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Arytenoid dislocation
Journal of Voice
Vol. 1, No. 4, pp. 368-377 © 1988 Raven Press, Ltd., New York
Arytenoid Dislocation Robert Thayer Sataloff, Marc Feldman, Kathe S. Darby, Linda M. Carroll, Joseph R. Spiegel, and Barbara-Ruth Schiebel Department of Ototaryngology, Thomas JeJJerson University, Philadelphia, Pennsylvania, U.S.A.
Summary: Arytenoid dislocation is a common yet infrequently diagnosed complication of laryngeal trauma. It may result in various symptoms, including permanent dysphonia, although immediate voice change is not always present. Early reduction is the treatment of choice; however, late reduction is often successful in restoring voice. A high index of suspicion based on the history of the patient is necessary to recognize arytenoid dislocation. Thorough physical examination and objective tests are helpful in confirming this diagnosis. Key Words: Arytenoid dislocation--Laryngeal trauma--Dysphonia--Vocal-cord paralysis.
cases have been reported (2-8). This is undoubtedly due to frequent misdiagnosis by surgeons, anesthesiologists, and even by expert otolaryngologists (see Cases 1 and 8 below). In 1973, Komorn et al. described one patient with right arytenoid dislocation following 14.5 h of endotracheal intubation (2). Immediately after extubation, the patient reported hoarseness, difficulty in coughing, dysphagia, and odynophagia. Reduction was performed 16 days later. Although the authors reported incomplete reduction, the patient was satisfied with the result. In 1974, Prasertwanitch et al. reported a case of left arytenoid dislocation following 7.5 h of intubation (3). The major complaint of the patient was hoarseness. Schultz-Coulton described a female patient with acromegaly who experienced left arytenoid-cartilage dislocation after general anesthesia (4). The authors hypothesized that the patient's overproduction of somatotropic hormone caused degenerative changes in the cricoarytenoid joint. There is insufficient data to conclude that acromegaly predisposes patients to arytenoid dislocation, but it is interesting to note that Case 8 in this report also had acromegaly. In 1978. Quick and Merwin reported three cases of arytenoid dislocation, each following one incident of endotracheal intubation (5). In each case, the pa-
The cricoarytenoid joint is a complex, delicate structure. It may be injured during intubation, extubation, or external laryngeal trauma. In such situations, soft-tissue injury provides a ready and misleading explanation for dysphonia, and swelling may o b s c u r e subtle alterations in laryngeal anatomy, rendering diagnosis difficult. Vocal-cord immobility may be incorrectly attributed to recurrent laryngeal-nerve injury (1). Recognizing arytenoid dislocation under such circumstances is crucial to permit early reduction, thus optimizing the chance for return to good vocal quality. We report 12 cases of arytenoid dislocation treated by the author (R.T.S.) between 1983 and 1987. They are discussed to emphasize the variability of presentation and response to treatment, as well as the value of objective testing performed on the more recent cases. BACKGROUND Considering the frequency with which arytenoid dislocation occurs, it is surprising that only 11 Presented at the Sixteenth Symposium: Care of the Professional Voice, New York, June 1986. Address correspondence and reprint requests to Dr. R. T. Sataloff at 1721 Pine Street, Philadelphia, PA 19103, U.S.A.
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A R YTENOID D I S L O C A T I O N tient was diabetic. They were all hospitalized to be evaluated for renal transplantation. In all three, the left arytenoid was dislocated. Dudley et al. described one case of dislocation of the right arytenoid cartilage after endotracheal intubation (6). The patient's only complaint was a " w e a k " voice. Stanley and Coleman reported six cases of unilateral degloving injuries of the arytenoid cartilage, each due to external blunt trauma (7). The chief complaint in five patients was hoarseness. One patient complained of pain during phonation. Of the six patients, two had vertical fractures of the thyroid ala ipsilateral to a degloved and immobile arytenoid cartilage. One patient had disruption of the arytenoid cartilage itself. None of the patients with degloved and dislocated arytenoid cartilages regained vocal-cord mobility 6 to 12 months after reduction. The other three patients experienced degloving, but the arytenoid cartilages remained normal. They had normal vocal-cord mobility and voice in follow-up examinations. Chatterji et al. reported an unusual case of bilateral arytenoid dislocation after extubation (8). This "spontaneously resolved" after coughing. None of the cases reported had objective documentation of the diagnosis. ANATOMY AND EMBRYOLOGY The primordium of the larynx, trachea, bronchi, and lungs arises as an outgrowth of the pharynx during the 3rd week of embryonic life, forming a laryngotracheal groove (9). This anterior groove lies immediately posterior to the hypobranchial eminence and becomes the primitive laryngeal aditus. The aditus lies between the sixth branchial arches. The laryngotracheal groove fuses in a caudocranial direction at about the 4th week. The ventral ends of the sixth branchial arches grow and form the arytenoid eminences. During the 7th week, a fissure appears on each arytenoid eminence extending into the primitive vestibule. This is the laryngeal ventricle. The last portion of the laryngotracheal groove to be obliterated is the intraarytenoid sulcus at about 11 weeks. Laryngeal hyaline cartilages develop from branchial arch mesoderm, and elastic cartilages are derived from mesoderm of the floor of the pharynx (10). Most of the arytenoid is composed of hyaline cartilage. However, the vocal processes are developed separately in association with the vocal folds and consist of elastic cartilage. "Arytenoid" comes
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from the Greek word arytainoeides, meaning ladleshaped. The cartilages are pyramidal, consisting of an apex, base, and two processes. The base articulates with the cricoid cartilage. The apex attaches to the corniculate cartilage of Santorini and to the aryepiglottic fold. The vocal process projects anteriorly to connect with the vocal ligament, and the muscular process is the point of insertion for most of the muscles that move the arytenoid (11). The cricoarytenoid facets are well defined, smooth, and symmetrical. Each arytenoid articulates with an elliptical facet on the posterior superior margin of the cricoid ring. The cricoid facet is about 6 mm long and is cylindrical (12). Most of the cricoarytenoid motion is rocking. However, along the long axis of the cricoid facet, gliding also occurs (13). Limited rotary pivoting is permitted as well. The arytenoid cartilages and the cricoarytenoid facets are extremely symmetric and consistent (12). The cricoarytenoid joint is an arthrodial joint, supported by a capsule lined with synovium. The capsule is strengthened posteriorly by the cricoarytenoid ligament (1). This ligament is strong and ordinarily prevents anterior subluxation. The axis of the joint is at an angle of 45 ° from the sagittal plane and 40° from the horizontal plane. The cricoarytenoid joint controls abduction and adduction of the true vocal cords, thereby facilitating respiration, protection of the airway, phonation, and other laryngeal functions. Arytenoid motion is controlled directly by intrinsic laryngeal muscles, including the posterior cricoarytenoid, lateral cricoarytenoid, transverse arytenoid, oblique arytenoid, and thyroarytenoid. It is also affected by the cricothyroid muscle, which adducts and increases longitudinal tension on the vocal fold (which attaches to the vocal process of the arytenoid), and to a lesser degree by the thyroepiglottic muscle, which tenses the aryepiglottic fold. CASE REPORTS Case 1
This was a 37-year-old female otolaryngologist whose neck struck the steering wheel during a motor vehicle accident. Initially, she noted throat pain, severe odynophagia, and referred otalgia. Physical examination by two other otolaryngologists revealed a hematoma in her left pyriform sinus and bilateral vocal-fold hemorrhage. Soft-tissue ra-
