cricoarytenoid joint dislocation

7/23/2019 Cricoarytenoid Joint Dislocation

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Dr. Supreet Singh Nayyar, AFMC 2012

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Cricoarytenoid Joint Dislocation

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Arytenoid dislocation refers to complete separation of the arytenoid cartilagefrom the joint space

Arytenoid subluxation partial displacement of arytenoid within the joint

Epidemiology

Incidence rare injury fewer than 80 cases have been reported inworldwide literature

Any age

M : F = 1 : 1

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 jointo Laryngomalaciao Acromegalyo Diabetes mellituso Chronic renal failureo Rheumatic diseaseo Long-term corticosteroid use

Relevant Anatomy

Arytenoid cartilageo Composed of hyaline and elastic cartilageso Pyramid-shapedo Consists of an apex, base, and 2 processeso Vocal process articulates with vocal ligamento Muscular process is the insertion point for the muscles that move arytenoido Base rests on cricoid cartilage

o Apex articulates with the AE fold and the corniculate cartilage Cricoarytenoid joint

o Synovial joint enclosed by a joint capsuleo Rocking and gliding movemento Posterior support from posterior cricoarytenoid ligamento Controls adduction and abduction of true vocal cords

Pathophysiology

Anterior displacemento 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
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Posterior dislocationo Traumatic extubation with a partially inflated cuffo Posterolateral force applied to the arytenoid by convex curve of

endotracheal tube as it passes into the airway

o Blunt ant trauma to larynx

Presentation (features of vocal paresis)

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,FOLo Reduced vocal fold mobilityo Arytenoid edemao Loss of arytenoid symmetryo Poor glottic closure

o Posterior glottic chinko Malalignment of true vocal cords

Differentiation from RLN palsyo Important because early management of AS consists of endoscopic reduction,

whereas early management of vocal fold paralysis frequently consists of observation

with voice therapyo Difficult if based only on history and physical examinationo Laryngeal electromyography (EMG)

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


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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 afterreduction

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 thepyriform sinus with the lip of the Miller blade in the subluxated joint cartilageis lifted and repositioned anteromedially

Intraoperative steroids (triamcinolone) into joint space

Postoperative Voice rest

Steroids Humidified oxygen Close observation for breathlessness (laryngeal oedema) Antibiotics Antireflux medications Analgesics Voice therapy

Complications Failure to reduce Recurrence of subluxation Iatrogenic disruption of laryngeal mucosa Laryngeal oedema

Outcome and Prognosis 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

(for more toics & presentations in ENT, please visitwww.nayyarENT.com)
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cricoarytenoid joint dislocation

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