Arytenoid Cartilage Dislocation: A 20-year Experience
Introduction
Vocal fold immobility or hypomobility can result from injury to the recurrent or superior laryngeal nerve, or from a laryngeal structural problem, such as arytenoid cartilage dislocation or cricoarytenoid joint fixation. Accurate diagnosis is critical to devising the optimal therapeutic approach. Arytenoid cartilage dislocation or subluxation is diagnosed infrequently, but it may be mistaken easily for vocal fold paralysis or paresis. If the otolaryngologist is not considering the diagnosis, he or she will probably miss it. Early diagnosis and treatment are more likely to reestablish or improve joint mobility; however, previous reports have demonstrated that a good voice result can be obtained even with late surgical intervention.1, 2
The cricoarytenoid joint is diarthrodial, with a synovium-lined capsule. It is formed by the articulation of the pyramidal-shaped arytenoid cartilage and the elliptical cricoid facet. The intrinsic forces from attached laryngeal muscles and ligaments provide support to the joint. The joint axis lies approximately at a 45° angle from the sagittal plane and a 40° angle from the horizontal plane.1, 3 Although traditional teaching describes cricoarytenoid joint motion as a combination of rotating, gliding, and rocking,4 its movement is more complicated. This complex mechanism controls abduction and adduction of the true vocal folds and is, therefore, critical for protection of the airway and phonation.
Section snippets
Subjects
Sixty-three patients evaluated in our office between 1983 and 2003 were found to have arytenoid cartilage dislocation. Twenty-six of them were reported previously.1, 2
Evaluation
Patients suspected of having an arytenoid dislocation underwent a complete head and neck evaluation and a thorough voice evaluation including fiberoptic laryngoscopy and rigid videostroboscopy. Laryngeal electromyography (LEMG) is performed by a neurologist who is board certified in electromyography and has performed over 4000
Results
Demographics, origin, treatment, and voice result are summarized in Table 1. The mean age of the study group was 42.5 years (SD = 18.6), with patients ranging from 2 to 76 years old. There were 39 females (61.9%) and 24 males (38.1%). The most common symptom was hoarseness, followed by breathiness, volume disturbance, vocal fatigue, dysphagia, stridor, and pain. The origin of arytenoid cartilage dislocation was intubation trauma in 49 patients (77.8%), external blunt trauma in 10 patients
Discussion
Not including the patients reported in this study or previously by the senior author (RTS), 74 cases of arytenoid cartilage dislocation are reported in the literature.7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31 The actual incidence is most likely higher than the literature reflects, because many are misdiagnosed as vocal fold paralysis. This study involves the largest number of cases reported to date.
The most common etiologic factor of
Conclusions
The diagnosis of arytenoid cartilage dislocation should be considered in all cases of vocal fold hypomobility and immobility. Videostroboscopy is the most critical part of the examination, although laryngeal CT and EMG are useful to otolaryngologists. An attempt at endoscopic reduction should be considered even when diagnosis has been delayed. Equalizing the heights of the vocal processes might improve the voice even without return of joint mobility.
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