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DIAGNOSIS PLEASE
Case 223: Arytenoid Dislocation1

n CASE 223
Avi G. Oppenheimer, MD
History A 71-year-old man with a history of atrial fibrillation re-
Vishal Gulati, MS
fractory to medical therapy and lung cancer status after
Jacobo Kirsch, MD
left upper lobectomy presented to our hospital for elective
Gilberto O. Alemar, MD cardioversion and rate control with tikosyn. Overnight,
the patient became unresponsive and was found to be in a
state of cardiogenic shock. A code was called, and he was
stabilized after cardioversion and bedside intubation. His
stay in the intensive care unit was complicated by ventila-
tor-associated pneumonia. The patient subsequently un-
derwent multiple failed extubation attempts, requiring
two additional reintubations. He was finally extubated
18 days after his initial admission to the intensive care
unit. After he was discharged, he reported a hoarse voice
and was only able to whisper. His voice varied in timbre
and volume, and it became hoarser with use. Otolaryngol-
ogy evaluation, including laryngoscopy and video strobos-
copy, showed immobility of the right vocal cord. He was
referred for speech therapy, and a computed tomographic
(CT) examination of the neck was ordered.

recurrent laryngeal nerve–mediated vo-

Part one of this case appeared 4 months previously
and may contain larger images.
Published online
10.1148/radiol.2015140145 Content code:
Radiology 2015; 277:607–611
1 From the Departments of Radiology (A.G.O., V.G., J.K.)
and Otolaryngology (G.O.A.), Cleveland Clinic Florida, 2950
Cleveland Clinic Blvd, Weston, FL 33331. Received January
20, 2014; revision requested February 26; revision received
June 17; accepted June 27; final version accepted July 14.
Address correspondence to A.G.O. (e-mail: oppenha@
ccf.org).
Conflicts of interest are listed at the end of this article.
q RSNA, 2015
Imaging Findings
Unenhanced CT of the neck revealed
dislocation of the right arytenoid. The
right true vocal cord was rotated medi-
ally and displaced caudally, leading to
a height disparity of the vocal cords
(Figs 1, 2). Oblique-sagittal images
showed complete disruption of the cri-
coarytenoid joint, with the dislocated
arytenoid positioned anterior and infe-
rior to its usual location along the top of
the cricoid cartilage (Fig 3). Postopera-
tive changes related to prior left upper
lobectomy were present (Fig 2).
Discussion
The history of multiple intubations cou-
pled with the CT findings of a disparity
in vocal cord height and the presence of
complete anterior arytenoid dislocation
make traumatic arytenoid dislocation
the most likely diagnosis.
Differential diagnosis may also in-
clude traumatic laryngeal hematoma,
cal cord paralysis, and direct laryngeal
tumor invasion. Absence of a laryngeal
hemorrhagic mass or an infiltrative
glottic lesion was sufficient to exclude
traumatic laryngeal hematoma and tu-
mor in this patient. Palsy of the right
recurrent laryngeal nerve would be un-
likely due to the prior left-sided thora-
cotomy for left upper lobectomy. Trau-
matic intubation of the piriform sinus
can also directly injure the recurrent
laryngeal nerve, as the nerve enters
the larynx just anterior to the piriform
sinus apex. However, the presence of
an anteriorly displaced arytenoid en-
abled us to confirm that traumatic dis-
location, rather than palsy, was the cor-
rect diagnosis.
Arytenoid dislocation is an uncom-
mon but underdiagnosed condition.
