Arytenoid Dislocation
Cedric A. Quick, MD, Gerald E. Merwin, MD
\s=b\ The reported incidence of arytenoid
cartilage dislocation is low. This may be
due to the wide range and orientation of
motion allowed by the cricoarytenoid ar-
ticulation and the laxity of its joint
capsule. In two previously reported
instances of arytenoid dislocation, the
authors have suggested that endotracheal
intubation is generally not sufficient to
cause dislocation of an arytenoid carti-
lage, but that, in their cases, a predis-
posing factor had set the occasion for
dislocation.
In this communication, three cases of
arytenoid cartilage dislocation, which
each followed a single instance of endo-
tracheal intubation are presented. In all
three cases, painful swallowing was the
main presenting symptom. Clinical fea-
tures that differentiate arytenoid cartilage
dislocation from vocal cord paresis are
summarized. Early reduction of the dislo-
cation, while the patient is under local
anesthesia, is recommended, and the
techniques are described in detail.
(Arch Otolaryngol 104:267-270, 1978)
Endotracheal
that
risk of
intubation carries
laryngeal complications
a
include ulcération, granuloma
formation, glottic and subglottic ede¬
ma, mucosal laceration and abrasion,
and, ultimately, stricture.1 Dislocation
of an arytenoid cartilage has gener-
Accepted for publication June 3, 1977.
From the Department of Otolaryngology,
University of Minnesota Hospital, Minneapolis.
Reprint requests to Box 406, 420 Delaware St
SE, Minneapolis, MN 55455 (Dr Quick).
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ally not been included in the list of
complications of endotracheal intuba¬
tion since the reported incidence is
rare. Two cases have been reported in
the literature; both were found to
follow endotracheal intubation. In one
instance, an acromegalie endocrine
disorder that involved degenerative
changes of the cricoarytenoid joints,
with loosening of their ligaments, was
believed to be a predisposing factor.2
In the other reported case, dislocation
was thought to be due to prolonged
intubation and movement of the endo¬
tracheal tube related to suctioning
and positioning for postural drain¬
age.1 We report three cases of aryte¬
noid cartilage dislocation, which each
followed a single instance of endotra¬
cheal intubation in three diabetic
patients who were hospitalized for
evaluation for renal transplantation.
In each case, the presenting complaint
was characteristic odynophagia; spe¬
cifically, there was localized pain in
the throat on swallowing both liquids
and solids.
REPORT OF CASES
Case l.-A 31-year-old man was hospital¬
ized for evaluation prior to renal transplan¬
tation. The patient had diabetes mellitus at
the age of 12 years and had been depen¬
dent on insulin since that time. One year
prior to this admission, a presumptive
diagnosis of Kimmelstiel-Wilson's disease
was made. On admission, the patient had
massive edema and a pericardial friction
rub on auscultation of the heart. Initial
laboratory studies disclosed the following
values:hemoglobin, 6.3 gm/100 ml; BUN,
120 mg/100 ml; and serum creatine, 14.6
mg/100 ml. A chest roentgenogram showed
massive enlargement of the heart, which
was thought to be consistent with pericar¬
dial effusion. There was no history of
previous endotracheal intubation or
surgery, and the patient gave no history of
problems referable to the larynx. There
was no history of bone or joint disease.
On admission, the patient was immedi¬
ately dialyzed, with loss of the edema, but
there was persistence of the pericardial
rub. Pericardiocentesis was attempted, but
no fluid was obtained. Following this
attempt, the patient's systolic blood pres¬
sure fell to 90 mm Hg, and he was taken to
the operating room on an emergency basis
for the creation of a pericardial window to
relieve the cardiac tamponade. Nasotra-
cheal intubation was accomplished in one
attempt without difficulty. A nasogastric
tube was also passed without difficulty at
the time of intubation. The nasotracheal
tube was removed after a total of three
hours. Within four hours, the patient
complained of a "sore throat." During the
ensuing six days, the patient continued to
complain of an increasingly severe sore
throat and pain with swallowing, and, on at
least one occasion, he refused to eat
because of the pain. The patient was
unable to talk at one point because of the
throat pain, and his voice was slightly
husky. On otolaryngologic examination,
eight days postoperatively, the patient had
edema and poor motion of the left vocal
cord with marked swelling in the region of
the left arytenoid cartilage. With no
improvement on voice rest, the patient was
scheduled for direct laryngoscopy under
general anesthesia on the 13th postopera¬
tive day. A left arytenoid dislocation was
 detected and was reduced with gentle an-
teromedial pressure applied to the postero-
lateral aspect of the left arytenoid. Follow¬
ing this maneuver, the arytenoid cartilages
were found to be symmetric in position,
and passive mobility of the cords was
within normal limits.
