Cricoarytenoid arthritis in children

Posterior glottic stenosis

Posterior glottic stenosis in children is not uncommon and must be differentiated from vocal cord paralysis when there is posterior glottic fixation. Procedures aimed at increasing the airway lumen by tissue excision have not been uniformly successful. Chronic aspiration and poor voice results have been reported. Expansion of the posterior glottis yields excellent results. Tracheotomy decannulation without aspiration and return of vocal cord mobility in children who have vocal cord fixation with achievement of a functional voice can be expected from widening the laryngeal framework. Scar incision without excision reduces the denuded laryngeal surface. The laryngeal framework is widened by anterior and posterior cricoid split and by stenting. Posterior cartilage grafting reduces scar tissue build-up and the duration of stenting.

A biomechanical study of the human cricoarytenoid joint

OBJECTIVES/HYPOTHESIS

To develop a model to investigate the biomechanics of the cricoarytenoid joint and establish stiffness, laxity, and range of motion of the cricoarytenoid joint in adult human larynges.

STUDY DESIGN

Laboratory investigation of freshly frozen larynges from adult humans, measuring the stiffness, laxity, and range of motion in intact and injured cricoarytenoid joints.

METHODS

Eight normal-appearing frozen cadaver larynges from adult humans were studied. The cricoid cartilage was fixed to a load cell sensitive to forces in three dimensions. A probe was rigidly fixed to the arytenoid cartilage and attached to a frame to allow active rotation, rocking, and gliding of the arytenoid. A computer program simultaneously recorded forces generated by these motions and tracked the motion of the arytenoid in three dimensions. The joint was studied before and after injury to the posterior cricoarytenoid ligament, and the joint surfaces were digitized after completion of these studies.

RESULTS

A successful method of evaluating the biomechanical properties of the cricoarytenoid joint was developed. Comparing intact and injured joints confirmed that laxity and range of motion increased during rocking, gliding, and rotational motion when the cricoarytenoid ligament had been divided. Stiffness measurements for rocking, rotation, and gliding also were documented.

CONCLUSIONS

The model of study introduced in this report provides a significant and unique method of investigating the biomechanics of the cricoarytenoid joint, allowing insight into the basic joint characteristics and alteration in joint biomechanics related to injuries and surgical procedures. Dividing the cricoarytenoid ligament increases laxity and range of motion in sagittal rocking, gliding, and axial rotation. Secondary constraints on the joint provide significant stiffness of greater degrees of displacement. Further studies should provide insight into the significant secondary elements supporting the joint and into the mechanisms of cricoarytenoid injuries, as well as the effect of surgical procedures on the cricoarytenoid joint.

Upper airway obstruction in the rheumatic diseases

Upper airway obstruction is a potentially life-threatening event that can be managed effectively when promptly recognized and treated. For this reason, all patients who are suspected of having disease affecting the larynx or trachea should be regarded as having a potentially compromised airway until proven otherwise. Although clinically significant upper airway diseases occur infrequently in rheumatic disorders, these manifestations should be considered in such patients who present with upper airway symptomatology.

Posterior glottic fixation in children

Vocal cord fixation from posterior glottic stenosis may produce progressive airway obstruction. Treatment involves scar excision with adjunctive procedures on healthy tissue, including arytenoidopexy, arytenoidectomy, cordectomy, and cordotomy. Twenty-five children with posterior glottic stenosis were studied; 6 had vocal cord fixation in the midline and 6 had limited vocal cord abduction. All were tracheotomy-dependent because of posterior glottic stenosis and secondary impairment of vocal cord mobility. All children were decannulated after scar incision and widening of the laryngeal framework with posterior cricoid split and stenting. Cartilage grafting was used in 11 patients to maintain an adequate glottic lumen. Ten regained full vocal cord mobility. One had limited adduction, while another's cords were refixed in the midline. A second procedure in the latter patient resulted in limited abduction. Aspiration did not occur in any of the patients, and the voice results were good. Scar incision with cricoid split, cartilage grafting, and stenting is an excellent method for treating posterior glottic fixation without destroying healthy tissue.