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Unusual cause of hoarseness: Arytenoid cartilage dislocation without a traumatic event
YAJEM-57044; No of Pages 2 American Journal of Emergency Medicine xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Unusual cause of hoarseness: Arytenoid cartilage dislocation without a traumatic event Yuji Okazaki, MD a,⁎, Toshihisa Ichiba, MD b, Yusuke Higashi, MD a a b
Department of Internal Medicine, Akiota Hospital, Japan Department of Emergency Medicine, Hiroshima Citizens Hospital, Japan
a r t i c l e
i n f o
Article history: Received 7 October 2017 Accepted 15 October 2017 Available online xxxx Keywords: Arytenoid cartilage dislocation Hoarseness
a b s t r a c t Arytenoid cartilage dislocation is a rare but curable cause of hoarseness and is commonly related to intubation or laryngeal trauma. We present a case of arytenoid cartilage dislocation without a traumatic event in a man who complained of acute hoarseness. An 82-year-old man visited our emergency department complaining of acute hoarseness. He had no history of general anesthesia or laryngeal trauma and had not caught a cold. He showed no abnormal physical findings including the pharynx. Examination using a laryngoscope revealed that the left vocal fold was fixed in the paramedian position. We performed contrast-enhanced computed tomography (CT), but we could not find any cause of the left recurrent laryngeal nerve paralysis. His hoarseness persisted for one month and the initial CT was therefore reassessed. It was found that the left arytenoid cartilage was dislocated forward, and we therefore made a diagnosis of arytenoid cartilage dislocation without a traumatic event. We tried to refer him to an otolaryngologist for surgical treatment, but he declined. Fortunately, his hoarseness gradually improved over a period of two months. Arytenoid cartilage dislocation rarely occurs without a traumatic event. CT is useful for accurate diagnosis of this condition. Since early diagnosis can lead to appropriate surgical treatment and improvement in vocal function, the possibility of arytenoid cartilage dislocation should be considered in patients with acute hoarseness without apparent causes. © 2017 Elsevier Inc. All rights reserved.
1. Introduction Hoarseness is a common symptom in patients seen by emergency physicians. However, self-limiting inflammation is the most common cause of hoarseness, other critical and curable causes are rarely discovered. Arytenoid cartilage dislocation is a rare but curable cause of hoarseness that is commonly related to intubation or laryngeal trauma [1]. We present a case of arytenoid cartilage dislocation without a traumatic event in a man who complained of acute hoarseness. 2. Case presentation An 82-year-old man with atrial fibrillation and hypertension visited our emergency department complaining of acute hoarseness that had persisted for four days. He had no history of general anesthesia or laryngeal trauma and had not caught a cold before the hoarseness occurred. He had no fever and showed no abnormal physical findings including the pharynx. Examination using a laryngoscope revealed that the left vocal fold was fixed in the paramedian position, suggesting left ⁎ Corresponding author at: Akiota Hospital, Japan, Shimotonogouchi 236, Akiota-chou, Yamagata-gun, Hiroshima 731-3622, Japan. E-mail address: [email protected] (Y. Okazaki).
recurrent laryngeal nerve paralysis (Fig.1). We suspected an aortic aneurysm or cervical or lung cancer and performed contrast-enhanced CT but could not find any cause of the left recurrent laryngeal nerve paralysis. His hoarseness persisted for one month and the initial CT was therefore reassessed by a radiologist and an otolaryngologist. Reassessment revealed that the left arytenoid cartilage was dislocated forward (Fig. 1), and we therefore made of a diagnosis of acute hoarseness caused by arytenoid cartilage dislocation without a traumatic event. We tried to refer him to an otolaryngologist for specific surgical treatment, but he declined because his hoarseness was gradually improving. Fortunately, his hoarseness resolved spontaneously after two months. 3. Discussion The course of the patient indicated two important clinical issues: 1) arytenoid cartilage dislocation rarely occurs without a traumatic event and 2) CT is useful for accurate diagnosis of this condition. First, arytenoid cartilage dislocation rarely occurs without a traumatic event. Many conditions ranging from self-limiting inflammation, or laryngitis to more serious systemic, neurologic, or cancerous conditions can casus hoarseness [2]. Arytenoid cartilage dislocation is a rare but curable cause of hoarseness, though less than 150 cases have been reported [3]. Arytenoid cartilage dislocation is defined as complete
https://doi.org/10.1016/j.ajem.2017.10.041 0735-6757/© 2017 Elsevier Inc. All rights reserved.
