Arytenoid Dislocation Treatment & Management

Updated: Aug 15, 2016
  • Author: Joshua S Schindler, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Treatment

Medical Therapy

Voice therapy is an important adjunctive treatment for all patients with arytenoid subluxation (AS). Proper voice use and vocal hygiene are important in the rehabilitation of cricoarytenoid joint integrity. Whenever possible, have the patient begin therapy with a trained speech and language pathologist with a background in voice disorders prior to surgery.

Voice therapy is also advocated in patients who refuse or do not require surgical intervention. Patients can be taught compensation techniques for breathiness and hoarseness, which is a common complication of tracheal intubation. [4] In addition, patients can be trained to protect their airway from aspiration.

Frequently, patients with AS or vocal fold paralysis develop muscle tension dysphonia that produces a strained voice quality, vocal fatigue, frequent neck pain, and a sore throat. These symptoms reflect lack of compensation for incomplete glottic closure in both processes. Voice therapy may help prevent and correct dysphonia by redirecting the patient into better compensatory techniques.

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Surgical Therapy

Surgical therapy is the treatment of choice for arytenoid subluxation (AS). Several treatment options are available.

A prospective study by Lee et al indicated that arytenoid dislocation can be successfully treated with closed reduction and that early surgical intervention improves outcomes in this procedure. The study involved 22 patients with arytenoid dislocation, including 16 with anterior dislocation and 6 with posterior dislocation. Patients were treated with closed reduction with or without adjunct therapy (injection laryngoplasty or botulinum toxin administration), with the exception of one patient who recovered spontaneously. Of the treated patients, 18 regained arytenoid motion, accompanied by voice improvement, with recovery sustained 6 months postsurgery. The investigators also found that patients who underwent closed reduction within 21 days after the presumed dislocation event tended to have better restoration of arytenoid motion. [5]

A study by Cao et al on patients who underwent closed reduction for arytenoid dislocation under local anesthesia, with 26 out of 33 patients (79%) classified as satisfied with the procedure’s results. These patients demonstrated significant improvement in grade, roughness, breathiness, asthenia, maximum phonation time, self-assessed Voice Handicap Index, jitter%, shimmer%, normalized noise energy, and noise-to-harmonic ratio. [6]

Generally, the earlier the intervention in AS, the better the outcome for voice quality. Treatment of AS can be divided into early and late interventions.

Early treatment

Early treatment of AS includes 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 is preferred by some practitioners. [7]

Tracheotomy may be required in the acute period of laryngeal edema and airway compromise. Other reports in the literature advocate arytenoidectomy via an endoscopic approach or externally via laryngofissure. Arytenoidectomy has not been widely accepted and could pose a greater risk of aspiration and poor airway protection. Usually, arytenoidectomy is reserved for when the arytenoid obstructs the airway or when all other interventions have failed.

Late treatment

Vocal fold medialization, via a type 1 thyroplasty with silastic implantation as described by Isshiki, is the treatment of choice for late AS. Other options for medialization include Gelfoam injection, autologous fat injection, and Teflon injection into the true focal fold. Teflon has largely fallen out of favor because of the possibility of granuloma formation.

Gelfoam and fat are resorbed over time and are therefore considered temporary treatments. Gelfoam and fat are considered in patients who are likely to regain vocal fold mobility and closure.

Direct laryngoscopy with attempted reduction of the displaced arytenoid, as in early AS, is another treatment option for late AS. The likelihood of successful reduction is greatly reduced in delayed diagnoses of AS because of fibrous ankylosis of the cricoarytenoid joint. Canine studies have shown that even minor injury to the joint capsule can affect arytenoid mobility. Arytenoid mobility can be significantly impaired, even with successful reduction. Although one large series demonstrated phonatory improvement with reductions as late as 1 year following injury, late endoscopic reduction has not been widely accepted as the first line of treatment for late AS.

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Preoperative Details

Obtain informed consent prior to all surgical procedures. Include a careful discussion with the patient regarding risks of airway compromise and the possible need for tracheotomy. If extensive supraglottic edema is coexistent, treatment with oral steroids or antireflux agents may be considered prior to surgical therapy.

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Intraoperative Details

Endoscopic procedures are performed with the patient under general anesthesia or under local anesthesia with intravenous sedation.

Various instrumentation techniques have been used to reduce the subluxated cartilage. Sataloff et al recommend the Holinger laryngoscope for anterior dislocations. The tip of the scope is contacted with the joint interface; the displaced arytenoid is then lifted and reduced posterolaterally. Other authors report success with the laryngeal spatula during endoscopy.

