Arytenoid appearance and vertical level difference between the paralyzed and innervated vocal cords

OBJECTIVES/HYPOTHESIS

In unilateral vocal fold paralysis, it has been generally accepted that the paralyzed vocal fold presents at a higher level than a normally innervated vocal fold. In this study, we correlate the appearances of the paralyzed arytenoid and the differences in level between the paralyzed and innervated vocal folds.

STUDY DESIGN

Retrospective review using video-recorded images of larynx.

METHODS

A total of 38 patients were selected for this study who reported symptoms of voice change attributable to a paralyzed vocal fold unilaterally. Video recordings were obtained using the laryngeal telescope. The heights were assessed according to the paralyzed positions, status (inspiration or phonation), and appearances of the paralyzed arytenoid. The appearances of paralyzed arytenoid were further clarified as the portions of the medial surface of the arytenoid that were visualized.

RESULTS

In medial paralysis, the paralyzed vocal fold appeared mainly as being at an equal vertical level or as having no distinct difference from normal vocal fold during phonation. However, a few cases of medial paralysis showed a lower than normal or higher than normal vocal fold during phonation, depending on the appearance of the paralyzed arytenoid. In lateral paralysis, most of the paralyzed vocal folds were not higher than the innervated vocal folds during phonation.

CONCLUSIONS

The heights of paralyzed vocal folds were variable depending on the paralyzed positions, the status of the larynx, and appearances of the paralyzed arytenoid. The fact that the paralyzed vocal fold is at a higher level than the normal vocal fold should be reconsidered.

[The joint capsule of the cricoarytenoid joint: biomechanical and clinical aspects]

BACKGROUND

Impaired movement of the cricoarytenoid joint with hoarseness and immobility of the vocal ligament may occur as a consequence of laryngeal trauma and joint disease. Little is known to date about the cricoarytenoid joint capsule and its role in joint pathology.

METHODS

The present study analyses the structure of the cricoarytenoid joint capsule by means of histological, immunohistochemical, and scanning electron microscopical methods. Investigations are performed on larynges of 17 male and 16 female.

RESULTS

The cricoarytenoid joint was found to be lined by a wide and lax joint capsule consisting of a fibrous and a synovial membrane. The capsule was strengthened posteriorly by the cricoarytenoid ligament. As like the fibrous membrane the cricoarytenoid ligament consisted mainly of collagen types I and III. Moreover the ligament was found to be rich in elastic fibers. Unexpected large and intensively vascularized synovial folds projected into the joint cavity.

CONCLUSION

The capsule of the cricoarytenoid joint can be compared with the joint capsules of the limbs despite its structure and its involvement in joint pathology. Based on the laxity of the joint capsule it was concluded that invasive interventions at the respiratory tract with dislocation of the arytenoid cartilage can lead to incarceration of the synovial folds. After a trauma aero-synovitis or formation of hemarthrosis may occur, with subsequent fixation of the arytenoid in an abnormal position.

Causes of poor performance of horses during training, racing, or showing: 348 cases (1992-1996)

OBJECTIVE

To determine results for horses undergoing a high-speed treadmill examination, including videoendoscopy of the pharynx and larynx before and during exercise, echocardiography before and after exercise, and electrocardiography before, during, and after exercise, because of poor performance.

DESIGN

Retrospective study.

ANIMALS

348 horses.

RESULTS

A definitive diagnosis was obtained for 256 (73.5%) horses. One hundred forty-eight horses had dynamic obstruction of the airway during exercise, 33 had clinically important cardiac arrhythmias alone, 22 had a combination of dynamic airway obstruction and clinically important cardiac arrhythmias, 19 had poor cardiac fractional shortening immediately after exercise, 10 had exertional rhabdomyolyis, 15 had clinically apparent lameness, and 9 had other disorders. Thirty-nine of the horses with dynamic obstruction of the airway during exercise had multiple airway abnormalities. Fifty-three horses also had subclinical myopathy

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest that a complete evaluation, including a high-speed treadmill examination, should be conducted in horses with poor performance, regardless or whether horses do or do not have a history of abnormal respiratory noises and particularly if the horses have grade-II or -III left laryngeal hemiplegia.

