Abstract
Korman et al ( Laryngoscope .1973;83:683–690) first reported arytenoid dislocation as a rare and unusual complication of intubation. Since then, the terms arytenoid dislocation and arytenoid subluxation (AS) have been used interchangeably to describe disruption of the cricoarytenoid joint. Only 74 cases of AS have been reported in the literature to date. The most common cause of AS is intubation trauma and external neck injury. Only 1 case of AS due to coughing has been documented. Arytenoid subluxation cases are often misdiagnosed as vocal fold paralysis. A high index of suspicion based on the history, examination findings, and objective tests helps in early diagnosis and, thus, early surgical intervention. We present a rare etiology of AS due to a bout of coughing, which was diagnosed early and reduced under general anesthesia with complete reversibility of vocal fold motion, thus restoring normal voice function.
1
Introduction
Disruption of the cricoarytenoid joint can be complete or partial. Arytenoid dislocation refers to complete separation of the arytenoid cartilage from the cricoarytenoid joint space, and it usually results from severe laryngeal trauma. Arytenoid subluxation (AS) refers to a partial displacement of the arytenoid within the joint. Literature suggests that AS is a more common injury than arytenoid dislocation. The most common cause is intubation or laryngeal trauma, which results in laryngeal edema, hemorrhage, or mucosal tears. Cough causing AS is very rare. Symptoms of dysphonia and throat pain are mild and usually resolve in 24 to 48 hours. Severe laryngeal injury may cause AS or recurrent laryngeal nerve palsy, which leads to an immobile vocal fold and asymmetry of arytenoid cartilages. Hence, misdiagnosis is common. A detailed history, examination, computed tomographic (CT) scan, and laryngeal electromyogram (EMG) helps to differentiate between the 2 conditions. Early diagnosis and surgical intervention may restore normal voice function.
2
Case report
A 45-year-old male patient presented with sudden change of voice and throat pain since 2 days after a bout of severe coughing. The patient had undergone an upper gastrointestinal scopy 5 days back for suspected gastroesophageal reflux disease. After gastrointestinal scopy, the patient had a mild throat pain for which he was given medical line of treatment and was symptomatically better. He had a severe coughing episode 2 days later, after which he had a hoarse breathy voice and severe throat pain. There was no other significant medical or surgical history. The maximum phonation time (MPT) was 3 seconds. A 70° rigid laryngoscopy revealed an immobile left vocal fold, edema of the interarytenoid region, and a left anteriorly tilted arytenoid cartilage with absent jostle phenomenon ( Fig. 1 ), which suggested AS. Flexible laryngoscopy also confirmed the diagnosis. A CT scan from the base skull to upper mediastinum with contrast enhancement was performed. The CT scan was suggestive of a subluxated left arytenoid in the anterior position, asymmetry of bilateral vocal processes, obliteration of left cricoarytenoid space, and absence of any hematoma ( Fig. 2 ). No abnormality was detected along the course of recurrent laryngeal nerve.
The patient was started on oral steroids, and a confirmation of the diagnosis of AS was made by palpation under general anesthesia. The patient was maintained on intermittent mask ventilation and intravenous propofol. An early closed arytenoid reduction without endotracheal intubation was performed. A McIntosh anesthetic laryngoscope (Karl Storz, Germany) was used to expose the larynx. A Karl Storz blunt microflap elevator (Karl Storz, Germany) was used to reduce the anteromedially subluxated arytenoid by applying force on the body of the arytenoid in a posterolateral direction. Care was taken not to apply too much pressure on the vocal process, which may lead to its fracture. The patient was advised complete voice rest, oral steroids, and antibiotics for 7 days and was discharged on the same day. Gradual vocalization was permitted after 7 days of surgical intervention. On follow-up, 70° rigid laryngoscopy showed complete movement of the left vocal fold with bilateral symmetrical arytenoids on phonation. His postintervention MPT was 11 seconds.
2
Case report
A 45-year-old male patient presented with sudden change of voice and throat pain since 2 days after a bout of severe coughing. The patient had undergone an upper gastrointestinal scopy 5 days back for suspected gastroesophageal reflux disease. After gastrointestinal scopy, the patient had a mild throat pain for which he was given medical line of treatment and was symptomatically better. He had a severe coughing episode 2 days later, after which he had a hoarse breathy voice and severe throat pain. There was no other significant medical or surgical history. The maximum phonation time (MPT) was 3 seconds. A 70° rigid laryngoscopy revealed an immobile left vocal fold, edema of the interarytenoid region, and a left anteriorly tilted arytenoid cartilage with absent jostle phenomenon ( Fig. 1 ), which suggested AS. Flexible laryngoscopy also confirmed the diagnosis. A CT scan from the base skull to upper mediastinum with contrast enhancement was performed. The CT scan was suggestive of a subluxated left arytenoid in the anterior position, asymmetry of bilateral vocal processes, obliteration of left cricoarytenoid space, and absence of any hematoma ( Fig. 2 ). No abnormality was detected along the course of recurrent laryngeal nerve.
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