杓状软骨复位术治疗环杓关节脱位的临床分析

摘要：目的探讨环杓关节脱位的临床特性以及杓状软骨复位的治疗技术。方法回顾性分析2014年7月~2017年4月收治的17例环杓关节脱位患者进行杓状软骨复位治疗的临床资料,分析其病因、治疗手法、诊治时机及疗效。结果17例患者中2例1次复位成功,3例2次复位成功,其余12例均行3~4次复位治疗,其中6例关节活动未能完全恢复正常,但所有患者发音质量GRBAS评分均有明显改善。结论杓状软骨复位是治疗环杓关节脱位的有效治疗方法,病程越短相对复位效果越满意,但较长病程患者进行复位治疗仍有助于嗓音改善。

     

Spontaneous arytenoid dislocation and crico-arytenoid instability

IntroductionArytenoid dislocation is a rare occurrence, for which the pathophysiology is still unclear.MethodsWe report here an unusual case of spontaneous arytenoid dislocation, which casts doubts on the prevailing classical theory of hemarthrosis.Results and conclusionsThis case and a review of the literature suggest that arytenoid dislocation could be linked to congenital or acquired arytenoid instability, thus facilitating arytenoid dislocation after even minor trauma. Once the diagnosis is established, we recommend to first attempt reduction, followed by speech therapy, though underlying diseases should be researched.     

Spontaneous dislocation of the arytenoid cartilage

Dislocation of the arytenoid cartilage occurs following medical instrumentation involving the laryngeal cavity or laryngeal injury from outside the larynx. We reported a case of spontaneously posterior dislocation of the arytenoid cartilage. A 53 year-old man suffering from suddenly recurring aphonia and its improvement many over 3 months without laryngeal injury or inducement eventually ceased to improve. Laryngoscopic findings showed that the left vocal fold was tensely prolonged and the vocal process of the arytenoid cartilage on the left side was dislocated posterolaterally. X-ray videofluorography of the larynx on repetitive phonation of /he/ showed abnormally high and diagonal displacement of the vocal fold and the upper structure of the arytenoid cartilage on the left side. Palpating the cricoarytenoid joint on the left side showed abnormal swelling with tenderness. Electomyography of the intrinsic laryngeal muscle on the left side showed normal action potential. From these findings, we diagnosed his voice disorder as spontaneously posterior dislocation of the arytenoid cartilage. We manually reduced it by pulling up a balloon inserted from the piriform sinus of the affected side to the esophagus.     

改良杓状软骨复位术治疗环杓关节脱位

目的 探讨环杓关节脱位临床特征及改良杓状软骨复位术的疗效.方法 改良杓状软骨复位术,即应用直角喉钳握持杓状软骨上部表面,根据脱位位置将杓状软骨向后外侧或前内侧方向旋转拨动.67例声带运动不良患者表面麻醉间接喉镜下行改良杓状软骨复位术,其中全身麻醉插管导致环杓关节脱位57例,非插管原因10例(6例为顿挫性喉外伤).对患者临床特征、嗓音功能、手术方法及疗效进行分析.结果 患者均有明显声音嘶哑,频闪喉镜下均见不同程度的声带运动障碍(50例为左侧,占74.6％)及声门闭合不良,杓状软骨向前内侧移位63例,向后外侧移位4例.行喉肌电图检查的38例插管患者中,10例(26.3％)肌电异常,可见失神经电位.改良杓状软骨复位后,57例全身麻醉插管导致环杓关节脱位患者声音均有改善,其中51例发音正常,6例轻度嘶哑;54例声带运动恢复正常,3例声带运动改善.10例非插管原因患者中,声带运动及发音7例恢复正常,1例改善,2例无效.结论 环杓关节脱位部分病例合并喉返神经损伤(多为暂时性损伤),脱位后6周内改良杓状软骨复位术可使声带运动及发音功能得到满意恢复.钝挫性喉外伤导致的声带运动不良原因复杂,即使杓状软骨复位,喉部瘢痕挛缩也可能影响疗效.     