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diographs revealed no laryngeal fracture. She had no hemoptysis. Her voice remained essentially normal for 2 weeks. She then noted hoarseness, breathiness, decreased volume, inefficient cough, and occasional aspiration of liquids. She was 6 weeks pregnant at the time of our examination. Physical examination revealed posterior dislocation of the left arytenoid cartilage, with the left vocal process higher than the right and sluggish motion of the left vocal fold. Despite the fact that the diagnosis was made 1 month after her injury, she was taken to the operating room and a left arytenoid reduction was accomplished with the patient under local anesthetic with sedation. Excellent reduction was obtained with return to normal voice. However, several hours later she had an episode of vomiting, and her voice deteriorated again. Reduction was repeated successfully 2 days later while the patient was given local anesthetic without sedation. Dislocation recurred with coughing the following day. Reduction was repeated again 2 days later with topical anesthetic without sedation, and excellent permanent reduction was established. Strobovideolaryngoscopy was performed prior to and after each procedure. This study confirmed overlap of her vocal folds prior to each reduction. Her voice has remained normal for more than 1 year after her last reduction, and she has had no further difficulty. Spectrography demonstrated the improvement (Fig. 1). C o m m e n t . Reduction in this case was possible even though the diagnosis was delayed for 1 month after the injury. Repeated dislocation probably reflects joint instability with tendinous and ligamentous laxity caused by the initial trauma, and the surgical trauma of late reduction. As with other weakened or dislocated joints (e.g., temporomandibular), spontaneous recurrence of dislocation of the cricoarytenoid joints is possible. Therefore, close monitoring is advisable in the immediate postoperative period. Case 2
A 35-year-old professional opera singer was struck in the throat 4 months prior to our examination. At the time of the injury, another otolaryngologist told him that the "back of the right vocal cord was not adducting," and had seen evidence of recent hemorrhage. No treatment had been given at the time his arytenoid dislocation was originally
Journal of Voice, Vol. 1, No, 4, 1987
diagnosed because of reasonably good arytenoid motion and voice quality. He had had intermittent difficulty with voice control, fatigue, had difficulty singing softly, and had a sensation of tightness in his throat during singing since the injury. Strobovideolaryngoscopy revealed slow adduction of the right vocal fold, decreased amplitude of the right waveform, and a posterior hypodynamic segment on the right. The examination was otherwise normal. C o m m e n t . This patient had had right arytenoid dislocation and vocal-fold hemorrhage. The arytenoid had reduced spontaneously, as probably happens often. The difficulties with control were due to instability of the joint and hyperfunctional voice abuse in a vain attempt to compensate for joint weakness and decreased longitudinal vocalfold tension. However, by the time the author examined this patient, the joint was functioning adequately, although not normally. The vocal-fold hemorrhage had produced a residual submucosal scar that was interfering with his vocal performance. Only continued voice training was recommended, and no surgery was offered. The management by the original oto/aryngologist was considered appropriate, although this and other cases raise questions about the advisability of incision and drainage of selected vocal-fold hematomas. Case 3
A 53-year-old man was involved in a speed-boat accident that resulted in loss of consciousness; near-drowning from which he was resuscitated; multiple head, face, and chest injuries; and intubation for respiratory support. He was hospitalized for approximately 1 month. Hoarseness was noted at the time of extubation. It persisted and was associated with vocal fatigue and decreased vocal loudness. It improved only slightly during the 1 year between his accident and his examination. The patient's voice was hoarse, weak, and breathy. Strobovideolaryngoscopy revealed normal motion of the left vocal fold. The right vocal fold was innervated but moved sluggishly, and did not move all the way to the midline. The right vocal process was higher than the left vocal process. Vocal-fold vibrations were normal under stroboscopic light, and there were no adynamic segments, but glottic closure was intermittently incomplete.
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Case 4 A 26-year-old professional singer underwent vertical banded gastroplasty for obesity. She had a hiatal hernia with reflux and had lost 49 kg of weight after surgery. Because of multiple abdominal problems she had required endoscopy on several occasions. She had " l a r y n g o s p a s m " during
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FIG. 1. Preoperative narrow-band spectrograph (A) of Case 1 with F0 116.5 Hz, FI 3.84. Postoperatively, narrow-band spectogram (B) reveals F1 = - 1 0 , F 2 = - 2 8 , decreased to 0.072. Phonations were done on the vowel/i/. Spectrographic a n a l y s e s (Kay Elemetrics Model 7000). Additional objective voice analysis of all c a s e s was trics) and PM Pitch A n a l y z e r (Voice Identification).
Comments. Slight difference in vocal process height and abnormal motion commonly follow arytenoid dislocation with imperfect spontaneous reduction. They may also be seen after surgical reduction in some cases.
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= - 2 3 , F 2 and F3 indistinguishable. Perturbation is F 3 = - 3 0 with a F 0 o f 121.5 Hz. Perturbation has were performed on a dual-channel digital sonograph performed using a Visi-Pitch SE 6095 ( K a y Eleme-
one of the procedures, which was followed by prolonged hoarseness, breathiness, and a feeling of difficulty in breathing. She was not referred for laryngoscopic examination for 5 months. Examination revealed a hoarse, breathy voice with inspiratory stridor. Her right vocal fold was immobile, with the right vocal process 2-3 mm higher than the left. Her speaking voice was lower in pitch than it had been prior to her injury, and she was midly stridorous. Strobovideolaryngoscopy confirmed overlap of her vocal folds. An attempt was made to reduce the dislocation with the patient under local anesthetic with seda-
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R. T. S A T A L O F F E T AL.
tion. She did not tolerate the procedure well. A tracheotomy was performed, and general anesthesia was induced. Palpation confirmed a frozen right arytenoid joint, and the presence of posterior commissure stenosis was diagnosed also. The stenosis was divided, allowing visualization of a subglottic stenosis that was treated with laryngeal dilators. Forceful reduction of the right arytenoid dislocation was accomplished, although it was not possible to bring the vocal process completely back to its normal level. It was still about 0.5 mm higher than the left vocal process, but mobility was reestablished and membranous vocal-fold approximation was nearly perfect. Steroids were injected into the posterior commissure and subglottic scars. Eight months after the procedure, her speaking voice has remained much less hoarse and breathy (Fig. 2) and its volume has been normal. She has been able to resume limited singing. However, because of the severity of her subglottic stenosis, she still has a tracheotomy. Case 5 A 14-year-old boy was struck by a car. He was initially examined while he was on a respirator. After extubation, examination by indirect laryngoscopy revealed severe bilateral contact erosions of his vocal processes and marked edema of both vocal folds. He had mucosal disruption of the posterior third of his right vocal fold. Both arytenoids were markedly swollen and could not be assessed. He was reexamined approximately 2 weeks later after the swelling had resolved, and strobovideolaryngoscopy revealed dislocation of his left arytenoid with overlapping of the vocal processes. His left vocal process was higher than the right vocal process. His voice remained hoarse, breathy, and soft. He underwent successful reduction, resulting in immediate and permanent normal voice. Case 6
A 68-year-old man underwent left parotidectomy, excision of his external auditory canal, and facial nerve grafting for squamous-cell carcinoma. He awakened with a hoarse voice. Fiberoptic laryngoscopy the day after surgery revealed right arytenoid dislocation. Reduction was postponed until 6 days after his original procedure because of other medical problems. Despite the extremely short time, arytenoid reduction could not be accomplished. His voice remained unsatisfactory. Six weeks later he
Journal of Voice, Vol. l, No. 4, 1987
underwent Teflon injection into his right vocal fold. He recovered good vocal quality and volume. His voice remained improved through I year of followup.