The patient had an uneventful postoper¬
ative course with marked symptomatic
improvement in throat pain and complete
resolution of the odynophagia. The voice
also improved. Within two days of reduc¬
tion, the patient was asymptomatic, and
indirect laryngoscopy revealed essentially
normal cord motion with minimal edema of
the left arytenoid. The patient was
discharged one day following the reduction
of the arytenoid cartilage dislocation, and,
to date, there have been no further laryn¬
geal symptoms.
Case 2.—A 31-year-old woman with a 24-
year history of juvenile onset insulin-
dependent diabetes mellitus was admitted
for complaints of dizziness and nausea for
2lk weeks. The patient had already been
evaluated for renal transplantation and
was awaiting an appropriate donor. This
patient had a history of endotracheal intu¬
bation on three occasions, the last of which
occurred four years prior to this admission.
At the time of admission, results of phys¬
ical examination notably showed retinal
changes consistent with diabetes and
moderate pitting edema of the extremities.
Notable laboratory findings included a
BUN level of 58 mg/100 ml and a serum
creatine level of 6.8 mg/100 ml. In prepara¬
tion for renal transplantation, the patient
underwent bilateral nephrectomy and va-
gotomy with pyloroplasty. The anesthetic
record from that operation indicates that
nasotracheal intubation was very difficult,
and three attempts were made. The same
nasotracheal tube was then employed for
oral intubation and was successful on the
second try. The operation was without
substantial complications, and the patient
was extubated 4Vè hours after intubation.
A nasogastric tube was placed intraopera-
tively. On the first postoperative day, the
patient complained of a severe sore throat.
The sore throat and pain on swallowing
continued through the seventh postopera¬
tive day, at which time, otolaryngologic
consultation was obtained.
A diagnosis of left arytenoid cartilage
dislocation was made, and the patient was
scheduled for direct laryngoscopy under
local anesthesia. On the 12th postoperative
day, direct laryngoscopy revealed that the
left vocal cord was abducted to the para-
median position, with marked swelling
over the region of the left arytenoid carti¬
lage. The arytenoid cartilage was displaced
posteriorly and laterally. With the use of a
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laryngeal spatula, the cartilage was re¬
duced to its normal position by pressure
applied in an anteromedial direction. Near
normal mobility of the cord was obtained
during voluntary phonation. The patient
noted dramatic improvement of throat
pain by the day following the laryngeal
reduction. Within six days, the patient was
again taken to the operating room for
renal transplantation, and although intu¬
bation was difficult and required two
attempts, arytenoid cartilage dislocation
did not result. The patient was eventually
discharged with no symptoms of hoarse¬
ness or odynophagia. Results of indirect
laryngoscopy prior to discharge showed an
essentially normal functioning larynx with
minimal swelling over the region of the left
arytenoid cartilage.
Case 3.—A 30-year-old woman was
admitted to the hospital for a renal allo-
graft from a living, related donor. Her
condition had been diagnosed as diabetes
mellitus for 29 years. The patient had
required weekly, home dialysis for chronic
renal failure secondary to her diabetes
mellitus. At the time of admission, there
were no complaints relating to voice, upper
airway, or deglutition. There was no
history of any bone or joint disorder.
Following an initial preoperative labora¬
tory and medical evaluation, the patient
was taken to the operating room for trans¬
plantation of a kidney donated by her
father. The patient was intubated without
apparent difficulty in one attempt with the
use of a No. 7.5 latex, cuffed, endotracheal
tube. Following this, multiple attempts at
passing a nasogastric tube were unsuccess¬
ful, and, eventually, McGill's forceps were
employed to successfully accomplish the
task. The operative procedure was com¬
pleted without notable complications in
four hours. The patient was extubated
without difficulty four hours and 15
minutes after initial intubation.
On the first postoperative day, the
patient had a "hoarse" voice but com¬
plained particularly of throat pain that she
related to the presence of the nasogastric
tube. The nasogastric tube was removed on
the second postoperative day. When persis¬
tent hoarseness and continued throat pain
was evident, otolaryngologic consultation
was obtained on the eighth postoperative
day.
Indirect laryngoscopy, at the time of
referral, showed edema over the left aryte¬
noid cartilage with poor motion of the
abducted vocal cord on that side. While
arytenoid cartilage dislocation was diag¬
nosed, the possibility of erosion of the
posterior larynx by the nasogastric tube
was considered, and initial conservative
management with mechanical soft diet and
voice rest was undertaken. On the 13th
postoperative day, indirect laryngoscopy
showed no improvement in the left vocal
cord motion, and the patient was scheduled
for direct laryngoscopy under local anes¬
thesia.