Without careful attention to the clinical
history and imaging findings, arytenoid
dislocation easily can be misdiagnosed
as vocal cord paralysis. Unlike vocal cord
paralysis, arytenoid dislocation can be

Radiology: Volume 277: Number 2—November 2015 n radiology.rsna.org 607

DIAGNOSIS PLEASE: Arytenoid Dislocation
Figure 1
Figure 1: Unenhanced axial (1-mm section thick-
ness) CT images (a) through the level of the true
vocal cords and (b) 3 mm caudal to a. In a, the left
cricoarytenoid joint and vocal cord (arrow) are
normal. The right cricoarytenoid joint is ill defined
at this level. In b, the right arytenoid projects into
the subglottic area (arrow). The right vocal cord is
foreshortened and inferomedially rotated (∗).
corrected with surgery. Early diagnosis
and prompt treatment are more likely
to reestablish normal joint mobility and
restore voice quality. Thus, an under-
standing of cricoarytenoid anatomy,
pathophysiology of arytenoid dislocation,
and its distinguishing imaging features
are vital concepts for the radiologist to
consider.
The cricoarytenoid joint is a diar-
throsis with a synovium-lined capsule
608
Figure 2
Figure 2: (a) Coronal multiplanar reformatted
CT image through the glottis shows asymmetric height
of the right and left cricoarytenoid joint (arrows).
There are postoperative changes from prior left
upper lobectomy. (b) Zoomed-in coronal multiplanar
reformatted CT image more anterior to a shows an
inferiorly displaced true vocal cord (arrow). This
finding is not seen in patients with vocal cord
paralysis.
composed of the pyramidal-shaped ary-
tenoid positioned on top of the ellipsoid
cricoid cartilage (1) (Fig 3b). The term
arytenoid subluxation is used when the
relationship of the cricoarytenoid artic-
ulation is abnormal but contact is main-
tained, whereas arytenoid dislocation
refers to complete disruption of the
joint (2). The arytenoid may be dislo-
cated either anteriorly or posteriorly
with respect to the cricoid. Anterior dis-
location usually results in anteromedial
displacement of the arytenoid cartilage,
radiology.rsna.org
Oppenheimer et al
Figure 3
Figure 3: (a) Oblique sagittal multiplanar refor-
matted CT image oriented through the plane of the
right cricoarytenoid joint shows the anteriorly dislo-
cated arytenoid (arrow) inferior to the cricoid apex.
(b) Contralateral oblique sagittal multiplanar refor-
matted CT image shows the normal anatomic
relationship of the left cricoarytenoid joint with the
arytenoid (arrow) perched on top of the cricoid (∗).
with an inferiorly located foreshortened
and dysfunctional vocal cord. In contrast,
with posterior dislocation, the vocal
cord is often superiorly positioned,
with posterolateral displacement of the
arytenoid cartilage (3).
The most common symptoms of ar-
ytenoid dislocation are hoarseness,
“breathy” voice quality, decreased voice
volume, and voice fatigue. Nearly 80%
of reported cases are attributed to intu-
bation trauma, followed by 15% of cases
caused by external blunt trauma (4).
n Radiology: Volume 277: Number 2—November 2015
DIAGNOSIS PLEASE: Arytenoid Dislocation
Figure 4
Figure 4: Schematic drawings of the subluxation mechanism. The arytenoid
(arrows) is deflected posteriorly during withdrawal of the endotracheal tube,
with an incompletely deflated cuff (left), or anteriorly as the arytenoid tip is
caught on the tube lumen during intubation (right).
Several authors suggest that the aryte-
noid cartilage is directly traumatized by
the endotracheal tube or stylet during
intubation or by an incompletely de-
flated cuff during extubation (2). This
may explain why arytenoid dislocation
is slightly more common on the left side
of the body (56%), as right-handed in-
dividuals who perform intubation from
the head of the patient are more likely
to strike the contralateral larynx (4).
Furthermore, it may be deduced that
anterior arytenoid dislocation occurs
from direct intubation trauma, while
posterior dislocation can occur during
extubation (Fig 4). Although the true
incidence is unknown, arytenoid dislo-
cation has been reported in less than
0.1% of endotracheal intubations (5).
