Arytenoid Fixation
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Function of the cricoarytenoid (CA) joint depends on the complex interaction of several cartilaginous, muscular, and ligamentous structures. Any process affecting the normal neuromuscular inputs, supporting connective structures, or joint space may result in altered function and immobility. As a broad entity, CA (vocal-fold) immobility has dissonant etiologies, including CNS pathology, neuromuscular disease, malignancy, local trauma, and psychogenic causes. Among these, cricoarytenoid (CA) joint fixation is a recognized, albeit relatively uncommon, entity. The cricoarytenoid (CA) immobility and cricoarytenoid (CA) fixation are often used inexactly and interchangeably; such use blurs their distinctions. See the image below.
This discussion is limited to cricoarytenoid (CA) fixation resulting from altered function of the cricoarytenoid (CA) joint, which must be distinguished from other causes of vocal fold immobility to allow for timely diagnosis and effective treatment.
Cricoarytenoid (CA) fixation, in contrast to other forms of vocal fold immobility, is a direct result of restricted joint motion without regard for the neuromuscular integrity of the larynx. This discussion is limited to processes affecting the joint space and resulting in loss of mobility.
After cricoarytenoid (CA) joint fixation is diagnosed, determining the etiology is of paramount importance for therapeutic decision making. Following are the 3 general categories of causes of cricoarytenoid (CA) fixation:
Arthritides, primarily rheumatoid arthritis, account for many clinical diagnoses of cricoarytenoid (CA) fixation. Other known causes of joint arthritis include gout, Reiter syndrome, and ankylosing spondylitis. Anecdotal evidence suggests a mumps-associated laryngeal arthritis. This category also may include fixation secondary to radiation therapy.
Direct bacterial involvement of the joint space with infectious agents, such as streptococcal species, with resultant ankylosis is recognized.
Direct or external laryngeal trauma may result in joint injury. Mechanisms of intubation-related joint injury are suggested. These include posterior or anterior arytenoid displacement secondary to the distal tip of the endotracheal tube engaging the arytenoid during intubation. Some have noted the possibility of posterior dislocation resulting from extubation with a partially inflated endotracheal tube cuff. Another potential cause is arytenoid chondritis secondary to prolonged endotracheal intubation, which ultimately results in fibrosis. Zhong et al reported on a patient who experienced arytenoid dislocation following anterior cervical corpectomy and fusion. [1]
Previous authors have speculated that long-term paralysis with resultant cricoarytenoid (CA) immobility may lead to joint fixation, as observed in other diarthrodial joints in the body. However, histologic studies have failed to demonstrate this association.
A study by Tanaka et al reported that in transoral videolaryngoscopic surgery for hypopharyngeal and supraglottic cancer, resection of the medial and lateral pyriform sinus can lead to postoperative voice impairment; consequent to the operation, scar contracture around the cricoarytenoid joint can fix the arytenoid cartilage toward the lateral position and patients can experience insufficient glottic closure. [2]
Laryngeal manifestations of arthritis, specifically rheumatoid arthritis, have been recognized for more than a century. The pathologic features of laryngeal rheumatoid arthritis are identical to those of other involved joints in the body.
The soft tissues surrounding the joint may have typical rheumatoid stigmata, including rheumatoid nodules.
The typical history of a patient with cricoarytenoid (CA) fixation is identical to that for patients with other forms of joint immobility. Depending on the position of the immobilized vocal fold and the unilateral or bilateral nature of the dysfunction, symptoms may range from mild dysphonia to frank aspiration and even acute airway compromise. The diagnosis is contingent on the exclusion of the many other causes of immobility, and appropriate confirmatory examinations and studies are necessary.
In patients with an appropriate clinical history for cricoarytenoid (CA) fixation, physical examination should include complete head-and-neck examination, indirect laryngoscopy, and at least a cursory musculoskeletal survey. Operative direct laryngoscopy is the standard for clinical evaluation and definitive diagnosis of cricoarytenoid (CA) joint fixation (see Diagnostic Procedures).
In laryngeal rheumatoid arthritis, indirect laryngoscopy in the acute phase reveals erythema and swelling of the arytenoid mucosa. On clinical evaluation, 17-33% of patients with rheumatoid arthritis have identifiable laryngeal disease. Manipulation of the larynx is painful if the patient is awake. In the chronic stages of the disease, pain is unusual, and mucosal changes are somewhat less pronounced than before because they appear rough and thickened. Lateral bowing of the cords in inspiration, an uncommon finding in laryngeal paralysis, may be observed in both acute and chronic phases if both joints are involved.