At operation, the patient was found to
have a posterolaterally dislocated left
arytenoid cartilage and a linear superficial
ulcération of the postcricoid region. A
laryngeal spatula was employed to apply
pressure to the posterior surface of the
arytenoid to gently reduce it to its correct
anatomic position. At that point, the left
vocal cord functioned normally during
phonation and inspiration. Postoperative¬
ly, the patient had immediate, subjective
improvement in throat pain, and her voice
improved. On the sixth day following
reduction of the dislocated arytenoid carti¬
lage, results of indirect laryngoscopy
confirmed normal motion of both vocal
cords, but edema over the left arytenoid
cartilage persisted. The patient was dis¬
charged from the hospital 20 days after the
original renal transplant operation with a
normal voice and only mild discomfort on
swallowing. She was advised to obtain
follow-up examination by an otolaryngol-
ogist in her home state.
The patient was readmitted three days,
postdischarge, with increasing odynopha-
gia and hoarseness of voice. She was taken
to the operative suite for direct laryngos¬
copy at which time vocal cord function
appeared essentially normal, with evidence
of marked swelling and inflammation of
the mucosa of the medial wall of the left
piriform sinus and posterolateral aspect of
the arytenoid cartilage and of the postcri¬
coid region. An area of ulcerated mucosa
that measured 2 0.5 cm was noted over
the posterolateral aspect of the left aryte¬
noid. A biopsy specimen was obtained that
showed an acute inflammatory reaction.
Treatment included voice rest and soft diet
in addition to medication for early and
mild rejection. This patient was discharged
on the sixth postoperative day with an
essentially normal voice and no complaints
of odynophagia. Subsequently, the patient
died due to renal transplant rejection and
uncontrollable systemic viral infection. At
autopsy, the arytenoids were in good posi¬
tion, but an ulcération of the postcricoid
region was still evident.
COMMENT
In each of two cases of dislocation of
an arytenoid cartilage, which have
been reported in the literature, the
patient presented with hoarseness
following endotracheal intubation. In
the case reported by Schultz-Coulton,2
Fig 1 .—Artist's impression of dislocation of
left arytenoid that is lying posterolateral to
articular facet of cricoid.
the patient had a history of removal of
a tumor of the pituitary gland with an
acromegalie disturbance of growth.
He postulated that this endocrine
abnormality may have caused degen¬
erative changes at the cricoarytenoid
joints and produced a loosening of the
ligaments, which predisposed the ary¬
tenoid to dislocation by the minimal
direct trauma of intubation. The case
reported by Prasertwanitch and col¬
leagues,3 involved a dislocation of the
left arytenoid in a patient who had
required a prolonged period of endo¬
tracheal intubation of 11 days, with
the reported dislocation occurring
with reintubation for pulmonary toi¬
let 23 days later. They thought that
the period of prolonged intubation
and repeated manipulations of the
second endotracheal tube were re¬
sponsible for the dislocation. The
authors in both instances conjecture
that dislocation of an arytenoid carti¬
lage during endotracheal intubation
should not occur without underlying
abnormality of the joint. Despite the
fact that all of our cases were candi¬
dates for renal transplantation with
chronic renal failure, we could find no
evidence to suggest that their sys¬
temic disease was a predisposition to
subsequent arytenoid cartilage dislo¬
cation.
The incidence of arytenoid cartilage
dislocation following endotracheal in¬
tubation is very low as evidenced by
the paucity of published reports of
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Fig 2.—Left, Artist's impression of traumatized larynx shows arytenoid and abduction and
bowing of left vocal cord. Right, Normal larynx.
this complication. Probably this is due
to the wide range of passive motion
allowed by the cricoarytenoid joint.
The arytenoid facet of the synovial
joint is known to have a lax capsule
that allows a wide range of motion,4
including rotation, anteroposterior
rocking, and coronal gliding move¬
ments. Posteriorly, the articulation is
protected by a prominent posterior
cricoarytenoid ligamento Interesting¬
ly, in all cases of arytenoid dislocation
reported here and elsewhere, the left
arytenoid was dislocated. During en¬
dotracheal intubation, the laryngo¬
scope is usually held in the left hand
and inserted in such a way as to
produce a vertical displacement of the
suprahyoid structures, as well as the
larynx, which exposes the open glottis
to insertion of the tube from the right.
In addition, stretching of the aryepi-
glottic folds will produce an upward
and outward pull on the arytenoid
cartilages that are then drawn lateral¬
ly.11 In this position, the left arytenoid
cartilage is particularly subject to
dislocation. In all likelihood, it is the
convex curvature of the distal third of
the endotracheal tube, which exerts
the major force on the left arytenoid
cartilage, when intubating from the
right. This displaces the cartilage
posterolaterally. The articulating sur¬
face of the arytenoid will then lie on
the sloping shoulder of the cricoid
cartilage posterolateral to the artic¬
ular facet of the cricoid (Fig 1).