Even with a clinical history sugges-
tive of arytenoid dislocation, it can be a
challenge to make this diagnosis, as
traumatic intubation can also cause
submucosal hemorrhage or directly in-
jure the laryngeal nerve, resulting in iso-
lated or concomitant vocal cord
Radiology: Volume 277: Number 2—November 2015
paralysis or paresis. Furthermore,
whereas the position of the arytenoid is
usually described as paramedian (6), the
direction of dislocation (anterior or pos-
terior) is important to ascertain to
direct the otolaryngologist to the opti-
mal surgical approach (4). Thus, care-
ful review of CT images is required.
Thin-section (1 mm) CT of the lar-
ynx with multiplanar reformation is in-
dispensable in the diagnosis of arytenoid
dislocation, especially in the setting of
external trauma. CT can also be used to
evaluate for other cartilaginous or soft-
tissue injuries that may require surgical
repair. In addition to thin-section axial
imaging, coronal images have been de-
scribed in patients with arytenoid dislo-
cation as revealing a disparity in the
height of the vocal cords; this finding is
unique to arytenoid dislocation and is
not seen in patients with vocal cord
paralysis (2,7). However, coronal im-
ages may be limited in the setting of
arytenoid subluxation and in delineat-
ing the precise direction of the disloca-
n radiology.rsna.org
Oppenheimer et al
Figure 5
Figure 5: Image capture from video laryngoscopy.
For orientation, the epiglottis at the bottom of the
image is anterior and the top of the image is poste-
rior. There is asymmetric anterior location of the right
arytenoid cartilage (arrowhead) relative to the nor-
mally located left arytenoid (white arrow). The right
true vocal cord is incompletely visualized and is
redundant due to inferior medial displacement
(black arrow). Real-time video images showed the
right arytenoid was fixed in position during phonation.
tion. Thus, when considering a diagno-
sis of arytenoid dislocation, we advocate
obtaining a sagittal-oblique reformatted
image series oriented along the plane of
the dysfunctional cricoarytenoid joint
(Fig 3). A sagittal oblique orientation
and comparison with the contralateral
normal joint allow for more accurate
characterization of the position and in-
tegrity of the dislocated arytenoid and
the ability to detect subtle asymmetry
related to subluxation.
The surgical treatment of arytenoid
dislocation includes open or closed reduc-
tion. Good voice results may occur with
closed reduction, even with delayed treat-
ment. However, increased scarring and
ankylosis may result in cases of delayed
diagnosis and treatment, rendering an-
atomic and functional joint restoration
more challenging. Open procedures in-
clude thyroplasty and arytenoidopexy (8).
Spontaneous reduction of the dislocated
arytenoid has also been reported (9).
Additional imaging studies, such as lar-
yngoscopy and video stroboscopy, which
is a component of the initial ear, nose,
and throat work-up, can indicate the
diagnosis (Fig 5).
609
DIAGNOSIS PLEASE: Arytenoid Dislocation
In summary, this case highlights the
value of thin-section multiplanar refor-
matted CT in the setting of arytenoid
dislocation. This patient’s medical his-
tory of contralateral left lung cancer
and lobectomy serve as a distractor in-
cidental to the diagnosis of arytenoid
dislocation. Arytenoid dislocation
should always be considered in the dif-
ferential diagnosis of vocal cord dys-
function. Furthermore, the radiologist
should request and review both thin-
section axial and multiplanar reformat-
ted coronal and sagittal-oblique images
that may not be routinely included as
part of a standard CT neck protocol.
This patient’s neck CT images clearly
show both a disparity in the height of
the true vocal cords and a complete an-
terior arytenoid dislocation. Coupled
with the history of multiple intubations,
a diagnosis of traumatic arytenoid dis-
location should be rendered.
Disclosures of Conflicts of Interest: A.G.O. dis-
closed no relevant relationships V.G. disclosed
no relevant relationships. J.K. disclosed no rele-
vant relationships. G.O.A. disclosed no relevant
relationships.
References
1. Paulsen FP, Rudert HH, Tillmann BN. New
insights into the pathomechanism of pos-
tintubation arytenoid subluxation. Anesthesi-
ology 1999;91(3):659–666.
