Laryngology seminar 90.12.26
Arytenoid dislocation
R3 Tsai
1973 Korman
arytenoids dislocation, arytenoids subluxation, arytenoids displacement
Embryology and Anatomy
a. laryngeal hyaline cartilages develop from branchial arch mesoderm
b. elastic cartilages are derived from mesoderm of the floor of the pharynx
c. arytenoids – hyaline cartilage, vocal processes – elastic cartilages
d. arytenoids – comes from Green word arytainoeides, meaning “ ladle shaped”
e. pyramid shape
1. base: articulates with the cricoid cartilage
2. apex: attaches to the corniculate (cartilage of Santorini) and to the
aryepiglottic fold
3. two processes
anterior: vocal ligment ( vocal process)
posterior-lateral: PCA LCA insertion ( muscular process)
4. three surfaces: anterolateral, medial, and dorsomedial surfaces
f. the cricoid facet is 6mm long and cylindrical
g. motion: rocking gliding rotary pivoting
h. cricoarytenoid joint: arthrodial joint, supported – lax capsule lined with
synovium ( strengthened posteriorl by cricoarytenid ligment)
i. axis: 45 degrees from the sagittal plane, 40 degrees from the horizontal plane
j. control by: PCA, LCA, TA, oblique arytenoids, thyroarytenoid , cricothyroid ,
thyroepiglottic
Etiology and Symptoms
k. Symptoms: hoarseness, odynophagia, dysphagia, sorethroat, , dyspnea, vocal
fatigue, loss of vocal control, cough
l. Etiology: intubation trauma ( 50-80%), external blunt trauma ( 30%), laryngeal
mask, microdirect laryngoscopy, whiplash injury, unknown
m. Two types: Anterior arytenoids dislocation
Posterior arytenoids dislocation
n. Theory:
Quick and Merwin – three posterior lateral dislocation of left mechanisms
1. laryngoscope was held in left hand
2. intubation was from the right side – distal 1/3
3. end-stage renal disease in this series – other study had no chronic disease
Dudley – posterior dislocation mechanism
1. more extubation than intubation
2. tube cuff was deflated impletely – pull out posteriorly and superiorly
Close – anterior dislocation mechanism
1. the blade of laryngoscope displace the aryenoid directly anteriorly
2. the epiglottis , aryepiglottic fold, and arytenoids cartilages are being
tensed anteriorly
3. a misdirection of endotracheal tube tip or stylet injury
o. Risk factors: decrease elasticity of old, delicate larynx of child and women,
difficult mutiple prolonged intubations, inexperienced operator, endotracheal
tube manipulation, endocrine diseases…
p. Sex : 1:1
q. Age: 0-70 y/o( baby 2640 mg. 60 hours/old, acute dyspnea, progress rapidly in
24 hours, reintubation and tracheostomy on day 8, four weeks later – good )
r. Left side > right side ( in first paper 70%>30%), but equal later papers
s. complication: respiratory distress – 4 hours ( some case over 40 hours) post
extubation-- neck re-intubation or tracheostomy, hoarseness, aspiration,
effective cough, poor oral intake, joint fibrosis ankylosis
Diagnosis
@ tools
t. CT: 12/17 patients (+) in HRCT
5 patients (--), but 4/5 were younger than 15 y/o, insufficient
mineralization?
u. Strobovideolaryngoscoy – even 1 mm mobility can noted
v. Laryngeal EMG
1. can divided the RLN or SLN paresis from dislocation
2. if EMG (+), still possible of dislocation happened
w. Directed mirror evaluation – even a experienced doctor may missed
x. Flexible nasopharyngolaryngoscopy
@ recognition: stroboscope + maneuvers ( exam in different patches and
intensities)
@ anterior dislocation: displaced vocal process and fold inferiorly, medially
rotated
@ posterior dislocation: displaced vocal process and fold superiorly, laterally
rotated
Dislocation vs Vocal cord paralysis
y. odynophagia – early stage dislocation, palsy -- none
z. evidence of movement under stroboscope of previous diagnosed paralyzed
vocal Cord -- abnormal patterns of arytenoid movement
aa. absence of a jostle sign ( movement of the arytenoids on the abnormal side
caused by contact with the mobile side during adduction in cases of vocal fold
paralysis )
bb. absence of increase in length with increased pitch
cc. asymmetric vertical position of the vocal processes
---- suggest arytenoids dislocation rather than vocal cord paralysis
B. Treatment
@ early treatment was suggested
Rudert: within 21 days – good result
If late -- fibrotic ankylosis of joint – difficult of reduction
@ late reduction also had dramatic improved in some studies
a. Spontaneous recovery
b. voice therapy 4-6 weks
c. surgery therapy 3 days to 9 months
1. close reduction
under local anesthesia and sedation
evaluation of voluntary vocal fold motion and voice quality
under the Miller No. 3 laryngoscope blade for posterior dislocation
Holinger laryngoscope blade for anterior dislocation
Using the Laryngeal spatula or forceps
Gentile pressure to relocate
Cupped forceps lacerate the mucosa and exposure the cartilage
2. close reduction + steroid or fat or telflon injection
3. thyroplasty or arytenoids adduction/rotation
4. open reduction: Stanley and Colman via laryngofissure + mucosa repair,
poor result in mobility of arytenoids ( joint had fibrosis)
5. arytenoidectomy: Tolley, ( joint had fibrosis)
6. Botulinum toxin injection (rebalance) : Diagnosis – GA via jet ventilation
( to see the posterior commissure well) – 4 mm bronchoscope
reposition – Botulinum toxin 2.5 units/0.1cc injection to TA, LCA of
lesion site and IA – One week “splint” later, motion mild – one month
later, good recovered
7. forceps with cotton pad and balloon cather filled with 10 ml waterPeter LF,
Arthur TM. Arytenoid dislocation. Otolaryngol Head Neck Surg. 1996; 115:160-162
reference
1. Dion R, Tim M, Robert CB. Neonatal arytenoids dislocation. Pediatrics. 1988; 81:580-582
2. Sataloff RT. Bough ID Jr. Spiegel JR. Arytenoid dislocation: diagnosis and treatment. Laryngoscope.
1994;104:1353-61
3. Stack BC Jr. Ridley MB. Arytenoid subluxation from blunt laryngeal trauma. American Journal of
Otolaryngology. 1994 Jan; 15(1):68-73
4. Rontal E. Rontal M. Botulinum toxin as an adjunct for the treatment of acute anteromedial arytenoid
dislocation. Laryngoscope. 1999 Jan; 109(1):164-6
5. Rontal E. Rontal M. Laryngeal rebalancing for the treatment of arytenoid dislocation. Journal of
Voice.1998 Sep; 12(3):383-8
6. Brimacombe JR. Arytenoid dislocation and the laryngeal mask airway. [letter; comment].
Anesthesia & Analgesia. 1997, Aug; 85(2):463