Dr.

Supreet Singh Nayyar, AFMC

2012

Cricoarytenoid Joint Dislocation

(for more toics & presentations in ENT, please visit www.nayyarENT.com )

Arytenoid dislocation refers to complete separation of the arytenoid cartilage from the joint space Arytenoid subluxation partial displacement of arytenoid within the joint Incidence rare injury fewer than 80 cases have been reported in worldwide literature Any age M:F=1:1

Epidemiology

Etiology Intubation trauma Blunt and penetrating neck trauma Upper aerodigestive tract instrumentation e.g. Direct laryngoscopy, brochoscopy Whiplash injury Idiopathic Associated anomalies that weaken cricoarytenoid joint
o o o o o o Laryngomalacia Acromegaly Diabetes mellitus Chronic renal failure Rheumatic disease Long-term corticosteroid use

Relevant Anatomy Arytenoid cartilage

o o o o o o o Composed of hyaline and elastic cartilages Pyramid-shaped Consists of an apex, base, and 2 processes Vocal process articulates with vocal ligament Muscular process is the insertion point for the muscles that move arytenoid Base rests on cricoid cartilage Apex articulates with the AE fold and the corniculate cartilage Synovial joint enclosed by a joint capsule Rocking and gliding movement Posterior support from posterior cricoarytenoid ligament Controls adduction and abduction of true vocal cords

Cricoarytenoid joint
o o o o

Pathophysiology Anterior displacement o By blade of a laryngoscope as it is inserted and lifted in an anterior direction o Lateral trauma to larynx with medially displaced thyroid ala
1

www.nayyarENT.com

Dr. Supreet Singh Nayyar, AFMC

2012

Posterior dislocation o Traumatic extubation with a partially inflated cuff o Posterolateral force applied to the arytenoid by convex curve of endotracheal tube as it passes into the airway o Blunt ant trauma to larynx (features of vocal paresis)

Presentation

Hoarseness Breathiness Asthenia Decreased pitch Decreased intensity of voice Dysphagia Odynophagia Sore throat Cough History of recent upper aero digestive tract instrumentation or intubation IDL,FOL
o o o o o o Reduced vocal fold mobility Arytenoid edema Loss of arytenoid symmetry Poor glottic closure Posterior glottic chink Malalignment of true vocal cords Important because early management of AS consists of endoscopic reduction, whereas early management of vocal fold paralysis frequently consists of observation with voice therapy Difficult if based only on history and physical examination Laryngeal electromyography (EMG)

Differentiation from RLN palsy

o o o

Investigations

LEMG CT scan MRI Laryngeal videostroboscopy

Diagnostic Procedures
Direct laryngoscopy Under general anesthesia Palpation of arytenoid cartilage

Medical Therapy
Voice therapy Arytenoid subluxation Patients who refuse surgery

Surgical Therapy

Treatment of choice
2

www.nayyarENT.com

Dr. Supreet Singh Nayyar, AFMC

2012

Earlier the intervention, better the outcome Early treatment Direct laryngoscopy and closed reduction of the displaced arytenoid Injection of steroid preparations (eg, triamcinolone) into the cricoarytenoid joint space at the time of reduction suggested in literature Tracheostomy may be required in the acute period of laryngeal edema Other option Arytenoidectomy via an endoscopic approach or laryngofissure Late treatment Direct laryngoscopy with attempted reduction of the displaced arytenoid success less because of fibrous ankylosis & reduced joint mobility even after reduction Vocal fold medialization Type 1 thyroplasty Fat /Teflon injection

Operative Details for joint reduction

GA Endoscopic procedures Holinger laryngoscope for anterior dislocation Tip of laryngscope is contacted with joint interface displaced arytenoid is then lifted and reduced posterolaterally For posterior subluxations Miller-3 straight intubating laryngoscope is favored for its unique curved tip placement of the laryngoscope in the pyriform sinus with the lip of the Miller blade in the subluxated joint cartilage is lifted and repositioned anteromedially Intraoperative steroids (triamcinolone) into joint space Voice rest Steroids Humidified oxygen Close observation for breathlessness (laryngeal oedema) Antibiotics Antireflux medications Analgesics Voice therapy Failure to reduce Recurrence of subluxation Iatrogenic disruption of laryngeal mucosa Laryngeal oedema Early diagnosis and intervention is the best hope for a favorable outcome in the treatment of arytenoid subluxation (AS). Some patients are able to compensate for the immobile vocal fold and return to near-normal voice quality without surgical intervention However, most patients require either endoscopic reduction in the early period or medialization procedures in the late period

Postoperative

Complications

Outcome and Prognosis

(for more toics & presentations in ENT, please visit www.nayyarENT.com )

www.nayyarENT.com