New insights into the pathomechanism of postintubation arytenoid subluxation

BACKGROUND

Impaired movement of the cricoarytenoid joint with hoarseness and immobility of the vocal ligament can occur as a consequence of endotracheal intubation. The biomechanics and pathomechanism of cricoarytenoid subluxation have not been demonstrated to date.

METHODS

The present study attempts to simulate the trauma that has been associated with arytenoid cartilage subluxation in intubation trials on 37 unfixed larynges in cadavers from persons aged 25 to 89 years. Larynges were intubated or extubated according to former conceptions of arytenoid subluxation, which assume that the arytenoid tip enters the lumen of the tracheal tube, or that a deflection of the arytenoid occurs during withdrawal of the endotracheal tube with the cuff of the tube only partially deflated. Also, manual attempts were carried out to subluxate the arytenoid cartilage. Subsequently after dissecting the left and right cricoarytenoid joint from each larynx, the morphologic changes induced experimentally were analyzed using gross microscopic and histologic methods.

RESULTS

Within the scope of the experiment, it proved impossible to produce any subluxation of a cricoarytenoid joint. Histologic analysis revealed injuries of synovial folds, joint-surface impressions of the articular cartilage, and fractures in the area of the subchondral bone in some joints.

CONCLUSIONS

Based on the morphologic results, it was concluded that intubation trauma of the cricoarytenoid joint does not cause subluxation per se, but rather that formation of a hemarthros or fractures of the joint bodies lead to fixation of the joint surfaces in an abnormal position. Subsequent ankylosis may occur.

[A multifocal granular-cell tumor of the upper airways]

Granular cell tumor now is considered to be a neoplasm with the same origin as schwannomas and it should be considered in the differential diagnosis of small tumors of the upper airway. These tumors usually appear as isolated lesions. We report the case of a male patient with three simultaneous granular cell tumors located in the anterior pillar of the tonsil, vocal cord and arytenoid. Although seldom malignant, these tumors can be misdiagnosed as squamous-cell carcinomas because they induce pseudoepitheliomatous hyperplasia of the overlying epithelium. They should be excised with broad margins because they tend to infiltrate.

Evidence for laryngeal paralysis in cricoarytenoid joint arthritis

OBJECTIVE/HYPOTHESIS

To demonstrate denervation atrophy of laryngeal muscles in a case of gout involving the cricoarytenoid joint.

METHODS

The posterior cricoarytenoid (PCA) and arytenoideus (A) muscles from a 72-year-old man with extensive gout were compared with those from a normal adult larynx (age and sex unknown) using stereologic techniques for changes in muscle composition and fiber diameter.

RESULTS

The PCA and A muscles in the gout specimen contained changes Indicative of muscle degeneration. In the PCA the volume fraction (VF) of intact muscle was 0.30, of degenerating muscle 0.13, and of fat 0.16. A normal PCA had a VF for intact muscle of 0.64 and 0 for degenerating muscle and fat. Similar changes were seen in the gout A muscle but were not measured. Muscle fiber diameters in the gout PCA (1,024 fibers) showed a significantly higher atrophy and hypertrophy factor than the normal PCA (1,255 fibers). The variability coefficient in the gout PCA (487) was almost double that in the normal PCA (290). Although muscle fiber diameters were not measured in the A muscle in gout, variability in fiber size was seen.

CONCLUSIONS

The pattern and magnitude of muscle fiber degeneration in the PCA and A muscles from a larynx with gout fixation of the cricoarytenoid joint indicate neural degeneration. Since similar changes were not found in the thyroarytenoid (TA) and lateral cricoarytenoid (LCA), the neuropathy is selective for the posterior branch of the recurrent laryngeal nerve. This neuropathy is likely responsible for vocal cord adduction (stridor) and incomplete closure of the posterior commissure (aspiration) associated with acute cricoarytenoid arthritis. In chronic cricoarytenoid joint arthritis, ankylosis of the joint space maintains the adducted cord position.

Airway obstruction due to arytenoid prolapse in a child

In paediatric patients, obstruction of the upper airway is still a common problem during general anaesthesia. This case report documents the susceptibility of arytenoids to prolapse in paediatric patients during halothane anaesthesia. The use of video endoscopy provides an excellent tool for visualizing this type of airway obstruction; and continuous positive airway pressure is an effective treatment for clearing the airway.