2. Close LG, Merkel M, Watson B, Schaefer SD.
Cricoarytenoid subluxation, computed tomog-
raphy, and electromyography findings. Head
Neck Surg 1987;9(6):341–348.
3. Alexander AE Jr, Lyons GD, Fazekas-May MA,
et al. Utility of helical computed tomography
in the study of arytenoid dislocation and ary-
tenoid subluxation. Ann Otol Rhinol Laryngol
1997;106(12):1020–1023.
4. Rubin AD, Hawkshaw MJ, Moyer CA, Dean
CM, Sataloff RT. Arytenoid cartilage dislo-
cation: a 20-year experience. J Voice 2005;
19(4):687–701.
5. Yamanaka H, Hayashi Y, Watanabe Y,
Uematu H, Mashimo T. Prolonged hoarseness
and arytenoid cartilage dislocation after tracheal
intubation. Br J Anaesth 2009;103(3):452–455.
6. Agha FP. Recurrent laryngeal nerve paralysis:
a laryngographic and computed tomographic
study. Radiology 1983;148(1):149–155.
7. Paquette CM, Manos DC, Psooy BJ. Unilat-
eral vocal cord paralysis: a review of CT find-
610
ings, mediastinal causes, and the course of the
recurrent laryngeal nerves. RadioGraphics
2012;32(3):721–740.
8. Hoffman HT, Brunberg JA, Winter P, Sullivan
MJ, Kileny PR. Arytenoid subluxation: diag-
nosis and treatment. Ann Otol Rhinol Laryngol
1991;100(1):1–9.
9. Gauss A, Treiber HS, Haehnel J, Johannsen
HS. Spontaneous reposition of a dislocated
arytenoid cartilage. Br J Anaesth 1993;70(5):
591–592.
Congratulations to the 137 individuals
and eight resident groups that submit-
ted the most likely diagnosis (arytenoid
dislocation) for Diagnosis Please, Case
223. The names and locations of the in-
dividuals and resident groups, as sub-
mitted, are as follows:
Individual responses
Gholamali Afshang, MD, Tinley Park, Ill
Albert J. Alter, MD, PhD, Blanchardville, Wis
Guis S. Astacio, MD, Rio de Janeiro, Brazil
Dean E. Baird, MD, Potomac, Md
Sasha Bhan, Belleville, Ontario, Canada
Bas Boekestijn, MD, Leiden, Zuid-Holland, the
Netherlands
Manon N. Braat, MD, Utrecht, the Netherlands
Eric L. Bressler, MD, Minnetonka, Minn
Douglas C. Brown, MD, Virginia Beach, Va
Michael P. Buetow, MD, Okemos, Mich
Ian A. Burgess, MD, Manly, New South Wales,
Australia
Andre Carvalho, MD, Porto, Portugal
Tirso Cascajares Murillo, MD, Hermosillo,
Sonora, Mexico
Michael H. Childress, MD, Washington, DC
Haris Chrysikopoulos, Corfu, Greece
Christopher Chu, MBBS, FRANZC, Sydney,
New South Wales, Australia
Silvia Cisneros Carpio, MD, Durango, Vizcaya,
Spain
Mauricio Ramos Corral, MD, El Paso, Tex
Ricardo G. Correia, MD, Porto, Portugal
Marco A. Cura, MD, Dallas, Tex
Carlos Francisco M. da Silva, MD, Setubal,
Estremadura, Portugal
Anil K. Dasyam, MD, Pittsburgh, Pa
Marc G. De Baets, MD, Collina d'Oro, Ticino,
Switzerland