Please cite this article as: Okazaki Y, et al, Unusual cause of hoarseness: Arytenoid cartilage dislocation without a traumatic event, American Journal of Emergency Medicine (2017), https://doi.org/10.1016/j.ajem.2017.10.041
2
Y. Okazaki et al. / American Journal of Emergency Medicine xxx (2017) xxx–xxx
Fig. 1. Examination using a laryngoscope revealed that the left vocal fold was fixed in the paramedian position (A). Axial CT of the larynx showed forward dislocation of the left arytenoid cartilage and asymmetry of the left and right arytenoid cartilages (B). Normal axial CT of the larynx showed no asymmetry of the left and right arytenoid cartilages (C). CT: computed tomography.
separation of the arytenoid cartilage from the cricoarytenoid joint, which causes vocal fold immobility and results in hoarseness. Over 90% of the cases were caused by intubation and laryngeal trauma, and a few cases of idiopathic cases have also been reported [1]. Our patient developed hoarseness without an apparent traumatic event, and our case was therefore extremely rare. However, physician are not familiar with arytenoid cartilage dislocation, and a considerable number of cases may therefore be underdiagnosed or misdiagnosed as unexplained unilateral vocal fold paralysis [4]. Fortunately, the hoarseness in our patient gradually improved spontaneously, but prompt diagnosis before development of joint ankylosis can lead to specific surgical treatment, such as direct microlaryngoscopy with arytenoid reduction and repositioning, and improvement in vocal function [5]. We should therefore differentiate this condition from other causes of acute hoarseness accurately. Second, CT is useful for accurate diagnosis of this condition. Arytenoid cartilage dislocation is usually diagnosed by a combination of laryngoscopy, laryngeal electromyography and laryngeal CT. Laryngoscopy may show either an anteromedial or posterolateral arytenoid position with reduced vocal fold motion [5], but it is difficult, especially for non-otolaryngologists, to make accurate diagnosis without suspicion of arytenoid cartilage dislocation. Moreover, laryngeal electromyography cannot be performed by non-otolaryngologists. In contrast, CT is easy to perform and evaluate statically, and it can rule out other causative etiologies. Recently, CT has become widely used in clinical settings and its resolution has been greatly increased. Laryngeal CT can therefore be a useful adjunctive examination in patients with suspected arytenoid cartilage dislocation [6]. However, laryngeal CT has some limitations. In young patients, cartilage is frequently not ossified, and assessment might therefore be difficult. If possible, highquality images with thin slices and reconstruction of the larynx are helpful to confirm the diagnosis [1,5]. It is also essential to suspect this condition in patients complaining of acute hoarseness with typical risks or without any causative etiology and to interpret laryngeal CT with focus on the arytenoid cartilage. Arytenoid cartilage dislocation rarely occurs without a traumatic event. Computed tomography is useful for accurate diagnosis of this
condition. Prompt diagnosis can lead to appropriate surgical treatment and improvement in vocal function. We should therefore know about this condition and differentiate arytenoid cartilage dislocation in patients complaining of acute hoarseness without an apparent cause. Hoarseness usually resolves spontaneously, and emergency physicians tend not to have an interest in its cause. We should therefore also acknowledge other rare but critical and curable causes of hoarseness, especially neoplasm and aortic dissection [2,7]. Acknowledgement None declared. Conflict of interest None declared. Funding None declared. References [1] Rubin AD, Hawkshaw MJ, Moyer CA, Dean CM, Sataloff RT. Arytenoid cartilage dislocation: a 20-year experience. J Voice 2005;19:687–701. [2] Cooper L, Quested RA. Hoarseness: an approach for the general practitioner. Aust Fam Physician 2016;45:378–81. [3] Lee SW, Park KN, Welham NV. Clinical features and surgical outcomes following closed reduction of arytenoid dislocation. JAMA Otolaryngol Head Neck Surg 2014; 140:1045–50. [4] Oppenheimer AG, Gulati V, Kirsch J, Alemar GO. Case 223: arytenoid dislocation. Radiology 2015;277:607–11. [5] Norris BK, Schweinfurth JM. Arytenoid dislocation: an analysis of the contemporary literature. Laryngoscope 2011;121:142–6. [6] Alexander Jr AE, Lyons GD, Fazekas-May MA, Rigby PL, Nuss DW, David L, et al. Utility of helical computed tomography in the study of arytenoid dislocation and arytenoid subluxation. Ann Otol Rhinol Laryngol 1997;106:1020–3. [7] Wang JY, Chen H, Su X, Zhang ZP. Aortic dissection manifesting as dysphagia and hoarseness: Ortner's syndrome. Am J Emerg Med 2016;34:e1-.
