Blunt laryngeal trauma resulting in arytenoid dislocation and dysphonia

Auris Nasus Larynx 33 (2006) 75–78 www.elsevier.com/locate/anl

Blunt laryngeal trauma resulting in arytenoid dislocation and dysphonia§ Ganapathy Dhanasekar *, Maziar Sadri, Sharat Mohan, Kate Young, Jacob Leiberman Department of Otolaryngology, Derbyshire Royal Infirmary, Derby, UK Received 19 January 2005; accepted 22 July 2005 Available online 5 October 2005

Abstract We present a case of left arytenoid dislocation due to blunt laryngeal trauma causing a subsequent large granuloma formation resulting in dysphonia and stridor. The patient underwent emergency excision of the obstructive granuloma and speech therapy was started postoperatively. A few weeks after surgery, the granuloma started to recur and laryngeal manipulation by a specialist osteopath was performed. A few weeks after the conservative management, the recurred granuloma resolved completely and patient’s voice improved remarkably. Dislocation of the arytenoid cartilage due to blunt trauma is relatively rare and a consequent spontaneous granuloma formation has not been reported so far in the literature. This is also the first report about efficacy of speech therapy combined with laryngeal manipulation in the management of the arytenoid dislocation and the subsequent laryngeal granuloma. # 2005 Elsevier Ireland Ltd. All rights reserved. Keywords: Dysphonia; Arytenoid; Dislocation; Granuloma; Larynx

1. Case report A 55-year-old lady presented to us complaining of odynophagia and hoarseness immediately after slipping and injuring her neck on the corner of a kitchen bench. She had one episode of haemoptysis. She also gave a previous history of gastroesophageal reflux. On examination she had no respiratory distress but had a hoarse voice. Neck examination revealed minimal swelling, erythema and tenderness over the thyroid cartilage, with no surgical emphysema. Oral cavity and oropharynx examination was normal. Flexible nasoendoscopy in the emergency clinic revealed swelling and oedema over the left arytenoid. The vocal cords appeared normal and the abduction and adduction movements of the vocal cords appeared normal. Rest of the ENT examination was unremarkable. A soft tissue lateral neck X-ray demonstrated laryngeal oedema. An urgent ultrasound of the neck showed no § This article was presented in the video presentation section at the BACO Meeting, Birmingham, U.K., July 2003. * Corresponding author. Tel.: +44 1902861022; fax: +44 8701334008. E-mail address: [email protected] (G. Dhanasekar).

haematoma or fluid collection and an incidental multinodular goitre. Mobility of the vocal folds or the arytenoids cartilages was not reported on the ultrasound scan. CT scan of the larynx showed significant swelling related to the left arytenoid and supraglottic region. Electromyography (EMG) was not indicated, as there was good muscle tone with good movements on video stroboscopy and was also not available in the hospital. At review in the voice clinic, a week later there had been some resolution of the previously noted oedema and the left arytenoid dislocation was identified on video stroboscopy (Fig. 1). This was not picked up by flexible nasoendoscopy done earlier during her first presentation in the emergency clinic. The arytenoid movement was impaired at the time of the accident and observed only at the first voice clinic assessment with videostroboscopy nasendoscopy equipment. The patient’s voice quality was moderately harsh and whispery with poor volume and vocal stamina. Whisperiness and a further decrease in volume were observed after 3– 5 min of conversation. Intonation was flat and pitch range was not demonstrated. Two weeks later she had also developed an arytenoid granuloma over the dislocation and the left vocal cord mobility was impaired. These ‘glottal

0385-8146/$ – see front matter # 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.anl.2005.07.007

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Fig. 1. Laryngeal photograph showing the dislocated left arytenoid cartilage.