Peter De Baets, MD, Damme, Belgium
Wagner D. de Paula, MD, Brasilia, Brazil
Mustafa K. Demir, MD, Istanbul, Turkey
Thaworn Dendumrongsup, MD, Songkhla,
Thailand
Robert J. Dym, MD, Teaneck, NJ
Seyed A. Emamian, MD, PhD, Bethesda, Md
Francis T. Flaherty, MD, Ridgefield, Conn
Toshihiro Furuta, MD, PhD, Bunkyo-ku, Tokyo,
Japan
radiology.rsna.org
Oppenheimer et al
Kiran Gangadhar I, MD, MBBS, Seattle, Wash
Douglas J. Gardner, MD, Toronto, Ontario,
Canada
Bradley S. Gluck, MD, Southampton, NY
Mark G. Goldshein, MD, Andover, Mass
Alvaro Gomez Naar, MD, Salta Capital, Salta,
Argentina
Wataru Gonoi, MD, PhD, Bunkyo-ku, Tokyo,
Japan
Maria A. Gosein, MBBS, FRCR, Santa Cruz,
Trinidad And Tobago
Michael F. Grantham, MD, Granger, Ind
Pramod K. Gupta, MD, Plano, Tex
Akifumi Hagiwara, MD, Tokyo, Japan
Osamu Hasegawa, MD, Koriyama, Fukushima,
Japan
D. C. Heasley, Jr, MD, Dallas, Tex
Christoph Hefel, Feldkirch, Austria
Yuusuke Hirokawa, MD, Kyoto, Japan
Sodai Hoshiai, MD, Tsukuba, Ibaraki, Japan
Ming Lin Hsieh, MD, Troy, Mich
Alberto C. Iaia, MD, Wilmington, Del
Noriatsu Ichiba, MD, Otsu, Shiga, Japan
Mitsuru Ikeda, MD, Nagoya, Japan
Akitoshi Inoue, MD, Otsu, Shiga, Japan
Richard N. Irion, MD, South Jordan, Utah
Sharada Jayagopal, MD, East Williston, NY
Diana Susana Jimenez Paez I, MD, Mexico
Kouhei Kamiya, MD, Tokyo, Japan
Koki Kato, MD, Utsunomiya, Tochigi, Japan
Takao Kiguchi, MD, Niigata, Japan
Osamu Kizu, MD, Ohtsu, Japan
Mitchell A. Klein, MD, Mequon, Wis
Masamichi Koyama, MD, PhD, Tokyo, Japan
Richard E. Krauthamer, MD, Rolling Hills,
Calif
Mario A. Laguna, MD, Franklin, Wis
David A. Lisle, MBBS, Brisbane, Queensland,
Australia
Rafael Maffei Loureiro, MD, Sao Paulo, Brazil
Naganathan B. Mani, MD, Chesterfield, Mo
Claire McArthur, MBChB, FRCR, Bridge of
Weir, Renfrewshire, United Kingdom
Manabu Minami, MD, PhD, Yokohama, Japan
Kenichi Mizuki, MD, Hamamatsu-shi, Shizuoka-
ken, Japan
Toshio Moritani, MD, PhD, Iowa City, Iowa
Tomonori Murakami, Nagasaki, Japan
Takaki Murata, MD, Sendai, Japan
Kyoko Nagai, MD, Yokohama, Kanagawa,
Japan
Hirotsugu Nakai, MD, Kyoto City, Kyoto, Japan
Tammam N. Nehme, MD, Mattawan, Mich
Hiroshi Nobusawa, MD, PhD, Ota, Tokyo,
Japan
James P. O'Brien, MD, MBA, Charlotte, NC
Roque Oca, MD, Bilbao, Vizcay, Spain
Shoji Okuda, Oita, Japan
Yuya Onodera, MD, Sapporo, Hokkaido, Japan
Ryusuke Ookura, MD, Kobe, Japan
Vishal Panchal, MD, San Francisco, Calif
David M. Panicek, MD, New York, NY
Ioannis E. Papachristos, MD, Agrinio, Greece
Sana Parsian, MD, Seattle, Wash
n Radiology: Volume 277: Number 2—November 2015
DIAGNOSIS PLEASE: Arytenoid Dislocation
Narendrakumar P. Patel, MD, Newburgh, NY