Comment. Although common teaching holds that late reductions are impossible and early reduction of arytenoid dislocation provides good results, this case illustrates that improvement may not be possible even with very early diagnosis. Other cases in this report illustrate the value of attempting late reduction.
Case 7 A 29-year-old woman was extremely anxious and was involved in malpractice litigation at the time of her initial examination. She was labile emotionally and had a remarkably strong gag reflex that was activated simply by asking her to open her mouth. Most of the time, she could not tolerate nasal fiberoptic laryngoscopy even after topical anesthetic and oral diazepam. She had undergone excision of her right submandibular gland and had awakened with hoarseness, breathiness, vocal fatigue, and dysphagia. An otolaryngologist attempted to perform indirect laryngoscopy shortly thereafter, without success. Two months later he attempted to perform direct laryngoscopy in the operating room with the patient under intravenous sedation. The patient did not tolerate this procedure and general anesthetic with intubation was necessary. No diagnosis was made. She was initially examined by the author 4 months after her initial surgery, at which time fiberoptic laryngoscopy was performed successfully but with difficulty. She had obvious dislocation of her right arytenoid cartilage, with the right vocal process higher than the left and markedly diminished mobility of the right vocal fold. Her voice was hoarse, breathy, and soft. She had extreme neck, facial, tongue, shoulder, and supraglottic muscle hyperactivity on attempts at phonation. Despite the 4-month period between her surgery and the diagnosis, she was taken to the operating room where partial reduction of her right arytenoid cartilage was accomplished under general anesthesia. The vocal process was returned to a nearly normal level, and good motion was restored. Postoperatively, her voice intensity and quality improved dramatically for a few days. However, her excessive muscle tension persisted and she devel-
AR YTENOID DISLOCATION
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FIG. 2. P r e o p e r a t i v e narrow-band spectrogram (A) in Case 4 reveals a F0 of 103.3 Hz. H i ghe r formats are absent. P e r t u r b a t i o n is 3.44, Po sto perativ e n a r r o w - b a n d spectrogram (B) shows FI and F z. F3 is also pre s e nt but difficult to see, P e rt urba t i on d e c r e a s e d to 0.84. Ph onations were done on the v o w e l / i / . F0 p o s t o p e r a t i v e l y w a s 127.8 Hz.
oped severe dysphonia plica ventricularis. Direct laryngoscopy in June 1986, performed while she was laughing, confirmed that her vocal-fold motion had remained nearly normal, and her vocal processes were at the same level. Her legal case is still in progress, and her dysphonia plica ventricularis persists. Case 8
A 39-year-old man underwent transsphenoidal h y p o p h y s e c t o m y for acromegaly. He used his speaking voice professionally and sang occasionally with a barbershop quartet. As soon as he awoke from anesthesia he noticed an extremely hoarse, soft, breathy voice. His voice never re-
turned to serviceable volume or quality in the 8 months between his surgery and his examination. In the interim, he had been seen by an experienced otolaryngologist at the university hospital where the hypophysectomy had been performed. A diagnosis of vocal-cord paralysis had been made. At the time of examination by the author, strobovideolaryngoscopy revealed posterior dislocation of his left arytenoid with the left vocal process higher than the right vocal process. Although there was complete fixation of the arytenoid, the vocal fold was innervated and attempting to move against the immobile cricoarytenoid joint. This could be seen under continuous light as muscle contractions causing changes in the shape and tension of the su-
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praglottic tissues on the immobile side. Overlapping of the vocal folds was obvious under stroboscopic light. There were no nonvibrating segments, and vocal-fold mucosal waves were normal. Glottic closure was incomplete. Laryngeal electromyography was performed because of controversy regarding the diagnosis, as well as potential litigaton. It confirmed normal muscle activity bilaterally, further establishing the diagnosis as arytenoid dislocation rather than vocal-fold paralysis. Despite the 8-month delay from the time of injury, arytenoid reduction was accomplished with partial success. Although only minimal mobility returned to the joint, the vocal process was returned to its normal level. This allowed good contact with the mobile vocal cord and reestablished complete glottic closure. The hoarseness and breathiness resolved, the patient's volume improved substantially (comfortable speaking increased from 48.3 to 64.5 dB with his fundamental frequency essentially unchanged), and his singing range and vocal quality improved enough to allow him to return to avocational singing (Fig. 3). Although his harmonics were not restored, his frequency range improved from 90.4 Hz (F#-2) to 267 Hz (C-4) preoperatively, to 75.0 Hz (D-2) to 391.4 Hz (G-4) postoperatively. His perturbation decreased from 2.33 to 0.84. Comment. This case provides another example in which late reduction provided substantial improvement although not a return to normal. It also illustrates the value of objective tests in differentiating arytenoid dislocation from vocal-fold paralysis. Although computed tomography (CT) scans have been used only in our most recent cases, they have proven valuable in detecting arytenoid dislocaton and we are now using them routinely. Case 9
A 70-year-old woman was involved in a motor vehicle accident. She suffered head and neck injuries and loss of consciousness. She was intubated for several days and hospitalized for 7 months. She had no voice problems prior to her accident but has had only a whisper since her injury. She was seen for the first time l year after her accident. Examination revealed a breathy, whispered voice. Laryngoscopy revealed left arytenoid dislocation as well as an anterior glottic web. Her right vocal fold crossed the midline, but the dislocated cord was at a higher level. Contact was not adequate for good
Journal of Voice, Vol. 1, No. 4, 1987
phonation or cough. Mild spontaneous aspiration of saliva was observed. She had marked supraglottic hyperfunction including dysphonia plica ventricularis in efforts to compensate for her dysphonia. At present, the patient has declined further therapy. Case 10
A 50-year-old woman had a history of 10 episodes of spontaneous right arytenoid dislocation beginning approximately 15 years previously. These were diagnosed by several laryngologists, and educed spontaneously. She did well until she required intubation for treatment of a drug overdose. After extubation, she was diagnosed as having "bilateral vocal-cord paralysis," and underwent tracheotomy. She was initially seen by this author 19 months later. Her voice was hoarse and breathy. She had a tracheotomy tube in place. This was occluded for the purpose of examination, and she had no significant airway distress. Her left vocal fold moved normally. Her right vocal fold was immobile. The diagnosis of right arytenoid dislocation was confirmed by CT scan (Fig. 4) and by laryngeal e l e c t r o m y o g r a p h y , which revealed normal muscle activity bilaterally. At present, the patient has declined further therapy. Comment. This represents an unusual case of recurrent arytenoid dislocation with spontaneous reduction. We suspect she had bilateral arytenoid dislocation after intubation misdiagnosed as bilateral vocal-fold paralysis. Certainly, at the time of our examination, her left vocal fold was normal, and her right vocal fold was fully innervated with a dislocated arytenoid. Case 11
This 22-year-old woman was the driver in a motor vehicle accident. She struck her neck on the steering wheel. Subcutaneous emphysema and bleeding from the mouth and chin were noted in the emergency room, and an emergency tracheotomy was performed. The patient was not intubated. Computed tomography reportedly revealed laryngeal edema but no fracture. Following recovery, she was diagnosed as having an anterior glottic web and "left vocal-cord paralysis." She was referred for evaluation 10 months later. Her voice was hoarse and breathy. Despite an anterior glottic web that occluded nearly half of her airway, she had no respiratory distress. Pulmonary function tests were normal, as was her flow-volume loop. Strobovideo-
A R YTENOID D I S L O C A T I O N
