence in airway management use in the past 10 years, complications relating to their use will also be reviewed.