Spontaneous reposition of a dislocated arytenoid cartilage.
ABSTRACT We report a patient suffering from arytenoid cartilage dislocation after difficult tracheal intubation and the abrupt spontaneous reposition in the course of severe vomiting 1 month after the operation. Predisposing factors for the unusual reposition are discussed.
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ABSTRACT: The cricoarytenoid joints of 12 human adult male and female larynges were studied with regard to the anatomical reasons for arytenoid cartilage dislocation. The specimens were impregnated with curable polymers as a whole and then cut into 600–800 μm sections along different planes. The articulating surface at the upper border of the cricoid lamina revealed a striking extension backward and occasionally even slightly distalward. This may allow the arytenoid cartilage to glide in a posterior direction until it partially looses its contact to the cricoid facet. In physiologic conditions, the arytenoid position is balanced along a sagittal plane between the posterior cricoarytenoid ligament dorsally and the thyroarytenoid muscle ventrally. If one of these structures is damaged, i.e., by medical disease or trauma, the arytenoid cartilage may be pushed easily in the opposite direction. Arytenoid dislocation mainly in a posterior direction is described in literature as a possible complication of endotracheal intubation. Preparatory pharmacological muscle relaxation leads to paralysis of the thyroarytenoid muscle and its ventrally directed traction on the arytenoid cartilage. As the shape of the articulating surfaces, especially the peculiarities of the cricoid facet, even facilitates a dorsally directed movement of the Arytenoid cartilage, it may be easily displaced in a posterior direction during the procedure of endotracheal intubation. © 1994 Wiley-Liss, Inc.Clinical Anatomy 01/2005; 7(6):324 - 330. · 1.16 Impact Factor
- Operative Techniques in Otolaryngology-Head and Neck Surgery 12/1998; 9(4):196-202.
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ABSTRACT: CASE REPORT A 63 year old lady, with no antecedent co-morbid condition and a diagnosed case of chronic cholecystitis, was taken up for routine laparoscopic cholecystectomy. Anaesthesia was induced with Injection thiopentone and trachea intubated with a 7mm endotracheal tube (ETT) facilitated with succinylcholine 1-1.5 mg./kg iv. The cords were not very well visualised due to long overhang of the epiglottis. However, the tube could be passed in smoothly without any struggle. The surgical procedure was uneventful. On extubation, patient developed stridor and hypoxemia. Re-intubation attempted but the cords were seen obliterated with edema and hence this was not successful. An emergency tracheostomy was done and airway secured. Subsequently, the patient was evaluated with fibreoptic larngoscopy(FOL). Both the cords were in paramedian position and moving feebly. A CECT scan of larynx showed dislocation of cricoarytenoid joint (CAJ) bilaterally. The right CAJ was displaced anteriorly and superiorly with anticlockwise rotation with the left CAJ similarly dislocated. Thickening of aryepiglottic fold, false cord and edema around true cords seen. (Figure 1). An attempt at closed reduction with direct laryngoscopy was made. The right sided CAJ could be reduced and the cord seen to move well but, despite repeated attempts, it was not possible to reverse the left sided CAJ dislocation. At a subsequent review, the Rt side cord was seen mobile and compensating for the Lt sided immobile cord. Patient's tracheostomy was closed successfully and she had no respiratory distress. In her last follow-up, patient had hoarseness of voice but asymptomatic. DISCUSSION While Arytenoid dislocation (AD), usually a result of severe laryngeal trauma, entails complete separation of the arytenoid cartilage from the joint space, arytenoid subluxation (AS) refers to the partial displacement of the arytenoid within the joint and results from a lesser injury. 1 AD can result directly by the blade of a laryngoscope as it is inserted and lifted in an anterior direction. Posterior AS can result when postero lateral force gets applied to the arytenoid by the convex curve of the ETT as it passes into the airway. 2 Another theory suggests that traumatic extubation with a partially inflated cuff displaces the arytenoid posteriorly. 3 Quick and Merwin proposed that the left CAJ is more frequently injured because the laryngoscope is typically held in the left hand with the ETT being inserted from the right side and consequent force upon the left arytenoid by the convex curvature of the endotracheal tube. 4 True incidence of CA subluxation is controversial. Some argue that it occurs much more frequently than commonly realized. With the known occurrence of spontaneous repositioning of subluxed arytenoids and with the incidence of hoarseness following short term endotracheal intubation about 4%, they opine that the true incidence of arytenoid dislocation may be much higher than suspected. 2,5 However, in a large series of 1000 intubated patients, in which 6.2% had laryngeal trauma, only one case of AS was reported. 6 Systemic diseases (e.g. terminal renal insufficiency, bowel diseases, acromegaly) may cause degeneration of the cricoarytenoid ligaments, thus making the CAJ more susceptible to traumatic dislocation. 7 Laxity of the joint capsule and the large synovial folds too have been proposedJournal of Clinical anaesthesia and Pharmacology. 08/2009; 25(3):361-62.