Fig. 2. Laryngeal photograph demonstrating the granuloma with the vocal cords in abduction.

gestures’ are described at the time of the first assessment, 2 weeks following the accident.

arytenoid subluxation/dislocation was confirmed at surgery and reduction of the arytenoid dislocation was difficult and not possible. She was discharged and voice therapy sessions commenced post-operatively. Four weeks following surgery her voice had improved and she had no breathing problems. Voice quality was mildly harsh and whispery, volume and vocal stamina improved. The pitch range and flexibility was slightly reduced. Examination showed evidence of recurrence of the granuloma. The left vocal cord mobility was minimally impaired and mucosal wave amplitude on stroboscopy was slightly reduced. The right vocal cord mobility was nearly normal and the arytenoid mobility improved. The reasons for the improvement of the arytenoid movement could be

2. Phonation On full adduction the left vocal process was displaced superiorly into the glottis pushing the left vocal fold superior to the right vocal fold. The right and left vocal folds did not meet along the mid portion of the free edge. Contact was seen posteriorly between the right vocal process and the area under the left vocal process. Weak/minimal left arytenoid movement was noted as the vocal folds adducted. Full right arytenoid movement was noted. In adduction muscle tension was seen in the false vocal folds and at the base of the epiglottis. Reduced mucosal wave was noted in the right vocal fold but there was no mucosal wave in the left vocal fold.

3. Deep inspiration and expiration The right arytenoid was abducted fully and minimal or no left arytenoid movement was seen. The left vocal fold was ‘C’ shaped and convex into the glottis with a good airway. Vocal hygiene advice was given and further appointment for voice clinic arranged. Antireflux therapy in the form of Proton pump inhibitors was commenced for 6 weeks. Six weeks after the accident the patient rapidly developed mild stridor. The voice clinic appointment was brought forward. On examination the arytenoid granuloma had increased in size. Fig. 2 demonstrates the granuloma with the vocal cords in abduction. A CT scan done at this stage showed the swelling over the left vocal cord (Fig. 3). The patient underwent urgent microlaryngoscopy and excision of the granuloma. After difficult intubation, the granuloma, which measured 1.5 cm in size, was excised in toto. The

Fig. 3. CT scan (axial view) at the laryngeal level showing the swelling and granuloma over the left vocal cord.

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due to natural recovery, the removal of the large granuloma, which may have been impairing some movement, and/or manual therapy treatment carried out by the Specialist Speech & Language Therapist and vocal hygiene instructions. The impairment improved over the treatment period but is not absolutely normal. Six weeks following surgery physical manipulation, which included soft tissue massage and articulation to the crico-thyroid joint was performed by a specialist osteopath. Manual therapy techniques are specifically applied where muscles appear tight and tender and joints demonstrate decreased range of movement. Physical techniques preceded by examination of the laryngeal structures described in the Lieberman protocol [1]. In this case, the assessment revealed the following: 1. In the resting state the crico-thyroid joint was held in the closed position (the distance between the cricoid notch and the inferior part of the thyroid cartilage was diminished). 2. Dynamically, a marked decrease in the movements of the crico-thyroid joint was noted. 3. In the resting state, the distance between the superior margin of the thyroid lamina and the hyoid bone was diminished. 4. Dynamically, the thyro-hyoid mechanism demonstrated decreased range of movement. 5. The hyoid and larynx were pulled backwards against the cervical spine renders palpation of the posterior margins of the thyroid lamina impossible. The findings were consistent with the hyperfunction voice use and poor vocal quality. It seemed that the patient was careful in the way she used her vocal mechanism. This is a common finding following physical trauma to the larynx. The treatment aimed to decrease the muscle tension in supra hyoid, thyro-hyoid and middle constrictor. The crico-thyroid joint was articulated in a caudal direction. After the larynx was relaxed, it was possible to access and inhibit the action of the right arytenoids thus encouraging the patient to vocalise using a lower position of the larynx and moving the left arytenoid. It should be noted that one of the important advantages of laryngeal manipulation is the direct interference with long standing vocal habits thus enabling new neuro-muscular patterns to develop aiming for more efficient voice production. The whole procedure lasted about 15 min. On the last follow up visit (15 months post-injury) following voice and manual therapy, her voice had returned to normal and even she was able to sing. The left vocal fold was only minimally bowed.

