Your patient with respiratory failure was successfully intubated and admitted to the MICU. Two weeks later he comes back to the ED complaining of persistent hoarse voice and dysphagia. He states he was extubated 1 week prior and was told his symptoms would resolve but they hadn’t. What could be going on?

Anatomy:

The arytenoid cartilages are a pair of pyramidal structures articulating with the cricoid cartilage posteriorly from which the vocal cords emanate from anteriorly. The cricoarytenoid joint is a synovial joint which can be subluxed or dislocated with direct trauma, either via intubation or neck trauma. The arytenoid cartilages can either dislocate anteriorly or posteriorly although anterior dislocation is more common.

Gray952

Epidemiology:

Arytenoid cartilage dislocation (ACD) is a relatively rare outcome of endotracheal intubation. It is estimated that 0.1% of intubations result in ACD, although this number may be underestimated.

Pathophysiology:

As stated above, ACD can occur from external trauma or endotracheal intubation. Since the vocal cords are suspected from the AC’s, patients will often present with hoarse voice, breathy voice, or dysphagia. Flexible laryngoscopy may reveal vocal cord hypomotility and asymmetry of the AC’s. Additionally, laryngeal electromyography may show paresis of the superior laryngeal nerve which may add to the patient’s symptoms.

Clinical Manifestations:

The most common presenting symptom is hoarse voice, followed by voice breathiness. In fewer cases, stridor, dysphagia, and odynophagia have also been reported. Patients will typically have a recent history of neck trauma or intubation.

Imaging:

Noncontrast CT of the neck with fine cuts through the larynx is a good first-line imaging modality to assess for ACD, although not 100% sensitive, especially in younger patients who have decreased ossification of the cartilages. Flexible bronchoscopy and eventually rigid stroboscopy in the office will be able to directly image the anatomy of the patient’s larynx.

Treatment:

The AC’s can typically be reduced via closed reduction in an outpatient setting using local anesthesia. ENT’s may additionally use Botox to ensure stability of surrounding muscles as well as steroids to help reduce inflammation. Rarely, ACD can self-reduce without intervention. Voice therapy has also been shown to help aid in healing.

Prognosis:

After reduction in a series of 50 patients, 9 regained normal voice, 27 had significant improvement of hoarse voice, 10 had minimal voice improvement, 2 had no improvement, and 2 were lost to follow up. In general, the sooner it is repaired the better the prognosis.


Sources:

Rubin AD, Hawkshaw MJ, Moyer CA et al (2005) Arytenoid cartilage dislocation: a 20-year experience. J Voice 19:687–701

Paulsen FP, Jungmann K, Tillmann BN (2000) The cricoarytenoid joint capsule and its relevance to endotracheal intubation. Anesth Analg 90:180–185