Closed reduction for arytenoid dislocation under local anesthesia

Conclusion: Closed reduction under local anesthesia continues to be an effective and well-tolerated method for treating arytenoid dislocation. Bilateral arytenoid dislocation is an uncommon occurrence, and the principles of management are the same as for unilateral dislocation. Objectives: To evaluate the treatment outcomes of closed reduction for arytenoid dislocation under local anesthesia and to conduct an exhaustive review of the literature on bilateral arytenoid dislocation. Methods: Thirty-three patients with arytenoid dislocation were treated with closed reduction under local anesthesia. Arytenoid motion, GRBAS (grade, roughness, breathiness, asthenia, strain), maximum phonation time (MPT), self-assessed Voice Handicap Index (VHI), and acoustic voice analysis were used to evaluate the clinical outcomes. Results: Following closed reduction, 33 patients were divided into a ‘satisfied’ group (n?=?26) and a ‘dissatisfied’ group (n?=?7). In the ‘satisfied’ group, G, R, B, A, MPT, VHI, jitter%, shimmer%, normalized noise energy (NNE), and noise-to-harmonic ratio (NHR) were significantly improved compared with measurements taken before closed reduction (p?相似文献   

Blunt laryngeal trauma resulting in arytenoid dislocation and dysphonia

We present a case of left arytenoid dislocation due to blunt laryngeal trauma causing a subsequent large granuloma formation resulting in dysphonia and stridor. The patient underwent emergency excision of the obstructive granuloma and speech therapy was started post-operatively. A few weeks after surgery, the granuloma started to recur and laryngeal manipulation by a specialist osteopath was performed. A few weeks after the conservative management, the recurred granuloma resolved completely and patient's voice improved remarkably. Dislocation of the arytenoid cartilage due to blunt trauma is relatively rare and a consequent spontaneous granuloma formation has not been reported so far in the literature. This is also the first report about efficacy of speech therapy combined with laryngeal manipulation in the management of the arytenoid dislocation and the subsequent laryngeal granuloma.     

Fiberscopic reduction under local anesthesia for anterior arytenoid cartilage dislocation

Arytenoid cartilage dislocation is a known complication of tracheal intubation and is also a type of laryngeal injury. Although spontaneous recovery has been reported, most patients require reduction via pharyngoscopy under general or neuroleptic anesthesia, and some must be treated by open reduction such as laryngoplasty. We report 8 cases of arytenoid cartilage dislocation between August 2003 and August 2004. Excluding 3 patients who recovered spontaneously, we conducted reduction under local anesthesia as an ambulatory procedure in the other 5 with anterior dislocation, i.e., 2 men and 3 women aged 53 to 75 years old. Of these 5, dislocation occurred after tracheal intubation in 4, and in 1 after wearing a laryngeal mask. The outcome was favorable in all 5. Surgery was conducteded after a fiberscope was inserted nasally and a urethral balloon catheter was inserted via the other nasal cavity under topical anesthesia with 4% lidocaine for both nasal cavities and the larynx. While monitoring the larynx, we expanded the balloon and pulled it away from the glottis. The expanded balloon was then placed at the arytenoid region for a few seconds. This procedure was repeated several times to achieve reduction. Three patients recovered well within 1 to 2 weeks of the first reduction, while 2 requierd a second reduction because of insufficient improvement after the first. These two both showed improved vocal cord movement and recovery from hoarseness within 1 to 2 weeks after the second reduction. We conducted 7 reductions without complications in any patient. Our approach is usable in the ambulatory setting, and is simple, minimally invasive, and effective. We consider it to be useful treatment for anterior arytenoid cartilage dislocation.     

直接喉镜下环杓关节脱位闭合复位的疗效观察

环杓关节脱位是全身麻醉插管所致的一种严重并发症〔1〕。1997-05-2010-11我科对42例环杓关节脱位患者在直接喉镜下采用器械拨动闭合复位,术中辅以颈外推拿及语音疗法,疗效满意。现报告如下。1资料与方法临床资料     

Management of bilateral arytenoid cartilage fixation versus recurrent laryngeal nerve paralysis