4. Discussion Laryngeal injury occurs in less than 1% of all adult patients with blunt trauma and is even less common in

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children [2–4] the most common cause of laryngeal trauma is striking the extended neck on the steering wheel in road traffic accidents. Hoarseness results if the vocal folds themselves or their attachments are injured or if airflow is partially obstructed by laryngeal injury. Soft tissue oedema or haematoma, laryngeal cartilage fractures, arytenoid dislocation, recurrent laryngeal nerve injury or impacted foreign body [5] can all cause airway obstruction. Isolated arytenoids dislocation and subluxation are uncommon laryngeal injuries most often resulting from endotracheal intubation. However, these diagnoses should be considered in all patients who sustain laryngeal trauma [6]. Two types of dislocation have been described, anteromedial [7] and posterolateral [8], each with a different mechanism of causation. The term arytenoid subluxation is described as cricoarytenoid joint dislocation with some remaining contact of joint surfaces [9] whereas arytenoid dislocation is used to describe complete separation of arytenoid cartilage from the surfaces of the crico-arytenoid joint space [9,10]. The first case of the condition reported by Korman et al. as an unusual complication of intubation in 1973 [11]. Later Prasertwanitch et al. reported arytenoid dislocation following prolonged endo-tracheal intubation [7]. Although it is predominantly an adult’s problem but it has also been reported in paediatric age groups [12] and neonates [13]. The condition is rare after blunt laryngeal trauma and the majority of reported cases are subsequent to endotracheal intubation. In the largest study in literature, only 8 patients out of 26 have been due to external trauma [14], whereas intubation trauma has been the cause in 87% of cases [15]. It has also been reported due to laryngeal mask airway [16]. Suggested significant factors contributing to the injury due to intubation are: retrognathia, dental mal-occlusion, large tongue base and intubation inexperience [17]. The condition is frequently misdiagnosed as vocal fold paralysis [18]. The chief presenting complaint in all studies have been hoarseness, poor vocal fold mobility, and insufficient or inefficient glottic closure cause rough voice quality and breathiness [14]. Diagnosis is usually by endoscopy, CT scan of the larynx and laryngeal electromyography. Conventional CT is considered the main stay in the evaluation of the larynx. A major difficulty with utilizing this modality, especially in the study of the arytenoids, is the time necessary to perform a thin-slice examination through a structure that has a propensity to move with respiration and swallowing. The introduction of helical CT allows multiple high-resolution multilane reconstructions to be obtained and significantly reduces the time necessary for laryngeal study [19]. The primary role of EMG in differential diagnosis of arytenoid dislocation is to rule out laryngeal paresis or paralysis as a cause for impaired vocal fold movements [20]. It is extremely important to be alert to the possibility of arytenoid dislocation, as it can usually be reduced successfully. Although surgical repair becomes more

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difficult when diagnosis is delayed, successful reduction has been accomplished even many months following dislocation [17]. Vocal granulomas are benign but frequently recurrent lesions. In our case the aetiology for the granuloma formation was mainly due to the left vocal process, which was positioned pointing superiorly and medially into the glottis therefore touching the right arytenoid and posterior glottis with increased force. The laryngeal movements to achieve glottal closure were forceful with hard contact between the left and right posterior glottis observed under stroboscopy in the voice clinic. This was exaggerated by the patient talking constantly and not resting her voice. The other aetiological factor was the acid from the laryngopharyngeal reflux. Aetiologic factors for vocal granulomas include endotracheal intubation, vocal abuse and gastroesophageal reflux [21]. Conventional treatment for granulomas has included medical, voice and surgical therapy, none with uniform success. Laryngeal manipulation is used in the management of hyper-function voice disorders. The aim is to assess and improve the tone in laryngeal muscles, the quality of joint movements and the general movements that take place during swallowing and voice production [1]. We report an unusual case of a blunt trauma to the neck causing arytenoid dislocation and the subsequent development of a granuloma over the dislocated arytenoid cartilage. Laryngeal manipulation, which is a new and non-invasive treatment modality, was also performed and can be quite useful in appropriate patients.

Acknowledgements We would like to thank Mr. Sharp for allowing us to report his case and also correcting the manuscript.

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