Suresh K. Patel, MD, Chicago, Ill
Aruna R. Patil, MD, FRCR, Bangalore,
Karnataka, India
John M. Plotke, MD, Naperville, Ill
Elias Primetis, MD, Athens, Greece
Deepak Raghavan, MD, Stafford, Va
Daniel C. Rappaport, MD, Toronto, Ontario,
Canada
Marcio Rodrigues, MD, Braga, Portugal
Hugo Rodriguez Requena, MD, Madrid, Spain
Daniel Romeu Vilar, MD, Bertamirans, A
Coruna, Spain
Stefan Roosendaal, MD, PhD, Rotterdam, the
Netherlands
Akihiko Sakata, MD, Kyoto, Japan
Yusuke Sakurai, Nagoya, Aichi, Japan
Kohei Sasaguri, MD, Saga, Japan
Akihiro Sawada, MD, Kohnan, Kochi, Japan
Meir H. Scheinfeld, MD, PhD, Suffern, NY
Miguel A. Schuller Arteaga, MD, Bilbao,
Vizcaya, Spain
Steven M. Schultz, MD, Fort Worth, Tex
Anthony J. Scuderi, MD, Johnstown, Pa
Matthew P. Shapiro, MD, Charlottesville, Va
Hideki Shima, MD, Narita, Chiba, Japan
Taro Shimono, MD, Osaka, Japan
Radiology: Volume 277: Number 2—November 2015
Ichiro Shirouzu, MD, Tokyo, Japan
Paul J. Shogan, MD, Clarksville, Tenn
Ken Simmons, MD, Sydney, New South Wales,
Australia
David F. Sobel, MD, La Jolla, Calif
Luis A. Sonoda, MD, Sao Paulo, Brazil
Luis A. Sosa, MD, Mexico City, Mexico
James D. Sprinkle Jr, MD, Spotsylvania, Va
Hongliang Sun, MD, Beijing, China
Frank R. Tamura, MD, Fresno, Calif
Eliko Tanaka, MD, Yokohama, Japan
Takashi Tanaka, MD, Okayama, Japan
Satoshi Tatsuno, MD, Ichikawa, Chiba, Japan
Shanigarn Thiravit, MD, Muang Nonthaburi,
Thailand
Eugene Tong, MD, Austin, Tex
Meric Tuzun, MD, Ankara, Turkey
Atsushi Uehara, Niigata, Japan
Ricardo L. Videla Sr, MD, Cordoba, Argentina
Ainhoa Viteri, MD, Bilbao, Biscay, Spain
Christopher P. Vittore, MD, Belvidere, Ill
Ivan Vollmer, MD, Barcelona, Spain
Haruo Watanabe, MD, Gifu, Japan
Yusuke Watanabe, MD, Itabashi-ku, Tokyo,
Japan
Yi-Wei Wu, MD, Singapore
Takayuki Yamamoto, MD, Kyoto, Japan
n radiology.rsna.org
Oppenheimer et al
Tatsuya Yamamoto, MD, Yoshida-gun, Fukui,
Japan
Mihoko Yamazaki, MD, Higashimatsuyama,
Japan
Koichiro Yasaka, MD, Tokyo, Japan
Hajime Yokota, MD, Los Angeles, Calif
Satoru Yoshida, MD, PhD, Muroran, Hokkaido,
Japan
Kaneko You, Gifu, Japan
Ahmed Zidan, MD, Barcelona, Spain
Resident group responses
Hospital de Santa Maria Radiology Residents,
Lisbon, Portugal
ICESP Residents, Sao Paulo, Brazil
Mater Dei Hospital Radiology Residents, Malta
Mie University Hospital Radiology Residents,
Tsu, Mie, Japan
Montefiore Medical Center Radiology
Residents, Bronx, NY
Radiology Residents Prince of Songkla
University, Songkhla, Thailand
Tsukuba University Hospital Radiology
Residents, Tsukuba, Ibaraki, Japan
University of Pennsylvania Radiology Residents,
Philadelphia, Pa
611