Please cite this article as: Okazaki Y, et al, Unusual cause of hoarseness: Arytenoid cartilage dislocation without a traumatic event, American Journal of Emergency Medicine (2017), https://doi.org/10.1016/j.ajem.2017.10.041
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Unusual cause of hoarseness: Arytenoid cartilage dislocation without a traumatic event Yuji Okazaki, MD a,⁎, Toshihisa Ichiba, MD b, Yusuke Higashi, MD a a b
Department of Internal Medicine, Akiota Hospital, Japan Department of Emergency Medicine, Hiroshima Citizens Hospital, Japan
a r t i c l e
i n f o
Article history: Received 7 October 2017 Accepted 15 October 2017 Available online xxxx Keywords: Arytenoid cartilage dislocation Hoarseness
a b s t r a c t Arytenoid cartilage dislocation is a rare but curable cause of hoarseness and is commonly related to intubation or laryngeal trauma. We present a case of arytenoid cartilage dislocation without a traumatic event in a man who complained of acute hoarseness. An 82-year-old man visited our emergency department complaining of acute hoarseness. He had no history of general anesthesia or laryngeal trauma and had not caught a cold. He showed no abnormal physical findings including the pharynx. Examination using a laryngoscope revealed that the left vocal fold was fixed in the paramedian position. We performed contrast-enhanced computed tomography (CT), but we could not find any cause of the left recurrent laryngeal nerve paralysis. His hoarseness persisted for one month and the initial CT was therefore reassessed. It was found that the left arytenoid cartilage was dislocated forward, and we therefore made a diagnosis of arytenoid cartilage dislocation without a traumatic event. We tried to refer him to an otolaryngologist for surgical treatment, but he declined. Fortunately, his hoarseness gradually improved over a period of two months. Arytenoid cartilage dislocation rarely occurs without a traumatic event. CT is useful for accurate diagnosis of this condition. Since early diagnosis can lead to appropriate surgical treatment and improvement in vocal function, the possibility of arytenoid cartilage dislocation should be considered in patients with acute hoarseness without apparent causes. © 2017 Elsevier Inc. All rights reserved.
1. Introduction Hoarseness is a common symptom in patients seen by emergency physicians. However, self-limiting inflammation is the most common cause of hoarseness, other critical and curable causes are rarely discovered. Arytenoid cartilage dislocation is a rare but curable cause of hoarseness that is commonly related to intubation or laryngeal trauma [1]. We present a case of arytenoid cartilage dislocation without a traumatic event in a man who complained of acute hoarseness. 2. Case presentation An 82-year-old man with atrial fibrillation and hypertension visited our emergency department complaining of acute hoarseness that had persisted for four days. He had no history of general anesthesia or laryngeal trauma and had not caught a cold before the hoarseness occurred. He had no fever and showed no abnormal physical findings including the pharynx. Examination using a laryngoscope revealed that the left vocal fold was fixed in the paramedian position, suggesting left ⁎ Corresponding author at: Akiota Hospital, Japan, Shimotonogouchi 236, Akiota-chou, Yamagata-gun, Hiroshima 731-3622, Japan. E-mail address: [email protected] (Y. Okazaki).
recurrent laryngeal nerve paralysis (Fig.1). We suspected an aortic aneurysm or cervical or lung cancer and performed contrast-enhanced CT but could not find any cause of the left recurrent laryngeal nerve paralysis. His hoarseness persisted for one month and the initial CT was therefore reassessed by a radiologist and an otolaryngologist. Reassessment revealed that the left arytenoid cartilage was dislocated forward (Fig. 1), and we therefore made of a diagnosis of acute hoarseness caused by arytenoid cartilage dislocation without a traumatic event. We tried to refer him to an otolaryngologist for specific surgical treatment, but he declined because his hoarseness was gradually improving. Fortunately, his hoarseness resolved spontaneously after two months. 3. Discussion The course of the patient indicated two important clinical issues: 1) arytenoid cartilage dislocation rarely occurs without a traumatic event and 2) CT is useful for accurate diagnosis of this condition. First, arytenoid cartilage dislocation rarely occurs without a traumatic event. Many conditions ranging from self-limiting inflammation, or laryngitis to more serious systemic, neurologic, or cancerous conditions can casus hoarseness [2]. Arytenoid cartilage dislocation is a rare but curable cause of hoarseness, though less than 150 cases have been reported [3]. Arytenoid cartilage dislocation is defined as complete
https://doi.org/10.1016/j.ajem.2017.10.041 0735-6757/© 2017 Elsevier Inc. All rights reserved.
