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Arytenoid fixation surgery for the treatment of arytenoid fractures and dislocations

1999; Wiley; Volume: 109; Issue: 5 Linguagem: Inglês

10.1097/00005537-199905000-00029

1531-4995

Nicolas E. Maragos,

Dysphagia Assessment and Management

The lateral Isshiki approach to the arytenoid cartilage affords an efficient approach to cartilage defects, dislocations, and fractures.1, 2 The author has used a systematic approach through a posterior “window”3 for arytenoid cartilage medialization (Isshiki arytenoid adduction) and treatment of other arytenoid cartilage defects including fractures, dislocations, ankylosis, and capsular fixation. Exposure of the posterolateral larynx through this modification of the Isshiki approach allows for direct, definitive diagnosis and treatment of these defects while preserving the cricothyroid joint and recurrent and superior laryngeal nerves. Arytenoid fixation is useful in patients in whom transoral reduction of an arytenoid dislocation is unsuccessful, or when exploration of the cricoarytenoid joint and arytenoid is deemed necessary. This technique affords unsurpassed visualization of the cricoarytenoid joint and arytenoid cartilage and preserves vocal cord mucosa and thus phonatory capability. It is an excellent initial approach to the correction of arytenoid deformities, but is not the best approach for gross defects of the arytenoid cartilage. The surgical technique for arytenoid fixation uses the lateral Isshiki approach to the arytenoid cartilage to expose the entire posterolateral larynx. The operation may be performed with the patient under local anesthesia with intravenous sedation or with general anesthesia, depending on patient and surgeon preference. If general anesthesia is used, a tracheotomy tube must be placed preoperatively to free the larynx for manipulation. With local anesthesia (0.5% bupivacaine with 1:200,000 epinephrine) a horizontal skin incision is made at the level of the cricothyroid membrane from 5 cm on the ipsilateral side to 2 cm on the contralateral side of the injury. Skin flaps are raised superiorly to above the thyroid notch, inferiorly to below the cricoid cartilage, and laterally to completely expose the ipsilateral strap muscles. Intramuscular bupivacaine is injected into the sternohyoid muscle 2 cm below the hyoid, and the muscle divided. The thyrohyoid muscle is injected at its origin and “shaved” from the oblique line. The larynx is rotated 75° with a large hook at the posterior border of the thyroid ala, and the inferior constrictor is divided. The height of the thyroid ala from its midline lower border to the thyroid notch is measured with a caliper, and half that distance used as the level of the vocal fold line. A mark is made at that halfway point and the same distance measured superiorly from the lower border of the thyroid ala just anterior to the inferior cornu (Fig. 1). The line between those two points marks the level of the vocal fold and hence the level of the arytenoid and cricoarytenoid joint. The vocal line is continued posteriorly to intersect with the posterior border of the thyroid ala. The perichondrium of the posterior border of the thyroid ala between the superior and inferior cornua is sharply incised with a No. 15 blade, and the perichondrium on the inner surface of thyroid ala is elevated anteriorly, superiorly, and inferiorly for about 10 mm from the intersecting point. A posterior “window” is fashioned by roughly drawing a semicircle with a radius of 10 mm in males and 9 mm in females and removing the cartilage, leaving the previously elevated inner perichondrium attached medially to the piriform sinus mucosa. The inner perichondrium is grasped, incised vertically at the anterior-most extent of the window, and bluntly dissected with the piriform sinus mucosa posteriorly off the posterior cricoarytenoid muscle. The muscular process is identified by following the posterior cricoarytenoid muscle fibers upward to their insertion where they turn tendinous and white. As an alternative, the muscular process is found by following the vocal cord line posteriorly, palpating the arytenoid directly, or following the lateral cricoid lamina superiorly to the cricoarytenoid joint. Other identifiable structures include the lateral cricoarytenoid and thyroarytenoid muscles, lateral cricoid lamina, and the entire arytenoid cartilage. The recurrent laryngeal nerve courses across the inferior-most portion of the window below the cricoarytenoid joint. Right side of the larynx, cartilaginous structures; posterior window technique for exposure of the arytenoid cartilage. Curved lines are used in drawing and cutting this window to protect against thyroid cartilage fracture during forward retraction of the larynx. Right side of the larynx, cartilaginous structures, showing suturing of the arytenoid cartilage to the superior medial rim of the cricoid cartilage. Before opening the cricoarytenoid joint, the arytenoid cartilage is examined and its relation to the cricoid rim noted. Forward dislocations will be obvious but arytenoid fractures are frequently obscure, and meticulous dissection of the entire arytenoid cartilage may be necessary. The cricoarytenoid joint is opened laterally for 2 to 3 mm to facilitate diagnosis of joint ankylosis or capsular scarring, and the joint palpated with a gimmick. If the joint is relatively normal, the posterior cricoarytenoid muscle and cricoarytenoid joint capsule are sharply incised posterolaterally for another 5 mm to gain access to the superior cricoid rim and posterior lamina. If necessary, the entire posterior capsule may be incised, since the arytenoid will be permanently sutured to the cricoid. The fiberoptic nasopharyngoscope coupled to a videocassette recorder and television is then used to evaluate the internal larynx in real-time while the arytenoid is being manipulated externally. Arytenoid fixation is accomplished by permanently suturing the entire arytenoid cartilage, or the fractured piece containing the vocal process, directly to the medial cricoid cartilage rim with one to three sutures (4–0 nylon, P-3 needle, Ethicon, Somerville, NJ) (Fig. 2). The surgical site is drained with a Penrose drain, and the posterior cartilaginous window need not be replaced. The ipsilateral sternohyoid muscle is repaired and reapproximated to its counterpart, and the skin