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A B FIG. 3. Preoperative wide-band spectrogram (A) in Case 8 reveals aperiodicity and a weak first formant. Vertical striations are irregular. The F0 was 180.3 Hz. preoperatively. Postoperatively, the F0 was 171.8 Hz. The postoperative spectrogram (B) reveals markedly increased strength at the first formant with regularity of the vertical striations. All phonation was performed on the vowel/i/. laryngoscopy revealed attempted motion of her left vocal fold, although the cord appeared immobilized by arytenoid dislocation. The web also appeared on s t r o b o s c o p y to be a b o v e the level o f the vocal folds, r a t h e r than glottic. A CT scan revealed a spicule just above the anterior commissure at the level of the web (Fig. 5). It also demonstrated arytenoid dislocation. This was confirmed by normal e l e c t r o m y o g r a p h i c studies. Surgical t h e r a p y is planned for voice improvement. Case 12 A 10-year-old girl was struck in the neck with a baton 5 days prior to evaluation, in addition to being a baton twirler, she sang in the school choir and played the flute. She noticed decreased vocal range, decreased volume, and severe odynophagia. She had been able to eat only soft foods since the accident. She was also aware of a loud clicking sound when she swallowed. Initial examination included indirect laryngoscopy and strobovideolar-
yngoscopy during speech, singing, and playing the flute. H e r voice varied from breathy and slightly hoarse to nearly normal. During e n d o s c o p y , she was found to have an anterior dislocation of her right arytenoid cartilage. A loud click was heard and recorded during swallowing. Swallowing and coughing produced intermittent reduction or dislocation of her arytenoid cartilage coincident with abnormal or nearly normal vocal quality. She was placed on a regimen of relative voice rest, soft foods, and anti-inflammatory medication. H e r arytenoid cartilage reduced spontaneously and good vocal quality r e t u r n e d . This is i m p r o v i n g with speech therapy and singing lessions. DISCUSSION A r y t e n o i d dislocation, although f r e q u e n t l y unrecognized, is not a rare entity. Traditionally, arytenoid dislocation has been suspected on the basis Journal of Voice, Vol. I, No. 4, 1987
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generally lower on the abnormal side. In either case, the injured vocal fold may move sluggishly or be immobile. Rarely, abduction and adduction may appear almost normal under continuous light. Video documentation of the preoperative and postoperative appearance can prove particularly helpful in cases of arytenoid dislocation, because many of them may involve litigation. Objective preoperative voice assessment may include evaluation by a laryngologist and speech pathologist, measurements of frequency and intensity ranges, measurements of habitual frequency and intensity, measurement of maximum phonation time, spectrographic analysis, acoustic analysis by other glottal imaging tech~ niques, airflow analysis, CT scan, and electromyography. The most valuable tests are the stroboscopic examination to see differences in vocal process height, CT scan, which may image the arytenoid dislocation and laryngeal electromyography to differentiate an immobile dislocated arytenoid joint from vocal-fold paralysis. Air flow analysis is also particularly helpful in documenting changes. Additional experience with other objective tests is necessary to determine their clinical value, and we are currently performing a comprehensive objective test battery on all new cases of arytenoid dislocation and selected other lesions. Even though surgical reduction may be impossible even in rare early cases, it appears to be worth attempting reduction in all patients prior to treatment
FIG. 4. A: Axial computed tomography scan demonstrates dislocation of the right arytenoid cartilage (large arrow). The left arytenoid is in normal position (small arrow). B: During respiration, the left vocal fold abducts (small arrow), but the right vocal fold remains fixed in the midline.
of history and absence of the jostling phenomenon present in many cases of unilateral vocal-fold paralysis (15). Often it is not diagnosed until direct laryngoscopy reveals impaired passive mobility of the ,vocal fold. Preoperative differentiation between vocal-fold paralysis and arytenoid dislocation should be possible in virtually all cases. However, if not considered specifically, it will often be missed. Disparity in height between the vocal processes is much easier to see in slow motion under stroboscopic light, in posterior dislocations the vocal process and fold are usually higher on the dislocated side. In anterior dislocations they are Journal of Voice, Vol. l, No. 4, 1987
FIG. 5. Case 11. Computed tomography scan reveals a spicule secondary to laryngeal fracture just above the level of the vocal cords (straight arrow) and dislocation of the left arytenoid cartilage (curved arrow). The web is also visible (open arrow).
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tance of postoperative hoarseness. When severe dysphonia persists for more than 2 or 3 days after surgery, or when postoperative hoarseness is worse than expected, laryngoscopic examination by a skilled otolaryngologist should be performed. The importance of prevention through extreme care at the time of intubation and extubation should be stressed. Additional studies to determine the true incidence of arytenoid dislocation following anesthesia and neck trauma should be encouraged.
FIG. 6. Miller-3 laryngoscope blade was used for reducing posterior dislocations of the arytenoid. The raised tip (arrow) is especially helpful in lifting the joint into position.
with vocal-fold injection or other surgery. Even many months following injury, it has been possible to move the arytenoid enough to bring the vocal process back to normal height and allow good approximation with the mobile cord. We have found the anesthesiologist's straight Miller-3 laryngoscope blade the most useful instrument, especially in posterior dislocations (Fig. 6). The instrument is placed in the pyriform sinus with the rolled lip of the laryngoscope in the dislocated joint. An anteromedial lifting motion is applied. More force than expected is often necessary to reposition the cartilage. Anterior dislocations may be reduced with the tip of a Hollinger laryngoscope. More delicate instruments such as cupped forceps are not strong enough and are more likely to lacerate the mucosa and expose the cartilage to the risk of infection. When reduction is not possible, injection with Teflon (or possibly collagen) may be helpful in restoring glottic function. Implants and other techniques may be appropriate. Because of the value of early diagnosis in most cases, it is essential for otolaryngologists not only to be aware of arytenoid dislocation, but also to educate our anesthesiologist colleagues and other specialists about the impor-
Acknowledgement: The authors express thanks to Valerie Ragsdale and Helen Caputo for assistance and for preparation of the manuscript, and to Joanne Epstein, R.N., M.S., and Mary Hawkshaw, R.N., for their editorial assistance. REFERENCES 1. Pennington CL. External trauma of the larynx and trachea. Ann Otol Rhinol Laryngol 1972;81:546-54. 2. Komorn RM, Smith CP, Erwin JR. Acute laryngeal injury with short-term endotracheal anesthesia. Laryngoscope 1973 ;83:683-90. 3. Prasertwanitch Y, Schwarz JJH, Vandam LD. Arytenoid cartilage dislocaton following prolonged endotracheal intubation. Anesthesiology 1974;41:516-7. 4. Schultz-Coulton HJ. Luxation des arytaenoidknorpels als intubatiousschoden. HNO 1974;22:242-5. 5. Quick CA, Merwin GE. Arytenoid dislocaton. Arch Otolaryngol 1978;104:267-70. 6. Dudley JP, Mancuso AA, Fonkalsrud EW. Arytenoid dislocation and computed tomography. Arch Otolaryngol 1984;110:483-4. 7. Stanley RB, Coleman ME Unilateral degloving injuries of the arytenoid cartilage. Arch Otolaryngol Head Neck Surg 1986;112:516-8. 8. Chatterji S, Gupta NR, Mishra TR. Valvular glottic obstructon following extubation. Anaesthesia 1984;39:246-7. 9. Lee GJ. Essential otolaryngology, 3rd ed. New York: Medical Examination Publishing, 1983:306-10. 10. Langman J. Medical embryology, 3rd ed. Baltimore: Williams & Wilkins, 1975:269, 272. 11. Hollinshead WH. Anatomy for surgeons, vol 1, 3rd ed. New York: Harper & Row, 1982:423-7. 12. Maue WM, Dickson DR. Cartilages and ligaments of the adult human larynx. Arch Otolaryngol 1971;94:432-9. 13. Von Leden H, Moore E The mechanics of the cricoarytenoid joint. Arch Otolaryngol 1961 ;73:63-72. 14. Rudert H. Uber seltene intubationsbedingte innere Kehlkopftraumen. HNO 1984;32:393-8. 15. Jackson C, Jackson CL. Diseases and injuries of the larynx. New York: Macmillan, 1942:321.