Bilateral arytenoid cartilage fixation (ACF) closely resembles vocal cord immobility due to recurrent laryngeal nerve paralysis (RLNP). This study sought to determine the etiologic differences between these two entities and to derive conclusions about treatment. The charts of 218 consecutive adult patients with immobility of both vocal cords requiring surgery for airway restoration were reviewed. The results of laryngeal electromyography and laryngotracheoscopy were used to distinguish ACF from RLNP. In 186 patients (85.3%), RLNP was identified. Of these, 154 paralyses (82.8%) were caused by surgical interventions, 5 (2.7%) were caused by previous intubation, 16 (8.6%) were caused by various malignancies, and 7 (3.8%) were neurogenic. In 4 patients (2.2%), the cause remained unclear. We identified ACF in 32 patients. The etiologic factors included previous long-term intubation in 22 patients (68.8%), short-term intubation in 3 patients (9.4%), Wegener's granulomatosis in 3 patients (9.4%), rheumatoid arthritis in 2 patients (6.3%), previous laryngeal surgery in 1 patient (3.1%), and caustic ingestion in 1 patient (3.1%). Additional second-site airway stenosis was found in 10 of the RLNP patients (5.4%) and in 15 of the ACF patients (46.9%). All RLNP patients had endoscopic surgery without temporary tracheotomy. Eighteen ACF patients required open surgery, and 4 were managed endoscopically but required temporary tracheotomy. The etiologic factors were significantly different for the two entities under study. Additional sites of stenosis were more frequent in ACF patients. Stenosis due to RLNP could be managed endoscopically without preliminary tracheotomy, while ACF frequently required open surgery and temporary tracheotomy.     

New approach to diagnose arytenoid dislocation and subluxation using three-dimensional computed tomography

Understanding the complex three-dimensional (3D) arrangement of the arytenoid cartilage is necessary for diagnosing arytenoid dislocation (AD) and arytenoid subluxation (AS). We examined the 3D arrangements of AD and AS (AD/AS) cases by region and considered their new diagnoses. This retrospective study included 2 patients with AD, 10 with AS, and 23 with unilateral vocal fold paralysis (UVFP) for comparison. The etiologies were intubation-induced and idiopathic. We classified the AD/AS position into four joint regions: mediocaudal, laterocaudal, mediocranial, and laterocranial. We generated 3D computed tomography (3DCT) images during rest and phonation to analyze functional movements. We attempted to compare the endoscopic findings and 3DCT images of patients with UVFP and AD/AS. To examine the joint status, we especially focused on the position and movements of the muscular process (MP) on the joint because the arytenoid facet is mainly located on the back of the MP. We were able to obtain endoscopic and 3DCT findings characteristic of each AD/AS region. The dislocated MPs were localized to the mediocaudal, mediocranial, and laterocranial regions. Two AD cases were diagnosed due to complete separation of the joint surfaces during rest and phonation. The finding of MPs displacing partially outside the cricoid facet is common to both severe UVFP and AS. The most important differentiation point was that the MP in UVFP cases was located on both the medial and lateral side regions of the joint, but that of AS was on one side region only. Furthermore, no cases of passive gliding movements characteristic of UVFP that have been described previously by us were observed in AD/AS cases. AD can be diagnosed by findings of complete joint separation. AS can be diagnosed based on positions and movements distinct from those of UVFP.     

Office-based arytenoid palpation for diagnosis of disorders of bilateral vocal fold immobility

Bilateral vocal fold immobility is an uncommon but serious condition with many causes. Accordingly, accurate diagnosis is essential in order to treat patients promptly and avoid long-term sequelae. Historically, diagnosis has been performed in the operating room with the patient under general anesthesia. We present the case of a patient who was diagnosed with bilateral vocal fold immobility by in-office arytenoid palpation that required only topical anesthesia of the larynx. The patient subsequently underwent appropriate treatment. In our opinion, office-based arytenoid palpation is a simple, safe, and accurate procedure for diagnosing bilateral vocal fold immobility.     

Unilateral arytenoid adduction improves voice in a patient with bilateral vocal fold immobility

Bilateral vocal fold immobility (BVFI) due to prolonged endotracheal intubation resulted in aphonia without any airway morbidity and was treated by several reconstructive procedures. Laryngeal reinnervation and silicone implantation failed to medialize one of those two fixed cords. Arytenoid adduction (AA) eventually achieved this goal. To select an optimal reconstructive procedure, a careful perusal of the history and head and neck examination including laryngeal electromyography, are necessary to determine the causes. AA procedure played an essential clinical indication in this study, not just an adjunct to the medialization laryngoplasty as usual. Since both the vocal cords positions were ranked as lateral positions subjectively, the full adduction for one of those two fixed vocal cords was performed without significant airway obstruction. The practice in this study provided an experience in correcting the voice in patients with BVFI. We need further experience to medialize the vocal cord in an appropriate magnitude since its counterpart may position variously and compromise the airway.     