The cricoarytenoid (CA) joint is a diarthrodial joint that includes a synovial lining and a fluid-filled bursa. The joint capsule and the ligamentous attachments, including the cricoarytenoid (CA) ligament, vocal ligament, and false vocal folds, limit normal motion of the joint. Motion of the arytenoid is characterized primarily as the arytenoid rocking over the long axis of the cricoid facet and gliding parallel to the long axis, as well as a small component of axial movement pivoting on the cricoarytenoid (CA) ligament. Three-dimensional analysis of cricoarytenoid mobility has demonstrated that the arytenoid has rotated superiorly, posteriorly, and laterally in full abduction. [3]
Zhong Z, Hu J, Wu N, et al. Prolonged Hoarseness Caused by Arytenoid Dislocation After Anterior Cervical Corpectomy and Fusion. Spine (Phila Pa 1976). 2016 Feb. 41 (3):E174-7. [Medline].
Tanaka S, Tomifuji M, Araki K, et al. Vocal function after transoral videolaryngoscopic surgery (TOVS) for hypopharyngeal and supraglottic cancer. Acta Otolaryngol. 2017 Apr. 137 (4):403-10. [Medline].
Wang R. Three-dimensional analysis of cricoarytenoid joint motion. Laryngoscope. 1998. 4 Pt 2 supp 86:1-17.
Young VN, Rosen CA. Arytenoid and posterior vocal fold surgery for bilateral vocal fold immobility. Curr Opin Otolaryngol Head Neck Surg. 2011 Oct 7. [Medline].
Schaefer SD, Close LG, Brown OE. Mobilization of the fixated arytenoid in the stenotic posterior laryngeal commissure. Laryngoscope. 1986 Jun. 96(6):656-9. [Medline].
Lee SW, Park KN, Welham NV. Clinical features and surgical outcomes following closed reduction of arytenoid dislocation. JAMA Otolaryngol Head Neck Surg. 2014 Nov 1. 140(11):1045-50. [Medline]. [Full Text].
Cao L, Wu X, Mao W, Hayes C, Wei C. Closed reduction for arytenoid dislocation under local anesthesia. Acta Otolaryngol. 2016 Mar 22. 1-7. [Medline].
Su WF, Lan MC, Liu SC. Suture lateralisation plus arytenoid cartilage release for treating bilateral vocal fold immobility with mechanical fixation. Acta Otorhinolaryngol Ital. 2018 Jan 31. [Medline].
Ejnell H, Bake B, Mansson I, et al. New mobilization and laterofixation procedure for cricoarytenoid joint ankylosis in rheumatoid arthritis. Ann Otol Rhinol Laryngol. 1985 Sep-Oct. 94(5 Pt 1):442-4. [Medline].
Cummings CW, Redd EE, Westra WH, Flint PW. Minimally invasive device to effect vocal fold lateralization. Ann Otol Rhinol Laryngol. 1999 Sep. 108(9):833-6. [Medline].
Rovo L, Venczel K, Torkos A, Majoros V, Sztano B, Jori J. Endoscopic arytenoid lateropexy for isolated posterior glottic stenosis. Laryngoscope. 2008 Sep. 118(9):1550-5. [Medline].
Kashima HK. Bilateral vocal fold motion impairment: pathophysiology and management by transverse cordotomy. Ann Otol Rhinol Laryngol. 1991 Sep. 100(9 Pt 1):717-21. [Medline].
Ossoff RH, Sisson GA, Duncavage JA, Moselle HI, Andrews PE, McMillan WG. Endoscopic laser arytenoidectomy for the treatment of bilateral vocal cord paralysis. Laryngoscope. 1984 Oct. 94(10):1293-7. [Medline].
Paul C Bryson, MD Associate Staff, Cleveland Clinic Foundation Voice Center, Head and Neck Institute
Paul C Bryson, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, Phi Beta Kappa, Triological Society
Disclosure: Nothing to disclose.
Robert A Buckmire, MD Associate Professor,Department of Otolaryngology-Head and Neck Surgery, University of North Carolina; Chief, Divison of Voice and Swallowing Disorders, Director, University of North Carolina Voice Center
Robert A Buckmire, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, National Medical Association
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Stephen G Batuello, MD Consulting Staff, Colorado ENT Specialists
Stephen G Batuello, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Association for Physician Leadership, American Medical Association, Colorado Medical Society
Disclosure: Nothing to disclose.
Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;Cliexa;Preacute Population Health Management;The Physicians Edge<br/>Received income in an amount equal to or greater than $250 from: The Physicians Edge, Cliexa<br/> Received stock from RxRevu; Received ownership interest from Cerescan for consulting; for: Rxblockchain;Bridge Health.
John Schweinfurth, MD Professor, Department of Otolaryngology, University of Mississippi Medical Center
John Schweinfurth, MD is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Laryngological Association, Triological Society, American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association
Disclosure: Nothing to disclose.
Arytenoid Fixation
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