Journal of Voice, Vol. 1, No. 4, 1987
Vol. 1, No. 4, pp. 368-377 © 1988 Raven Press, Ltd., New York
Arytenoid Dislocation Robert Thayer Sataloff, Marc Feldman, Kathe S. Darby, Linda M. Carroll, Joseph R. Spiegel, and Barbara-Ruth Schiebel Department of Ototaryngology, Thomas JeJJerson University, Philadelphia, Pennsylvania, U.S.A.
Summary: Arytenoid dislocation is a common yet infrequently diagnosed complication of laryngeal trauma. It may result in various symptoms, including permanent dysphonia, although immediate voice change is not always present. Early reduction is the treatment of choice; however, late reduction is often successful in restoring voice. A high index of suspicion based on the history of the patient is necessary to recognize arytenoid dislocation. Thorough physical examination and objective tests are helpful in confirming this diagnosis. Key Words: Arytenoid dislocation--Laryngeal trauma--Dysphonia--Vocal-cord paralysis.
cases have been reported (2-8). This is undoubtedly due to frequent misdiagnosis by surgeons, anesthesiologists, and even by expert otolaryngologists (see Cases 1 and 8 below). In 1973, Komorn et al. described one patient with right arytenoid dislocation following 14.5 h of endotracheal intubation (2). Immediately after extubation, the patient reported hoarseness, difficulty in coughing, dysphagia, and odynophagia. Reduction was performed 16 days later. Although the authors reported incomplete reduction, the patient was satisfied with the result. In 1974, Prasertwanitch et al. reported a case of left arytenoid dislocation following 7.5 h of intubation (3). The major complaint of the patient was hoarseness. Schultz-Coulton described a female patient with acromegaly who experienced left arytenoid-cartilage dislocation after general anesthesia (4). The authors hypothesized that the patient's overproduction of somatotropic hormone caused degenerative changes in the cricoarytenoid joint. There is insufficient data to conclude that acromegaly predisposes patients to arytenoid dislocation, but it is interesting to note that Case 8 in this report also had acromegaly. In 1978. Quick and Merwin reported three cases of arytenoid dislocation, each following one incident of endotracheal intubation (5). In each case, the pa-
The cricoarytenoid joint is a complex, delicate structure. It may be injured during intubation, extubation, or external laryngeal trauma. In such situations, soft-tissue injury provides a ready and misleading explanation for dysphonia, and swelling may o b s c u r e subtle alterations in laryngeal anatomy, rendering diagnosis difficult. Vocal-cord immobility may be incorrectly attributed to recurrent laryngeal-nerve injury (1). Recognizing arytenoid dislocation under such circumstances is crucial to permit early reduction, thus optimizing the chance for return to good vocal quality. We report 12 cases of arytenoid dislocation treated by the author (R.T.S.) between 1983 and 1987. They are discussed to emphasize the variability of presentation and response to treatment, as well as the value of objective testing performed on the more recent cases. BACKGROUND Considering the frequency with which arytenoid dislocation occurs, it is surprising that only 11 Presented at the Sixteenth Symposium: Care of the Professional Voice, New York, June 1986. Address correspondence and reprint requests to Dr. R. T. Sataloff at 1721 Pine Street, Philadelphia, PA 19103, U.S.A.
368
A R YTENOID D I S L O C A T I O N tient was diabetic. They were all hospitalized to be evaluated for renal transplantation. In all three, the left arytenoid was dislocated. Dudley et al. described one case of dislocation of the right arytenoid cartilage after endotracheal intubation (6). The patient's only complaint was a " w e a k " voice. Stanley and Coleman reported six cases of unilateral degloving injuries of the arytenoid cartilage, each due to external blunt trauma (7). The chief complaint in five patients was hoarseness. One patient complained of pain during phonation. Of the six patients, two had vertical fractures of the thyroid ala ipsilateral to a degloved and immobile arytenoid cartilage. One patient had disruption of the arytenoid cartilage itself. None of the patients with degloved and dislocated arytenoid cartilages regained vocal-cord mobility 6 to 12 months after reduction. The other three patients experienced degloving, but the arytenoid cartilages remained normal. They had normal vocal-cord mobility and voice in follow-up examinations. Chatterji et al. reported an unusual case of bilateral arytenoid dislocation after extubation (8). This "spontaneously resolved" after coughing. None of the cases reported had objective documentation of the diagnosis. ANATOMY AND EMBRYOLOGY The primordium of the larynx, trachea, bronchi, and lungs arises as an outgrowth of the pharynx during the 3rd week of embryonic life, forming a laryngotracheal groove (9). This anterior groove lies immediately posterior to the hypobranchial eminence and becomes the primitive laryngeal aditus. The aditus lies between the sixth branchial arches. The laryngotracheal groove fuses in a caudocranial direction at about the 4th week. The ventral ends of the sixth branchial arches grow and form the arytenoid eminences. During the 7th week, a fissure appears on each arytenoid eminence extending into the primitive vestibule. This is the laryngeal ventricle. The last portion of the laryngotracheal groove to be obliterated is the intraarytenoid sulcus at about 11 weeks. Laryngeal hyaline cartilages develop from branchial arch mesoderm, and elastic cartilages are derived from mesoderm of the floor of the pharynx (10). Most of the arytenoid is composed of hyaline cartilage. However, the vocal processes are developed separately in association with the vocal folds and consist of elastic cartilage. "Arytenoid" comes
369
from the Greek word arytainoeides, meaning ladleshaped. The cartilages are pyramidal, consisting of an apex, base, and two processes. The base articulates with the cricoid cartilage. The apex attaches to the corniculate cartilage of Santorini and to the aryepiglottic fold. The vocal process projects anteriorly to connect with the vocal ligament, and the muscular process is the point of insertion for most of the muscles that move the arytenoid (11). The cricoarytenoid facets are well defined, smooth, and symmetrical. Each arytenoid articulates with an elliptical facet on the posterior superior margin of the cricoid ring. The cricoid facet is about 6 mm long and is cylindrical (12). Most of the cricoarytenoid motion is rocking. However, along the long axis of the cricoid facet, gliding also occurs (13). Limited rotary pivoting is permitted as well. The arytenoid cartilages and the cricoarytenoid facets are extremely symmetric and consistent (12). The cricoarytenoid joint is an arthrodial joint, supported by a capsule lined with synovium. The capsule is strengthened posteriorly by the cricoarytenoid ligament (1). This ligament is strong and ordinarily prevents anterior subluxation. The axis of the joint is at an angle of 45 ° from the sagittal plane and 40° from the horizontal plane. The cricoarytenoid joint controls abduction and adduction of the true vocal cords, thereby facilitating respiration, protection of the airway, phonation, and other laryngeal functions. Arytenoid motion is controlled directly by intrinsic laryngeal muscles, including the posterior cricoarytenoid, lateral cricoarytenoid, transverse arytenoid, oblique arytenoid, and thyroarytenoid. It is also affected by the cricothyroid muscle, which adducts and increases longitudinal tension on the vocal fold (which attaches to the vocal process of the arytenoid), and to a lesser degree by the thyroepiglottic muscle, which tenses the aryepiglottic fold. CASE REPORTS Case 1
This was a 37-year-old female otolaryngologist whose neck struck the steering wheel during a motor vehicle accident. Initially, she noted throat pain, severe odynophagia, and referred otalgia. Physical examination by two other otolaryngologists revealed a hematoma in her left pyriform sinus and bilateral vocal-fold hemorrhage. Soft-tissue ra-
