Free
Correspondence  |   May 2000
Arytenoid Subluxation Caused by Laryngoscopy and Intubation
Author Notes
  • Department od Otorhinolaryngology, Head and Neck
  • Department of Anatomy
  • fpaulsen@anat.uni-kiel.de
  • Department of Otorhinolaryngology, Head and Neck Surgery
  • Department of Anatomy
  • Christian Albrecht Univerity of Kiel
  • 24098 Kiel, Germany
Article Information
Correspondence
Correspondence   |   May 2000
Arytenoid Subluxation Caused by Laryngoscopy and Intubation
Anesthesiology 5 2000, Vol.92, 1505. doi:
Anesthesiology 5 2000, Vol.92, 1505. doi:
In Reply:—
The background of our study was to show a new understanding of the pathomechanism leading to arytenoid dislocation. Based on our experiments we concluded that intubation trauma of the cricoarytenoid joint does not cause subluxation per se  , but rather that formation of a hemarthros or serosynovitis lead to fixation of the joint surfaces in an abnormal position. 1 
We agree that our study may exclude forces from singular endotracheal tube placement as the culprit in subluxation and we also agree that in a living patient the larynx undergoes movements during insertion of a laryngoscope which we were unable to simulate in our experiments. But this is not the point. Analyzing the anatomy of the human cricoarytenoid joint in several studies 2–4 we were able to show that the joint can be compared with diarthrodial joints at the limbs and that the joint capsule consists of unexpected large and intensively vascularized synovial folds projecting into the joint cavity. Laxity of the joint capsule and the large synovial folds are predisposing factors for intubation trauma of the cricoarytenoid joint, potentially leading to hemarthrosis and finally to cricoarytenoid joint dysfunction. 5 
Naturally, a postmortem study is not able to show what happens in a living patient but our experiments give us hints about the probable pathomechanism of arytenoid dislocation. Our concept with the occurrence of joint cavity hemorrhage or serosynovitis and after muscle contractures is able to explain all contradictions in the literature regarding arytenoid subluxation.
How would Professor Kempen explain cases of arytenoid dysfunction that occurred some days after easy intubation. In these cases phonation was normal directly after extubation and arytenoid dislocation primary occurred after some days. 6,7 How will he explain the experience of laryngologists 8 treating dislocated arytenoids who report that the arytenoid was movable when touching it with a spatula under light pressure but moved back in its starting position after release.
We do not contradict Professor Kempen that arytenoid subluxation may exist under intra vitam forces and conditions. But our experiments speak against this concept and allow the conclusion that arytenoid dislocation is based on the pathomechanism mentioned above 1 and therefore we should speak of “postintubation cricoarytenoid joint dysfunction.”
References
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
Paulsen F, Tillmann B: Degenerative changes in the human cricoarytenoid joint. Arch Otolarangol Head Neck Surg 1998; 124:903–6Paulsen, F Tillmann, B
Paulsen F, Tillmann B: Composition of extracellular matrix in human cricoarytenoid joint articular cartilage. Arch Histol Cytol 1999; 62:149–63Paulsen, F Tillmann, B
Paulsen F, Tillmann B: Osteoarthritis in cricoarytenoid joint. Osteoarthritis Cart 1999; 7:505–14Paulsen, F Tillmann, B
Paulsen F, Jungmann K, Tillmann B: The cricoarytenoid joint capsule and its relevance to endotracheal intubation. Anesth Analg 2000; 90:180–5Paulsen, F Jungmann, K Tillmann, B
Frink EJ, Pattison BD: Posterior arytenoid dislocation following uneventful endotracheal intubation and anesthesia. A nesthesiology 1989; 70:358–60Frink, EJ Pattison, BD
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
Pröschel U, Eysholdt U: Short-term changes of larynx and voice after intubation. Laryngo Rhino Otol 1993; 72:93–7Pröschel, U Eysholdt, U