经间接喉镜和直接喉镜杓状软骨拨动术的比较研究

目的 :探讨在局麻下经间接喉镜和直接喉镜杓状软骨拨动术对气管插管致环杓关节脱位的疗效。方法 :将 2 3例气管插管致环杓关节脱位患者随机安排在局麻下经间接喉镜或直接喉镜行杓状软骨拨动术 ,并对两组进行比较。结果 :每组患者的治疗起始时间与发音功能康复时间呈正相关 ;两组患者的治疗起始时间和发音功能康复时间的比较差异无显著性意义 (P >0 .0 5 ) ,复位次数差异有显著性意义 (P <0 .0 5 ) ,术后咽喉疼痛反应持续时间的差异无显著性意义 (P >0 .0 5 )。结论 :喉损伤的治疗起始时间对患者完全恢复发音功能有重要影响。两种方式对环杓关节脱位均有良好疗效。直接喉镜杓状软骨拨动术对喉损伤病程偏长的患者较为适合     

Endoscopic arytenoid repositioning for unilateral arytenoid fixation

OBJECTIVES: To describe a new endoscopic technique for medialization of the laterally fixed arytenoid. The surgical technique, endoscopic arytenoid repositioning, is described, and the results of a series of cases are discussed. STUDY DESIGN: Retrospective chart review. METHODS: Eight patients underwent the procedure. Six patients were available for long-term follow-up. Preoperative and postoperative voice ratings were compared to evaluate the success of the procedure. Follow-up ranged from 3 to 64 months (mean follow-up, 31.5 mo). RESULTS: Long-term follow-up in six cases revealed that 67% (4 of 6) patients had normal or near-normal postoperative voices and one patient experienced moderate improvement. The mean preoperative voice score was 4.24, and the mean postoperative voice score was 1.83 (range, 1-5). The difference was statistically significant (P < 0.001). CONCLUSIONS: Endoscopic arytenoid repositioning is a newly described procedure with a very specific indication: a unilateral, laterally fixed arytenoid complex resulting in a severely dysphonic voice. Though technically demanding, this procedure provides a promising option for medialization of the posterior glottis in a scarred larynx.     

Sling arytenoid adduction

The purpose of this study was to describe a simplified arytenoid rotation technique and to test its applicability in excised human larynges. A non-absorbable monofilament thread is slung around the muscular process of the arytenoid cartilage through an external approach. During visual control through flexible endoscopy, two needles and a wire loop needle threader are the only instruments needed. Thread tensioning and fixation results in a stabilized arytenoid adduction. This technique avoids cricothyroid joint disarticulation and leaves the thyroid cartilage intact. The practicability of the technique was proven in five excised larynx experiments. In two clinical cases, the muscular process was slung and pulled with a monofilament thread. Tension in the vector direction parallel to the LCA muscle showed an effective and stable arytenoid rotation with complete closure of the posterior glottis. The rotational effect following sling arytenoid adduction (SAA) is similar to conventional arytenoid adduction surgery outcome. However, SAA is performed from an external approach and avoids dissection of cartilage. Challenging dissections to reach the muscular process are avoided. In some cases of unilateral vocal fold immobility, arytenoid rotation may be performed by using the SAA technique, which allows for an external and extralaryngeal approach. Further studies should assess the clinical value of this technique. In principal, the wire loop needle threader can also be employed for external vocal fold lateralization procedures.     

单侧杓状软骨切除术联合同侧声带外移治疗双侧声带麻痹的疗效观察

目的 探讨单侧杓状软骨切除术联合同侧声带外移治疗双侧声带麻痹的临床疗效.方法 回顾分析2007年1月至2011年4月5例双侧声带麻痹患者的临床资料,所有患者均在全麻下行颈外径路单侧杓状软骨切除术联合同侧声带外移,观察术后临床效果和术前、术后6月患者的声学参数(基频-F0,基频微扰-jitter,振幅微扰-shimmer,标准化噪声能量-NNE和最长声时(MPT).结果 患者术后呼吸功能均显著改善,5例患者均成功1次拔管,平均拔管时间(18.67±4.83)d,发音质量无显著下降,术后随访6月无严重误吸、创面肉芽、再狭窄发生.术后6月患者的F0、jitter、shimmer、NNE显著降低,而MPT显著延长,P<0.05.结论 单侧杓状软骨切除术联合同侧声带外移治疗双侧声带麻痹临床效果好,无明显并发症,显著改善患者的声学参数和最大声时.