Correspondence  |   May 2000
Arytenoid Subluxation Caused by Laryngoscopy and Intubation
Author Notes
  • Paul M. Kempen, M.D., Ph.D.
  • Associate Professor
  • Department of Anesthesiology
  • University of Pittsburgh
  • Pittsburgh, Pennsylvania 15218
Article Information
Correspondence   |   May 2000
Arytenoid Subluxation Caused by Laryngoscopy and Intubation
Anesthesiology 5 2000, Vol.92, 1505. doi:
Anesthesiology 5 2000, Vol.92, 1505. doi:
To the Editor:—
I would like to question the conclusion of Paulsen et al.  , that “laryngeal trauma caused by tracheal intubation does not cause subluxation of arytenoid cartilage.”1 Whereas they found the forces from endotracheal tube manipulations and “manual squeezing” of the arytenoid produced no subluxation, it is unclear whether the “manual squeezing” described produced simple compression of the tissues, actual arytenoid displacement, or equalled the forces of laryngoscopy. Their study may exclude forces from singular endotracheal tube placement as culprit in subluxation, although blind intubation with stylets has resulted in clinical subluxation. 2,3 However, laryngoscopy and use of stylets are typically inherent in the intubation process, and significant, if not extreme and especially localized pressure, can be transmitted to delicate structures by the tip of a laryngoscope blade. Indeed, while instructing trainees and at times personally, I have had opportunity to visualize the esophageal opening, after laryngoscope placement has lifted the larynx anteriorly. I have also felt the larynx slip backward off the laryngoscope from this position in a “crunching” manner, while facilitating visualization via  thyroid cartilage pressure/maneuvers. Such placement of the laryngoscope would certainly allow for equal opportunity for right or left arytenoid subluxation to occur, and also under intubating conditions deemed simple.
Finally, while multiple joint fractures and ligament injuries were demonstrated histologically after trauma on multiple fresh postmortem larynxes in Paulsen’s study, the dead tissues provided no opportunity for in vivo  posttraumatic developments, including muscular spasm, bleeding, swelling, or the combination thereof, which may have led to sustained in vivo  subluxation. Finally, their own endoscopic view of a subluxated arytenoid (fig. 1) 1 and the suggested incidence of 1/1000 after direct laryngoscopic intubation, speaks for the existence of this clinical entity under intra vitam forces and conditions. 4,5 
Paulsen FP, Rudert HH, Tillmann BN: New insights into the pathomechanism of postintubation arytenoid subluxation. A nesthesiology 1999; 91:659–66Paulsen, FP Rudert, HH Tillmann, BN
Debo RF, Colonna D, Dewerd G, Gonzalez, C: Cricoarytenoid subluxation: Complication of blind intubation with a lighted stylet. Ear Nose Throat J 1989 68:517–20Debo, RF Colonna, D Dewerd, G Gonzalez, C
Szigeti CL, Baeuerle JJ, Mongan, PD: Arytenoid dislocation with lighted stylet intubation: Case report and retrospective review. Anesth Analg 1994 78:185–6Szigeti, CL Baeuerle, JJ Mongan, PD
Kambic V, Radsel Z: Intubation lesions of the larynx. Br J Anaesth 1987; 50:587–90Kambic, V Radsel, Z
Frink EJ, et al.: Posterior arytenoid dislocation following uneventful endotracheal intubation and anesthesia. A nesthesiology 1989; 70:358–60Frink, EJ