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diographs revealed no laryngeal fracture. She had no hemoptysis. Her voice remained essentially normal for 2 weeks. She then noted hoarseness, breathiness, decreased volume, inefficient cough, and occasional aspiration of liquids. She was 6 weeks pregnant at the time of our examination. Physical examination revealed posterior dislocation of the left arytenoid cartilage, with the left vocal process higher than the right and sluggish motion of the left vocal fold. Despite the fact that the diagnosis was made 1 month after her injury, she was taken to the operating room and a left arytenoid reduction was accomplished with the patient under local anesthetic with sedation. Excellent reduction was obtained with return to normal voice. However, several hours later she had an episode of vomiting, and her voice deteriorated again. Reduction was repeated successfully 2 days later while the patient was given local anesthetic without sedation. Dislocation recurred with coughing the following day. Reduction was repeated again 2 days later with topical anesthetic without sedation, and excellent permanent reduction was established. Strobovideolaryngoscopy was performed prior to and after each procedure. This study confirmed overlap of her vocal folds prior to each reduction. Her voice has remained normal for more than 1 year after her last reduction, and she has had no further difficulty. Spectrography demonstrated the improvement (Fig. 1). C o m m e n t . Reduction in this case was possible even though the diagnosis was delayed for 1 month after the injury. Repeated dislocation probably reflects joint instability with tendinous and ligamentous laxity caused by the initial trauma, and the surgical trauma of late reduction. As with other weakened or dislocated joints (e.g., temporomandibular), spontaneous recurrence of dislocation of the cricoarytenoid joints is possible. Therefore, close monitoring is advisable in the immediate postoperative period. Case 2
A 35-year-old professional opera singer was struck in the throat 4 months prior to our examination. At the time of the injury, another otolaryngologist told him that the "back of the right vocal cord was not adducting," and had seen evidence of recent hemorrhage. No treatment had been given at the time his arytenoid dislocation was originally
Journal of Voice, Vol. 1, No, 4, 1987
diagnosed because of reasonably good arytenoid motion and voice quality. He had had intermittent difficulty with voice control, fatigue, had difficulty singing softly, and had a sensation of tightness in his throat during singing since the injury. Strobovideolaryngoscopy revealed slow adduction of the right vocal fold, decreased amplitude of the right waveform, and a posterior hypodynamic segment on the right. The examination was otherwise normal. C o m m e n t . This patient had had right arytenoid dislocation and vocal-fold hemorrhage. The arytenoid had reduced spontaneously, as probably happens often. The difficulties with control were due to instability of the joint and hyperfunctional voice abuse in a vain attempt to compensate for joint weakness and decreased longitudinal vocalfold tension. However, by the time the author examined this patient, the joint was functioning adequately, although not normally. The vocal-fold hemorrhage had produced a residual submucosal scar that was interfering with his vocal performance. Only continued voice training was recommended, and no surgery was offered. The management by the original oto/aryngologist was considered appropriate, although this and other cases raise questions about the advisability of incision and drainage of selected vocal-fold hematomas. Case 3
A 53-year-old man was involved in a speed-boat accident that resulted in loss of consciousness; near-drowning from which he was resuscitated; multiple head, face, and chest injuries; and intubation for respiratory support. He was hospitalized for approximately 1 month. Hoarseness was noted at the time of extubation. It persisted and was associated with vocal fatigue and decreased vocal loudness. It improved only slightly during the 1 year between his accident and his examination. The patient's voice was hoarse, weak, and breathy. Strobovideolaryngoscopy revealed normal motion of the left vocal fold. The right vocal fold was innervated but moved sluggishly, and did not move all the way to the midline. The right vocal process was higher than the left vocal process. Vocal-fold vibrations were normal under stroboscopic light, and there were no adynamic segments, but glottic closure was intermittently incomplete.
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Comments. Slight difference in vocal process height and abnormal motion commonly follow arytenoid dislocation with imperfect spontaneous reduction. They may also be seen after surgical reduction in some cases.
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one of the procedures, which was followed by prolonged hoarseness, breathiness, and a feeling of difficulty in breathing. She was not referred for laryngoscopic examination for 5 months. Examination revealed a hoarse, breathy voice with inspiratory stridor. Her right vocal fold was immobile, with the right vocal process 2-3 mm higher than the left. Her speaking voice was lower in pitch than it had been prior to her injury, and she was midly stridorous. Strobovideolaryngoscopy confirmed overlap of her vocal folds. An attempt was made to reduce the dislocation with the patient under local anesthetic with seda-
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R. T. S A T A L O F F E T AL.
tion. She did not tolerate the procedure well. A tracheotomy was performed, and general anesthesia was induced. Palpation confirmed a frozen right arytenoid joint, and the presence of posterior commissure stenosis was diagnosed also. The stenosis was divided, allowing visualization of a subglottic stenosis that was treated with laryngeal dilators. Forceful reduction of the right arytenoid dislocation was accomplished, although it was not possible to bring the vocal process completely back to its normal level. It was still about 0.5 mm higher than the left vocal process, but mobility was reestablished and membranous vocal-fold approximation was nearly perfect. Steroids were injected into the posterior commissure and subglottic scars. Eight months after the procedure, her speaking voice has remained much less hoarse and breathy (Fig. 2) and its volume has been normal. She has been able to resume limited singing. However, because of the severity of her subglottic stenosis, she still has a tracheotomy. Case 5 A 14-year-old boy was struck by a car. He was initially examined while he was on a respirator. After extubation, examination by indirect laryngoscopy revealed severe bilateral contact erosions of his vocal processes and marked edema of both vocal folds. He had mucosal disruption of the posterior third of his right vocal fold. Both arytenoids were markedly swollen and could not be assessed. He was reexamined approximately 2 weeks later after the swelling had resolved, and strobovideolaryngoscopy revealed dislocation of his left arytenoid with overlapping of the vocal processes. His left vocal process was higher than the right vocal process. His voice remained hoarse, breathy, and soft. He underwent successful reduction, resulting in immediate and permanent normal voice. Case 6
A 68-year-old man underwent left parotidectomy, excision of his external auditory canal, and facial nerve grafting for squamous-cell carcinoma. He awakened with a hoarse voice. Fiberoptic laryngoscopy the day after surgery revealed right arytenoid dislocation. Reduction was postponed until 6 days after his original procedure because of other medical problems. Despite the extremely short time, arytenoid reduction could not be accomplished. His voice remained unsatisfactory. Six weeks later he
Journal of Voice, Vol. l, No. 4, 1987
underwent Teflon injection into his right vocal fold. He recovered good vocal quality and volume. His voice remained improved through I year of followup.
Comment. Although common teaching holds that late reductions are impossible and early reduction of arytenoid dislocation provides good results, this case illustrates that improvement may not be possible even with very early diagnosis. Other cases in this report illustrate the value of attempting late reduction.
