Immobile Vocal Cord After Intubation

 see video below

return to:Unilateral Laryngeal Paralysis or Vocal Cord Paralysis

or: Injection Laryngoplasty for Vocal Fold Paralysis and Glottic Incompetence

password protected site:Laryngeal Paralysis from Intubation Diagrams

1. Causes of Impaired Vocal Cord Motion
   1. Paralysis (RLN, Vagus, SLN, brainstem)
      1. RLN compression between inflated cuff of ETT and thyroid cartilage
      2. Anatomic studies have shown the anterior branch of the recurrent laryngeal nerve to be vulnerable to the lateral projection of the abducted arytenoid and thyroid cartilage (Cavo 1985; Brandwein 1986)
   2. Myopathy/myositis of the intrinsic laryngeal muscles (Yin 1996)
      1. Inflammation to the PCA with or without ulceration by nasogastric tube may impair vocal fold mobility (Apostolakis 2001; Landis 1988)
   3. Crico-arytenoid arthritis
   4. Scarring (fixation of arytenoid to cricoid; fixation of arytenoid to arytenoid)
   5. Crico-arytenoid subluxation or dislocation
      1. Impaired vocal cord (fold) motion after intubation has been ascribed to subluxation or dislocation of the arytenoid from its position on the cricoid. Contemporary thought identifies subluxation/dislocation is not an adequate explanation for the great majority of cases of impaired vocal cord movement seen after intubation (House 2011).
      2. Dislocation refers to complete separation of the cartilaginous surfaces whereas subluxation is a disruption of the normal anatomic contact but with still some residual contact between the joint surfaces.
         1. Crico-arytenoid dislocation is rare, and when it occurs it is usually associated with severe laryngeal trauma associated with mucosal disruption.
         2. The arytenoid is positioned on a wide joint base supported by the posterior cricoarytenoid ligament and the intrinsic muscles of the larynx
      3. Subluxation of the arytenoid occurs commonly in association with laryngeal paralysis.
         1. Paralysis of the LCA/TA/PCA and IA muscles may remove the balanced support to the arytenoid that keeps it in its normal anatomic position
         2. Crico-arytenoid subluxation may therefore be an expected consequence of laryngeal paralysis
2. Prospective analysis (House 2011) of 61 adults with recorded laryngeal exam after extubation (mean duration of 9 days)
   1. 100% with some degree of laryngeal injury
      1. 95%-97% Arytenoid edema and erythema with interarytenoid edema
      2. 89% vocal fold erythema
      3. 66% vocal fold edema
      4. 34% vocal process ulceration
   2. 39% with some degree of vocal fold immobility
      1. 54% unilateral, 46% bilateral
      2. 71% mild immobility; 29% moderate or severe immobility

3. DDX: Laryngeal Paralysis and (unlikely) Arytenoid SubluxationClick on video to activate (requires flash media - will not work on IPAD):

References:

1. Apostolakis LW, Funk GF, Urdaneta LF, McCulloch TM, and Jeyapalan MM: The Nasogastric Tube Syndrome: Two Case Reports and Review of the Literature. Head Neck 2001 Jan:23(1):59-63
2. Brandwein M, Abramson AL, Shikowitz MJ. Bilateral vocal cord paralysis following endotracheal intubation. Arch Otolaryngol Heada Neck Surg. 1986;112:866-882
3. Cavo JW:True Vocal Cord Paralysis Following Intubation. Laryngoscope 1985;95:1352-1359
4. Landis EE, Hoffman HT, Koconis CA: Upper Airway Obstruction Associated With Large Bore Nasogastric Tubes  South Med J 1988 Oct;81(10):1333
5. Norris BK and Schweinfurth: Arytenoid Dislocation: An Analysis of the Contemporary Literature. Laryngoscope 121:142-146, 2011
6. House JC, Noordzij JP, Murgia B and Landmore S: Laryngeal INjury from Prolonged Intubation: A Prospective Analysis of Contributing Factors. Laryngoscope 2011 March; 121(3):596-600
7. Yin SS, Qui WW, Stucker FJ: Value of Electromyography in Differential Diagnosis of Laryngeal Joint Injuries After Intubation. Ann Otol Rhinol Laryngol. 1996;105:446-451