Please cite this article as: Okazaki Y, et al, Unusual cause of hoarseness: Arytenoid cartilage dislocation without a traumatic event, American Journal of Emergency Medicine (2017), https://doi.org/10.1016/j.ajem.2017.10.041
2
Y. Okazaki et al. / American Journal of Emergency Medicine xxx (2017) xxx–xxx
Fig. 1. Examination using a laryngoscope revealed that the left vocal fold was fixed in the paramedian position (A). Axial CT of the larynx showed forward dislocation of the left arytenoid cartilage and asymmetry of the left and right arytenoid cartilages (B). Normal axial CT of the larynx showed no asymmetry of the left and right arytenoid cartilages (C). CT: computed tomography.
separation of the arytenoid cartilage from the cricoarytenoid joint, which causes vocal fold immobility and results in hoarseness. Over 90% of the cases were caused by intubation and laryngeal trauma, and a few cases of idiopathic cases have also been reported [1]. Our patient developed hoarseness without an apparent traumatic event, and our case was therefore extremely rare. However, physician are not familiar with arytenoid cartilage dislocation, and a considerable number of cases may therefore be underdiagnosed or misdiagnosed as unexplained unilateral vocal fold paralysis [4]. Fortunately, the hoarseness in our patient gradually improved spontaneously, but prompt diagnosis before development of joint ankylosis can lead to specific surgical treatment, such as direct microlaryngoscopy with arytenoid reduction and repositioning, and improvement in vocal function [5]. We should therefore differentiate this condition from other causes of acute hoarseness accurately. Second, CT is useful for accurate diagnosis of this condition. Arytenoid cartilage dislocation is usually diagnosed by a combination of laryngoscopy, laryngeal electromyography and laryngeal CT. Laryngoscopy may show either an anteromedial or posterolateral arytenoid position with reduced vocal fold motion [5], but it is difficult, especially for non-otolaryngologists, to make accurate diagnosis without suspicion of arytenoid cartilage dislocation. Moreover, laryngeal electromyography cannot be performed by non-otolaryngologists. In contrast, CT is easy to perform and evaluate statically, and it can rule out other causative etiologies. Recently, CT has become widely used in clinical settings and its resolution has been greatly increased. Laryngeal CT can therefore be a useful adjunctive examination in patients with suspected arytenoid cartilage dislocation [6]. However, laryngeal CT has some limitations. In young patients, cartilage is frequently not ossified, and assessment might therefore be difficult. If possible, highquality images with thin slices and reconstruction of the larynx are helpful to confirm the diagnosis [1,5]. It is also essential to suspect this condition in patients complaining of acute hoarseness with typical risks or without any causative etiology and to interpret laryngeal CT with focus on the arytenoid cartilage. Arytenoid cartilage dislocation rarely occurs without a traumatic event. Computed tomography is useful for accurate diagnosis of this
condition. Prompt diagnosis can lead to appropriate surgical treatment and improvement in vocal function. We should therefore know about this condition and differentiate arytenoid cartilage dislocation in patients complaining of acute hoarseness without an apparent cause. Hoarseness usually resolves spontaneously, and emergency physicians tend not to have an interest in its cause. We should therefore also acknowledge other rare but critical and curable causes of hoarseness, especially neoplasm and aortic dissection [2,7]. Acknowledgement None declared. Conflict of interest None declared. Funding None declared. References [1] Rubin AD, Hawkshaw MJ, Moyer CA, Dean CM, Sataloff RT. Arytenoid cartilage dislocation: a 20-year experience. J Voice 2005;19:687–701. [2] Cooper L, Quested RA. Hoarseness: an approach for the general practitioner. Aust Fam Physician 2016;45:378–81. [3] Lee SW, Park KN, Welham NV. Clinical features and surgical outcomes following closed reduction of arytenoid dislocation. JAMA Otolaryngol Head Neck Surg 2014; 140:1045–50. [4] Oppenheimer AG, Gulati V, Kirsch J, Alemar GO. Case 223: arytenoid dislocation. Radiology 2015;277:607–11. [5] Norris BK, Schweinfurth JM. Arytenoid dislocation: an analysis of the contemporary literature. Laryngoscope 2011;121:142–6. [6] Alexander Jr AE, Lyons GD, Fazekas-May MA, Rigby PL, Nuss DW, David L, et al. Utility of helical computed tomography in the study of arytenoid dislocation and arytenoid subluxation. Ann Otol Rhinol Laryngol 1997;106:1020–3. [7] Wang JY, Chen H, Su X, Zhang ZP. Aortic dissection manifesting as dysphagia and hoarseness: Ortner's syndrome. Am J Emerg Med 2016;34:e1-.
Please cite this article as: Okazaki Y, et al, Unusual cause of hoarseness: Arytenoid cartilage dislocation without a traumatic event, American Journal of Emergency Medicine (2017), https://doi.org/10.1016/j.ajem.2017.10.041