Case 7 A 29-year-old woman was extremely anxious and was involved in malpractice litigation at the time of her initial examination. She was labile emotionally and had a remarkably strong gag reflex that was activated simply by asking her to open her mouth. Most of the time, she could not tolerate nasal fiberoptic laryngoscopy even after topical anesthetic and oral diazepam. She had undergone excision of her right submandibular gland and had awakened with hoarseness, breathiness, vocal fatigue, and dysphagia. An otolaryngologist attempted to perform indirect laryngoscopy shortly thereafter, without success. Two months later he attempted to perform direct laryngoscopy in the operating room with the patient under intravenous sedation. The patient did not tolerate this procedure and general anesthetic with intubation was necessary. No diagnosis was made. She was initially examined by the author 4 months after her initial surgery, at which time fiberoptic laryngoscopy was performed successfully but with difficulty. She had obvious dislocation of her right arytenoid cartilage, with the right vocal process higher than the left and markedly diminished mobility of the right vocal fold. Her voice was hoarse, breathy, and soft. She had extreme neck, facial, tongue, shoulder, and supraglottic muscle hyperactivity on attempts at phonation. Despite the 4-month period between her surgery and the diagnosis, she was taken to the operating room where partial reduction of her right arytenoid cartilage was accomplished under general anesthesia. The vocal process was returned to a nearly normal level, and good motion was restored. Postoperatively, her voice intensity and quality improved dramatically for a few days. However, her excessive muscle tension persisted and she devel-
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oped severe dysphonia plica ventricularis. Direct laryngoscopy in June 1986, performed while she was laughing, confirmed that her vocal-fold motion had remained nearly normal, and her vocal processes were at the same level. Her legal case is still in progress, and her dysphonia plica ventricularis persists. Case 8
A 39-year-old man underwent transsphenoidal h y p o p h y s e c t o m y for acromegaly. He used his speaking voice professionally and sang occasionally with a barbershop quartet. As soon as he awoke from anesthesia he noticed an extremely hoarse, soft, breathy voice. His voice never re-
turned to serviceable volume or quality in the 8 months between his surgery and his examination. In the interim, he had been seen by an experienced otolaryngologist at the university hospital where the hypophysectomy had been performed. A diagnosis of vocal-cord paralysis had been made. At the time of examination by the author, strobovideolaryngoscopy revealed posterior dislocation of his left arytenoid with the left vocal process higher than the right vocal process. Although there was complete fixation of the arytenoid, the vocal fold was innervated and attempting to move against the immobile cricoarytenoid joint. This could be seen under continuous light as muscle contractions causing changes in the shape and tension of the su-
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praglottic tissues on the immobile side. Overlapping of the vocal folds was obvious under stroboscopic light. There were no nonvibrating segments, and vocal-fold mucosal waves were normal. Glottic closure was incomplete. Laryngeal electromyography was performed because of controversy regarding the diagnosis, as well as potential litigaton. It confirmed normal muscle activity bilaterally, further establishing the diagnosis as arytenoid dislocation rather than vocal-fold paralysis. Despite the 8-month delay from the time of injury, arytenoid reduction was accomplished with partial success. Although only minimal mobility returned to the joint, the vocal process was returned to its normal level. This allowed good contact with the mobile vocal cord and reestablished complete glottic closure. The hoarseness and breathiness resolved, the patient's volume improved substantially (comfortable speaking increased from 48.3 to 64.5 dB with his fundamental frequency essentially unchanged), and his singing range and vocal quality improved enough to allow him to return to avocational singing (Fig. 3). Although his harmonics were not restored, his frequency range improved from 90.4 Hz (F#-2) to 267 Hz (C-4) preoperatively, to 75.0 Hz (D-2) to 391.4 Hz (G-4) postoperatively. His perturbation decreased from 2.33 to 0.84. Comment. This case provides another example in which late reduction provided substantial improvement although not a return to normal. It also illustrates the value of objective tests in differentiating arytenoid dislocation from vocal-fold paralysis. Although computed tomography (CT) scans have been used only in our most recent cases, they have proven valuable in detecting arytenoid dislocaton and we are now using them routinely. Case 9
A 70-year-old woman was involved in a motor vehicle accident. She suffered head and neck injuries and loss of consciousness. She was intubated for several days and hospitalized for 7 months. She had no voice problems prior to her accident but has had only a whisper since her injury. She was seen for the first time l year after her accident. Examination revealed a breathy, whispered voice. Laryngoscopy revealed left arytenoid dislocation as well as an anterior glottic web. Her right vocal fold crossed the midline, but the dislocated cord was at a higher level. Contact was not adequate for good
Journal of Voice, Vol. 1, No. 4, 1987
phonation or cough. Mild spontaneous aspiration of saliva was observed. She had marked supraglottic hyperfunction including dysphonia plica ventricularis in efforts to compensate for her dysphonia. At present, the patient has declined further therapy. Case 10
A 50-year-old woman had a history of 10 episodes of spontaneous right arytenoid dislocation beginning approximately 15 years previously. These were diagnosed by several laryngologists, and educed spontaneously. She did well until she required intubation for treatment of a drug overdose. After extubation, she was diagnosed as having "bilateral vocal-cord paralysis," and underwent tracheotomy. She was initially seen by this author 19 months later. Her voice was hoarse and breathy. She had a tracheotomy tube in place. This was occluded for the purpose of examination, and she had no significant airway distress. Her left vocal fold moved normally. Her right vocal fold was immobile. The diagnosis of right arytenoid dislocation was confirmed by CT scan (Fig. 4) and by laryngeal e l e c t r o m y o g r a p h y , which revealed normal muscle activity bilaterally. At present, the patient has declined further therapy. Comment. This represents an unusual case of recurrent arytenoid dislocation with spontaneous reduction. We suspect she had bilateral arytenoid dislocation after intubation misdiagnosed as bilateral vocal-fold paralysis. Certainly, at the time of our examination, her left vocal fold was normal, and her right vocal fold was fully innervated with a dislocated arytenoid. Case 11
This 22-year-old woman was the driver in a motor vehicle accident. She struck her neck on the steering wheel. Subcutaneous emphysema and bleeding from the mouth and chin were noted in the emergency room, and an emergency tracheotomy was performed. The patient was not intubated. Computed tomography reportedly revealed laryngeal edema but no fracture. Following recovery, she was diagnosed as having an anterior glottic web and "left vocal-cord paralysis." She was referred for evaluation 10 months later. Her voice was hoarse and breathy. Despite an anterior glottic web that occluded nearly half of her airway, she had no respiratory distress. Pulmonary function tests were normal, as was her flow-volume loop. Strobovideo-