In our cases, the patients had no
history of bone or joint abnormalities
or complaints referable to the larynx
or pharynx prior to intubation. The
endotracheal tube was placed without
apparent difficulty in one attempt in
two cases and with marked difficulty
in one case. A complicating factor in
case 3 was the difficulty in passing a
nasogastric tube, which eventually
required the use of McGill's forceps.
The presence of nasogastric tubes
played no part in the production of
dislocation but did confuse the clinical
picture because pharyngeal discom¬
fort is produced by these tubes. Strohl
et al7 have previously reported ulcéra¬
tion and stenosis as complications in
the use of indwelling nasogastric
tubes.
Blanc and Tramblay" noted that the
incidence of sore throat following
endotracheal intubation is very high
but is fleeting and should resolve in 24
to 48 hours following extubation. They
also noted that dysphonia or aphonia
may occur in as many as 50% of
patients who undergo intubation but
should disappear in two to three days."
The complaint of hoarseness following
intubation was present in our pa¬
tients, but odynophagia was the
pathognomonic symptom in our series
of patients. This was not emphasized
in the two previous reports.
In all of our cases, the arytenoid
cartilage was dislocated posterolater-
ally, with the mobility of the vocal
 cord of the affected side impaired and
the cord resting in a position of abduc¬
tion (Fig 2). Results of indirect laryn¬
goscopy confirmed poor mobility of
the left vocal cord in all instances.
Recurrent laryngeal nerve trauma,
due to intubation or following thoracic
and neck operations, as well as chem¬
ical and pressure neurapraxia second¬
ary to intubation, are well known.9
Differentiating vocal cord paresis or
paralysis from arytenoid cartilage
dislocation is based primarily on the
complaint of odynophagia, as well as
hoarseness and the appearance on
indirect laryngoscopy of swelling or
edema in the region of the arytenoid
cartilage. It is essential that this
differentiation be made, since the
management of the two conditions is
vastly different. Reduction of a dislo¬
cated cartilage should be carried out
without delay.
Arytenoid cartilage dislocation is
not a benign complication of endotra¬
cheal intubation, particularly since the
patient is in the immediate postopera¬
tive period. With dislocation, the func¬
tion of the larynx as a sphincter of the
trachéal airway is impaired. This may
lead to pulmonary complications at¬
tendant on aspiration and loss of
effective cough. Pain with deglutition
and resultant decreased oral intake
are also important complicating fac¬
tors that could delay postoperative
recovery. In case 3, the ulcération of
the posterolateral aspect of the larynx
occurred secondary to the pressure of
the nasogastric tube against the
posterior aspect of the cricoid and was
exaggerated by the dislocated aryte¬
noid that projected into the anterolat-
eral laryngopharyngeal lumen. It is
suggested that correction of the dislo¬
cation should be undertaken as soon as
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the patient's general condition per¬
mits, so that further complications
may be avoided.
In our cases, we were able to obtain
satisfactory reduction by using gentle
pressure applied with a laryngeal
spatula to the posterolateral aspect of
the dislocated arytenoid and reducing
it in an anteromedial direction. This
was accomplished without difficulty
through a laryngoscope, with the
patient under general anesthesia in
one case and local anesthesia in the
other two cases. The following points
should be considered in choosing local
anesthesia when this procedure is
undertaken: (1) recent exposure to
general anesthesia and surgery; (2)
high probability of pulmonary compli¬
cations that may have arisen due to
aspiration pneumonia or atelectasis;
and, above all, (3) advantage of imme¬
diate visualization of the effects of
manipulations on the sphincter action
of the larynx and mobility of the cords
in phonation with an awake, coopera¬
tive patient. Without treatment, the
cricoarytenoid joint may become fi-
brosed and the cord fixed in an unfa¬
vorable position. Accepted treatment
of the abducted cord has included
injection of material into the abducted
vocal cord and surgical fixation of the
vocal cord in the paramedian posi¬
tion.10 Both of these techniques pro¬
duce a permanent change in laryngeal
function, which we consider nonphys-
iologic and less than ideal for aryte¬
noid cartilage dislocation.
In our series of three cases of left
arytenoid cartilage dislocation, each
case followed a single instance of
endotracheal intubation, and all pa¬
tient^ had characteristic odynophagia
and mild hoarseness. Closed reduction
of the dislocation was accomplished
without complications by manipula¬
tion of the arytenoid cartilage at
direct laryngoscopy while the patient
was under local or general anesthesia.
Once a diagnosis of arytenoid carti¬
lage dislocation has been established,
we recommend closed reduction, with
the patient under local anesthesia, at
the earliest time permitted by the
patient's general condition. Early re¬
duction may avoid possible complica¬
tions because of the loss of normal
sphincteric function of the larynx, as
well as improve the patient's postop¬
erative comfort and oral intake of
nourishment.
This study was supported in part by Renal
Transplant grant 2PO2-AM-13083-05 from the
National Institutes of Health.
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