Arytenoid dislocation after cardiac surgery

Incidental Diagnosis of Pediatric Arytenoid Cartilage Dislocation During Videofluoroscopic Swallowing Study: A Case Report

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.

Association between the use of a stylet in endotracheal intubation and postoperative arytenoid dislocation: a case-control study

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.

Cardiovascular operation: A significant risk factor of arytenoid cartilage dislocation/subluxation after anesthesia

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.

Arytenoid cartilage dislocation mimicking bilateral vocal cord paralysis: A case report

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.

Closed reduction for arytenoid dislocation under local anesthesia

CONCLUSION

Closed reduction under local anesthesia continues to be an effective and well-tolerated method for treating arytenoid dislocation. Bilateral arytenoid dislocation is an uncommon occurrence, and the principles of management are the same as for unilateral dislocation.

OBJECTIVES

To evaluate the treatment outcomes of closed reduction for arytenoid dislocation under local anesthesia and to conduct an exhaustive review of the literature on bilateral arytenoid dislocation.

METHODS

Thirty-three patients with arytenoid dislocation were treated with closed reduction under local anesthesia. Arytenoid motion, GRBAS (grade, roughness, breathiness, asthenia, strain), maximum phonation time (MPT), self-assessed Voice Handicap Index (VHI), and acoustic voice analysis were used to evaluate the clinical outcomes.

RESULTS

Following closed reduction, 33 patients were divided into a 'satisfied' group (n = 26) and a 'dissatisfied' group (n = 7). In the 'satisfied' group, G, R, B, A, MPT, VHI, jitter%, shimmer%, normalized noise energy (NNE), and noise-to-harmonic ratio (NHR) were significantly improved compared with measurements taken before closed reduction (p < 0.05). The results for F0 and S score were not significantly different. In the 'dissatisfied' group, VHI, MPT, F0, and shimmer% were not significantly different 1 month after reduction. However, statistically significant change was observed in jitter% and NHR.

Clinical Characteristics of Arytenoid Dislocation After Endotracheal Intubation

OBJECTIVE

The objective of this study was to review the clinical characteristics of the arytenoid dislocations after the endotracheal intubation and to identify the factors affecting voice recovery in the arytenoid dislocation after the endotracheal intubation.

METHODS

A retrospective chart review was performed at Chonnam National University Hwasun Hospital from April 2008 to February 2014.

RESULTS

A total of 13 patients with the arytenoid dislocation were identified. The patients had undergone the endotracheal intubation for head and neck surgery (n = 7), abdominal surgery (n = 4), and orthopedic surgery (n = 2). The most common symptom was hoarseness (100%), followed by swallowing difficulty (15.4%). All of the patients with the arytenoid dislocations after the endotracheal intubation were treated by the closed reduction. All of the patients regained normal voice and vocal fold movement after the closed reduction in spite of late surgical intervention. There was no statistical significance between the Cormack-Lehane classification, expertise of anesthetist, patient's position, operation time, duration between first operation and the closed reduction, and period of voice improvement.

CONCLUSION

This study indicates that the arytenoid dislocations after the endotracheal intubation may be needed for the aggressive surgical intervention, even if the diagnosis was delayed.

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.

Laryngeal dislocation after ventral fusion of the cervical spine

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.

Arytenoid dislocation as a cause of prolonged hoarseness after cervical discectomy and fusion

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.

A promising new technique for closed reduction of arytenoid dislocation

Objectives:

To study the effect of a new technique for closed reduction of dislocated arytenoids.

Methods:

The study included 21 females (72.4 per cent) and eight males (27.6 per cent) with a diagnosis of arytenoid dislocation. There were 18 cases of left arytenoid dislocation and 11 of right arytenoid dislocation.Twenty-eight cases had anteromedial dislocation and one had posterolateral dislocation. All patients were treated with closed reduction using custom-made metal rods and an operating microscope, under general anaesthesia.

Results:

Post-operatively, 21 patients’ voices returned completely to normal (including full vocal fold mobility), five had an improved voice and three failed to show any improvement. There were no post-operative complications.

Conclusion:

This new closed reduction technique is a safe procedure for patients with dislocated arytenoids. It is repeatable and the outcome is reliable and effective. Closed reduction can be a useful treatment for arytenoid dislocation.

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.