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A B FIG. 3. Preoperative wide-band spectrogram (A) in Case 8 reveals aperiodicity and a weak first formant. Vertical striations are irregular. The F0 was 180.3 Hz. preoperatively. Postoperatively, the F0 was 171.8 Hz. The postoperative spectrogram (B) reveals markedly increased strength at the first formant with regularity of the vertical striations. All phonation was performed on the vowel/i/. laryngoscopy revealed attempted motion of her left vocal fold, although the cord appeared immobilized by arytenoid dislocation. The web also appeared on s t r o b o s c o p y to be a b o v e the level o f the vocal folds, r a t h e r than glottic. A CT scan revealed a spicule just above the anterior commissure at the level of the web (Fig. 5). It also demonstrated arytenoid dislocation. This was confirmed by normal e l e c t r o m y o g r a p h i c studies. Surgical t h e r a p y is planned for voice improvement. Case 12 A 10-year-old girl was struck in the neck with a baton 5 days prior to evaluation, in addition to being a baton twirler, she sang in the school choir and played the flute. She noticed decreased vocal range, decreased volume, and severe odynophagia. She had been able to eat only soft foods since the accident. She was also aware of a loud clicking sound when she swallowed. Initial examination included indirect laryngoscopy and strobovideolar-
yngoscopy during speech, singing, and playing the flute. H e r voice varied from breathy and slightly hoarse to nearly normal. During e n d o s c o p y , she was found to have an anterior dislocation of her right arytenoid cartilage. A loud click was heard and recorded during swallowing. Swallowing and coughing produced intermittent reduction or dislocation of her arytenoid cartilage coincident with abnormal or nearly normal vocal quality. She was placed on a regimen of relative voice rest, soft foods, and anti-inflammatory medication. H e r arytenoid cartilage reduced spontaneously and good vocal quality r e t u r n e d . This is i m p r o v i n g with speech therapy and singing lessions. DISCUSSION A r y t e n o i d dislocation, although f r e q u e n t l y unrecognized, is not a rare entity. Traditionally, arytenoid dislocation has been suspected on the basis Journal of Voice, Vol. I, No. 4, 1987
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generally lower on the abnormal side. In either case, the injured vocal fold may move sluggishly or be immobile. Rarely, abduction and adduction may appear almost normal under continuous light. Video documentation of the preoperative and postoperative appearance can prove particularly helpful in cases of arytenoid dislocation, because many of them may involve litigation. Objective preoperative voice assessment may include evaluation by a laryngologist and speech pathologist, measurements of frequency and intensity ranges, measurements of habitual frequency and intensity, measurement of maximum phonation time, spectrographic analysis, acoustic analysis by other glottal imaging tech~ niques, airflow analysis, CT scan, and electromyography. The most valuable tests are the stroboscopic examination to see differences in vocal process height, CT scan, which may image the arytenoid dislocation and laryngeal electromyography to differentiate an immobile dislocated arytenoid joint from vocal-fold paralysis. Air flow analysis is also particularly helpful in documenting changes. Additional experience with other objective tests is necessary to determine their clinical value, and we are currently performing a comprehensive objective test battery on all new cases of arytenoid dislocation and selected other lesions. Even though surgical reduction may be impossible even in rare early cases, it appears to be worth attempting reduction in all patients prior to treatment
FIG. 4. A: Axial computed tomography scan demonstrates dislocation of the right arytenoid cartilage (large arrow). The left arytenoid is in normal position (small arrow). B: During respiration, the left vocal fold abducts (small arrow), but the right vocal fold remains fixed in the midline.
of history and absence of the jostling phenomenon present in many cases of unilateral vocal-fold paralysis (15). Often it is not diagnosed until direct laryngoscopy reveals impaired passive mobility of the ,vocal fold. Preoperative differentiation between vocal-fold paralysis and arytenoid dislocation should be possible in virtually all cases. However, if not considered specifically, it will often be missed. Disparity in height between the vocal processes is much easier to see in slow motion under stroboscopic light, in posterior dislocations the vocal process and fold are usually higher on the dislocated side. In anterior dislocations they are Journal of Voice, Vol. l, No. 4, 1987
FIG. 5. Case 11. Computed tomography scan reveals a spicule secondary to laryngeal fracture just above the level of the vocal cords (straight arrow) and dislocation of the left arytenoid cartilage (curved arrow). The web is also visible (open arrow).
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tance of postoperative hoarseness. When severe dysphonia persists for more than 2 or 3 days after surgery, or when postoperative hoarseness is worse than expected, laryngoscopic examination by a skilled otolaryngologist should be performed. The importance of prevention through extreme care at the time of intubation and extubation should be stressed. Additional studies to determine the true incidence of arytenoid dislocation following anesthesia and neck trauma should be encouraged.
FIG. 6. Miller-3 laryngoscope blade was used for reducing posterior dislocations of the arytenoid. The raised tip (arrow) is especially helpful in lifting the joint into position.
with vocal-fold injection or other surgery. Even many months following injury, it has been possible to move the arytenoid enough to bring the vocal process back to normal height and allow good approximation with the mobile cord. We have found the anesthesiologist's straight Miller-3 laryngoscope blade the most useful instrument, especially in posterior dislocations (Fig. 6). The instrument is placed in the pyriform sinus with the rolled lip of the laryngoscope in the dislocated joint. An anteromedial lifting motion is applied. More force than expected is often necessary to reposition the cartilage. Anterior dislocations may be reduced with the tip of a Hollinger laryngoscope. More delicate instruments such as cupped forceps are not strong enough and are more likely to lacerate the mucosa and expose the cartilage to the risk of infection. When reduction is not possible, injection with Teflon (or possibly collagen) may be helpful in restoring glottic function. Implants and other techniques may be appropriate. Because of the value of early diagnosis in most cases, it is essential for otolaryngologists not only to be aware of arytenoid dislocation, but also to educate our anesthesiologist colleagues and other specialists about the impor-
Acknowledgement: The authors express thanks to Valerie Ragsdale and Helen Caputo for assistance and for preparation of the manuscript, and to Joanne Epstein, R.N., M.S., and Mary Hawkshaw, R.N., for their editorial assistance. REFERENCES 1. Pennington CL. External trauma of the larynx and trachea. Ann Otol Rhinol Laryngol 1972;81:546-54. 2. Komorn RM, Smith CP, Erwin JR. Acute laryngeal injury with short-term endotracheal anesthesia. Laryngoscope 1973 ;83:683-90. 3. Prasertwanitch Y, Schwarz JJH, Vandam LD. Arytenoid cartilage dislocaton following prolonged endotracheal intubation. Anesthesiology 1974;41:516-7. 4. Schultz-Coulton HJ. Luxation des arytaenoidknorpels als intubatiousschoden. HNO 1974;22:242-5. 5. Quick CA, Merwin GE. Arytenoid dislocaton. Arch Otolaryngol 1978;104:267-70. 6. Dudley JP, Mancuso AA, Fonkalsrud EW. Arytenoid dislocation and computed tomography. Arch Otolaryngol 1984;110:483-4. 7. Stanley RB, Coleman ME Unilateral degloving injuries of the arytenoid cartilage. Arch Otolaryngol Head Neck Surg 1986;112:516-8. 8. Chatterji S, Gupta NR, Mishra TR. Valvular glottic obstructon following extubation. Anaesthesia 1984;39:246-7. 9. Lee GJ. Essential otolaryngology, 3rd ed. New York: Medical Examination Publishing, 1983:306-10. 10. Langman J. Medical embryology, 3rd ed. Baltimore: Williams & Wilkins, 1975:269, 272. 11. Hollinshead WH. Anatomy for surgeons, vol 1, 3rd ed. New York: Harper & Row, 1982:423-7. 12. Maue WM, Dickson DR. Cartilages and ligaments of the adult human larynx. Arch Otolaryngol 1971;94:432-9. 13. Von Leden H, Moore E The mechanics of the cricoarytenoid joint. Arch Otolaryngol 1961 ;73:63-72. 14. Rudert H. Uber seltene intubationsbedingte innere Kehlkopftraumen. HNO 1984;32:393-8. 15. Jackson C, Jackson CL. Diseases and injuries of the larynx. New York: Macmillan, 1942:321.
Journal of Voice, Vol. 1, No. 4, 1987