Degenerative changes in the human cricoarytenoid joint

OBJECTIVE

Changes in the human voice occur during the natural aging process. Occurrence of compromising alterations in the cricoarytenoid joint has been hypothesized as a possible reason for voice changes seen in advanced age and has been discussed controversially until today.

METHODS

The present study analyzes degenerative changes in 42 cricoarytenoid joints from 21 body donors (13 men and 8 women; age range, 42-98 years) by means of histological, immunohistochemical, and scanning electron microscopic methods.

RESULTS

Many patients older than 40 years show distinctly altered joint surfaces at varying levels of intensity. The articular cartilage surface is fibrillated in some places. Chondrocytes near the joint surface appear as voluminous chondrocyte clusters. The superficial cartilage layer shows a positive reaction to type III and type I collagen antibodies.

CONCLUSIONS

Chondrocyte proliferation next to the joint surface, changed collagen synthesis, and fibrillation of the joint surface indicate degenerative alterations. Such changes are well known in cases of limb diarthroses. The changes may impair gross positional or postural movements of the arytenoid cartilages and reduce the degree and extent of vocal ligament closure. The structural changes may also lead to negative functional consequences during vocal production, such as impaired vocal quality and reduced vocal intensity due to air leakage through incompletely or loosely approximated vocal ligaments.

Stridor in the neonate and infant. Implications for the paediatric anaesthetist. Prospective description of 155 patients with congenital and acquired stridor in early infancy

One hundred-and-fifty-five neonates and infants up to the sixth month of postnatal age were investigated to reveal the cause of clinically relevant stridor. In 100 patients congenital stridor was found, in 55 children the stridor was considered to be acquired. A curled, soft epiglottis, almost synonymously used with the diagnosis of congenital stridor, was found in 7% only, indicating different methods of investigation and different selection of patients compared to previous years. In acquired stridor the majority of infants showed laryngeal and tracheal trauma, mostly due to the use of too large tracheal tubes.

Difficult intubation from gastroesophageal reflux disease in adults

Two cases of difficult intubation are presented. Both cases presented with red swollen arytenoids, swollen false vocal cords, and subglottic stenosis. Tracheal intubation could not be achieved for these reasons. Both patients were placed on gastrointestinal prokinetic drugs and histamine-two blocker, as a diagnosis of gastroesophageal reflux disease (GERD) was made. In one case, follow-up by an otolaryngotic surgeon showed reversal of the above findings. In the other case, one tracheal intubation was achieved eventually. GERD occurs frequently. Clinicians need to maintain a high index of suspicion for GERD-related airway changes so as to avoid potential difficult intubations.

The significance of arytenoid edema following radiotherapy of laryngeal carcinoma with respect to residual and recurrent tumour

We sometimes experience patients with persistent or progressive arytenoid edema, among which residual or recurrent cancer is often accompanied. Because it is difficult to distinguish tumour rest or recurrence from normal tissue sequelae in the early period after irradiation, it is important to know both the contributing factors for arytenoid edema, and the incidence of residual or recurrent tumours in patients with postirradiation laryngeal edema. We therefore reviewed the charts of 67 patients with early laryngeal carcinoma who had received a curative dose of irradiation in the last 5 years. Fourteen patients (20.9%) had moderate or severe laryngeal edema persisting for or developing at more than 3 months after completion of a course of definitive radiotherapy. The incidence was highest in supraglottic T2 disease, followed by glottic T2 tumour. Of the 14 patients with edema, six (42.9%) had persistent or recurrent disease. The primary disease was uncontrolled in 18 patients, 17 of whom received successful salvage surgery. In patients without residual tumours, the edema was usually moderate and resolved within a year, although four patients had chronic edema lasting more than a year after treatment. All four had supraglottic T2 lesions and received 70 Gy of X-ray. We also reviewed, for sake of comparison, the records of 38 patients treated with radiotherapy at doses of more than 40 Gy between 1975 and 1980, when endoscopic microsurgery for laryngeal cancer was introduced as a primary part of treatment. The incidence of persistent or late developed edema over the period, though not significant, was 36.8%: nearly twice that of the last 5 years. Microscopic endolaryngeal surgical procedures seem to have been a causal factor for edema in this period.