closed. Antibiotics are given for 7 to 10 days postoperatively, and decreased voice usage (50% of normal) is encouraged for 2 weeks. All patients are advised that the voice will not be close to normal until 2 months after operation, and the first follow-up appointment is at 3 months after surgery. The lateral arytenoid approach has been used in 11 dysphonic patients to correct traumatic arytenoid diseases or disorders. Six patients were involved in motor vehicle accidents and had either traumatic arytenoid dislocations from endotracheal intubation performed emergently for airway compromise (three patients) or severe direct neck injuries with arytenoid fractures (three patients). Five patients had arytenoid dislocations after intubation or bronchoscopic trauma. Representative patient histories, examinations, and surgical findings are presented in the following two cases. Case numbers are keyed to Table I to prevent confusion. A 14-year-old girl sustained life-threatening trauma to her head and neck in an automobile accident. Emergency endotracheal intubation was followed by an extended period of tracheotomy tube placement. She was finally weaned from her tracheotomy tube, but her voice remained extremely breathy. She was unable to sustain more than three or four words on a full breath of air. She aspirated frequently, and after two episodes of aspiration pneumonitis her family sought further treatment for her voice and swallowing disorders. Fiberoptic examination of the larynx revealed an open posterior glottis and an apparent left vocal fold paralysis with bowing. She underwent a tracheotomy under local anesthesia and a left-side arytenoid adduction under general anesthesia. Postoperatively, however, she was only slightly better with both phonation and deglutition. Subsequent office fiberoptic examination and laryngeal visualization finally revealed forward displacement of the left arytenoid cartilage obscuring 80% of the glottis. Re-exploration of the left arytenoid and complete uncovering of the upper portion of the arytenoid cartilage revealed a fractured arytenoid cartilage. Initial trauma had sheared the upper body, vocal process, and superior process of the arytenoid from the muscular process and lower body. The superior and anterior arytenoid cartilage was lying anterior and lateral because of the thyroarytenoid muscle pull. The arytenoid cartilage fragments and vocal process were fixed to the superior rim of the cricoid cartilage near the midline using two permanent 4–0 nylon sutures. Postoperatively her swallowing and voice were much improved, although not normal. She has had no further aspiration pneumonitis in the subsequent 3 years after surgery. A 41-year-old man sustained severe limb and chest injuries including a traumatic aortic transection from involvement in a motor vehicle accident 1 year before admission. He required emergency intubation with repair of the aortic arch and remained intubated for 1 month before undergoing a tracheotomy. After intubation he had no movement of the left vocal fold, and on subsequent laryngeal examination the left arytenoid cartilage was dislocated anteriorly. The vocal quality was that of a gurgle, sound production being from the left arytenoid mucosa vibrating against the right aryepiglottic fold. The right vocal fold moved normally. He underwent an arytenoid fixation procedure, the dislocated arytenoid being fixed to the cricoid with three sutures of 4–0 nylon. A concurrent type I thyroplasty medialized the paralyzed vocal fold with postoperative airway and voice improvement. The lateral approach to the arytenoid cartilage provides easy access to the entire posterolateral larynx with direct external examination of the arytenoid and its related structures. The modified approach through a posterior “window” coupled with permanent arytenoid fixation to the cricoid rim improved the position of the affected vocal fold in eight patients with dislocated arytenoid cartilages and three patients with arytenoid fractures. Combinations of lateral vocal cord position, partial arytenoid loss, and mucosal scarring made preoperative voices extremely breathy or aphonic. Acoustic parameters improved after fixation (Table I) in 80% of tests, but only half of those voices could be considered normal (Table I). Seven patients (cases 1, 2, 4, 5, 7, 10, and 11) had improvement or remission of swallowing difficulties. One patient (case 8) had prolonged airway compromise and at the time of this writing required a tracheotomy tube for breathing, but no patients had postoperative aspiration. The arytenoid was approached on two occasions in one patient (case 3). Dissection along the superior rim of the cricoid cartilage is possible after opening the cricoarytenoid joint. The joint needs to be open wider for the arytenoid fixation (8 mm) than for an arytenoid adduction (3 mm) to gain access to the midline cricoid cartilage posteriorly. Incising the anterior fibers of the posterior cricoarytenoid muscle exposes the cricoarytenoid joint well without disturbing postoperative results, since arytenoid fixation is permanent. The piriform sinus and posterior cricoid mucosa are elevated and protected by staying directly on the cricoid during the surgery and avoiding entry into the pharynx. Permanent 4–0 nylon sutures secure the arytenoid to the cricoid to correct the defect. Arytenoid fixation usually results in a mild degree of membranous vocal fold laxity either attributable to a slight residual forward displacement of the arytenoid cartilage (1–3 mm) or resulting from thyroarytenoid muscle loss (paralysis or disuse). Correcting this residual vocal fold lateralization with a type I thyroplasty (cases 1 to 3 and 8 to 11) or open medialization (case 7) completed the total rehabilitation of the vocal fold and larynx in seven of these eight patients. The arytenoid fixation technique through an external, posterolateral approach after Isshiki has been shown to afford good access to dislocations and fractures of the arytenoid cartilage. The modified posterior window approach may be used to evaluate the arytenoid, cricoarytenoid joint, and cricoid rim and to secure the arytenoid or its fragments to the cricoid. Acoustic parameters and subjective symptoms may be improved in these very difficult problems. The arytenoid fixation technique is safe, reliable, and effective in directly accessing, assessing, and treating arytenoid cartilage injuries.