For posterior subluxations, the Miller-3 straight intubating laryngoscope is favored for its unique curved tip. Sataloff et al describe placement of the laryngoscope in the pyriform sinus with the lip of the Miller blade in the subluxated joint. The cartilage is lifted and repositioned anteromedially. Smaller microlaryngeal instruments (ie, cups forceps) are less likely to be effective and may lacerate the mucosa.

Intraoperative steroids have also been advocated by some authors. A preparation of triamcinolone acetate (Kenalog) at 40 mg/mL, in varying amounts, can be injected into the cricoarytenoid joint using a 25-gauge butterfly needle. This has been proposed to prevent joint ankylosis and reduce edema in persons with acute injuries. However, to date, intraoperative steroid injection has not been definitively shown to improve the outcome of endoscopic reduction.

Medialization thyroplasty is performed with the patient under local anesthesia with intravenous sedation, as needed. Ensure that the patient is awake in order to assess voice quality while positioning the vocal fold implant. The optimal voice quality for each patient is obtained using this method.

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Postoperative Details

Monitor all patients for airway compromise in the postsurgical period. Common signs include respiratory distress, tachypnea, and stridor. Also monitor oxygen saturation levels.

If symptoms develop, prompt fiberoptic laryngoscopy is indicated, as is intravenous steroid therapy to reduce laryngeal edema. Racemic epinephrine has also been recommended to reduce airway edema. Supportive measures, including humidified oxygen, are also useful. Close observation in an intensive care unit may be warranted. Tracheotomy may be indicated if these measures are ineffective.

The use of postoperative antibiotics, antireflux medications, and tapered oral steroid therapy for patients to complete at home are often advocated. Oral narcotic analgesics may be necessary.

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Follow-up

Most patients who have endoscopic arytenoid reductions are scheduled for a follow-up visit within 2-4 weeks. A period of voice rest may be recommended to allow the cricoarytenoid joint to stabilize.

Patients who undergo medialization thyroplasty are usually scheduled for a follow-up visit within 1-2 weeks. A period of voice rest, from 3 days to 1 week, may also be advocated.

All patients require voice therapy for speaking; when applicable, voice therapy is required for singing. Whenever possible, have the patient begin speaking voice therapy prior to surgical intervention.

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Complications

Failure to reduce the arytenoid is the most common complication of endoscopic reduction of arytenoid subluxation (AS). Histologic studies have shown that fibrosis of the cricoarytenoid joint can occur as early as 24 hours following injury.

Recurrence of subluxation after successful reduction is a related complication of the endoscopic approach. This complication is likely due to laxity of the ligamentous support of the cricoarytenoid joint following injury.

Iatrogenic disruption of the laryngeal mucosa can occur during attempts to reduce the arytenoid, thereby increasing the risk of infection.

Instrumentation of the airway can result in supraglottic edema, glottic edema, or both, thereby causing airway compromise.

Possible complications of medialization thyroplasty include the following: bleeding, infection, or hematoma of the surgical site; malpositioning of the implant, causing airway compromise or poor voice quality; extrusion of the implant; and chondritis.

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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 to achieve subjective and objective improvement in voice quality. Outcomes for both procedures have been favorable, although not uniformly successful.

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Future and Controversies

Arytenoid subluxation (AS) continues to be a rare, but challenging, problem for the laryngologist. Future management of AS will be directed toward developing more effective means of restoring cricoarytenoid joint structure and mobility, thereby improving phonatory outcomes for patients with this injury. Newer concepts that may add more treatment options for patients with AS are evolving.

The use of botulinum toxin as an adjunct to endoscopic reduction for anteromedial AS has been reported in a recent study. The study proposes that reduction of the arytenoid alone often fails because the surgeon cannot control unbalanced forces placed on the arytenoid by the intrinsic laryngeal musculature. Injection of botulinum toxin into the laryngeal adductor muscles on the affected side weakens these forces and allows the arytenoid to remain in the reduced position. Ten patients were studied, and results were favorable.

Some controversy exists in the literature over the timing of endoscopic reduction. One retrospective series reported favorable voice outcomes in patients who had endoscopic reduction as long as 1 year following injury. This finding challenges the dictum that medialization techniques are the best intervention for late treatment of AS. However, the overall consensus seems to be that, beyond 1 month following injury, the best voice outcomes will likely be obtained using medialization.

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