Changes in length and spatial orientation of the vocal fold with arytenoid adduction in cadaver larynges

Videoendoscopy suggests that arytenoid adduction (AA) surgery not only medializes the paralyzed vocal fold, but increases the length of its membranous portion so that it more closely resembles the normal side. This could represent either real length change or out-of-plane rotation. Computed tomography scanning was performed on adult male cadaver larynges before and after the AA procedure to measure changes in length and spatial orientation of the vocal fold. Three-dimensional coordinates of radiopaque markers on the anterior commissure, posterior glottic midline, and vocal processes were determined. The distance between the vocal processes was 3.9 mm before, and 0.8 mm after AA. The mean vocal fold length was 12.4 mm before, and 13.4 mm after AA (p = .14). The vocal process moved consistently caudally, an average of 3.5 mm (p = .02). The data suggest that clinically apparent vocal fold length changes with AA could be an illusion due to vertical displacement of the vocal process, and not actual lengthening.

[Chondrosarcoma of the larynx]

BACKGROUND

Manifestation of chondrosarcoma (CS) in the head and neck region is rare but it is the most frequently encountered non-epithelial malignancy of the larynx. Since this tumor entity is frequently neglected, its characteristics including differential diagnosis and therapy will be discussed in the following.

PATIENTS

From 1975 to 1995, five cases with CS were diagnosed and treated in the Department of Otorhinolaryngology, Head and Neck Surgery, University of Kiel.

RESULTS

The medical history of this five patients (one woman, four men, average age: 71 years) varied from 9 months to 10 years. Three patients had a fixation of the vocal cord; one patient had obviously reduced movement of the vocal cord. Two cases revealed a moderate and three cases a high differentiation in the histological examination. Initially one case was diagnosed as a chondroma. The origin of tumor growth was the cricoid cartilage in four patients and the cartilage of the arytenoid in one patient. Surgical treatment was either by partial or complete laryngectomy in two cases each. One patient refused any therapy. Two patients including the latter died of tumor related causes.

CONCLUSIONS

Laryngeal CS grow slowly. Diagnosis is frequently made late in the course of disease. Obtaining of tissue for histological examination and diagnostic delimitation towards a chondroma can be difficult. Therapy depends on the degree of histological differentiation with radical excision of low or moderately differentiated CS and function preserving surgery in case of high differentiation.

Unilateral arytenoid lateralisation and extraluminal polypropylene ring prostheses for correction of tracheal collapse in the dog

The surgical repair of tracheal collapse in 25 dogs is described. The initial presenting signs included coughing, dyspnoea, gagging, retching, exercise intolerance, cyanosis and collapse. Diagnosis was based upon the clinical signs, plain radiography and tracheal endoscopy. The collapse was corrected by the application of a number of extraluminal polypropylene prosthetic rings applied to the affected trachea. Additionally, a left arytenoid lateralisation was also performed. The perioperative complication rate was approximately 4 per cent, while the success rate was 75 per cent. The technique reduces the likelihood of catastrophic postoperative complications associated with iatrogenic laryngeal paralysis which is a possible complication of placement of extraluminal tracheal support devices.

Orotracheal intubation through the laryngeal mask airway in paediatric patients with Treacher-Collins syndrome

The laryngeal mask airway (LMA) is useful as an airway intubator (conduit) for an intubating tracheal bougie or fibreoptic bronchoscope, over which a tracheal tube is passed. However, in our paediatric patients with Treacher-Collins syndrome, only the latter technique was successful. This was attributed to the fact that a posteriorly protruded tongue displaced the LMA, made the glottis move considerably anterior and interfered with the attempts to enter the trachea with a bougie. Downward displacement of the epiglottis, which can sometimes impair the intubation technique through the LMA, was not observed in our patients. Partial obstruction of a tracheal tube within the LMA occurred in one of the patients.

Surgical repair of iatrogenic soft palate defects in two horses

A 4-year-old Thoroughbred filly was referred for evaluation of a soft palate defect that had been created several weeks earlier during surgical correction of epiglottic entrapment, performed transorally. Surgical correction of the defect was performed via mandibular symphysiotomy. At 85 days after repair, the horse raced successfully. A 2-year-old Thoroughbred filly was admitted for evaluation and treatment of epiglottic entrapment. The soft palate was lacerated during transnasal division of the entrapping membrane. A 2-cm full-thickness soft palate laceration was repaired transorally.