MD Noorain Alam describes for SIIC his article published in Indian Journal of Otology 21(1):33-36, January 2015

Jamnagar, India (special for SIIC)
Arytenoid cartilage dislocation is a relatively less reported (about 0.1%)¹ event which is an infrequent cause of vocal fold mobility. Primary cause of arytenoid cartilage dislocation within larynx is tracheal intubation followed by external laryngeal trauma. Tracheal intubation is performed in critically injured, ill or anesthetized patient, which involves placement of flexible plastic tube into trachea to maintain airway or to serve as a conduit for drug administration.

Arytenoid dislocation may cause painful swallowing² accompanied with voice symptoms like decreased volume and breathiness. In 14%-50% of patients who receive general anesthesia hoarseness after tracheal intubation has been reported.³ Phonosurgical treatment involves endoscopic reduction to align the height of the vocal processes. Another option is vocal cord medialization procedures in case of late arytenoid subluxation.⁴ Early diagnosis of arytenoid dislocation is important as delay may lead to ankylosis of cricoarytenoid joint with permanent impairment of voice quality and possibly compromised airway protection.⁵ There is a lack of literature on incidence of arytenoid dislocation.

The aim of present study was to find out the efficacy of voice therapy as independent management option in patient with arytenoid dislocation as a complication of tracheal intubation.

A 37 year old male patient underwent laprotomy (intestine surgery) at CU Shah Medical College and Hospital. Tracheal intubation was administered and post surgery the patient developed breathy and soft voice. He was referred to ENT department for the complaint of change in voice. Direct laryngoscopy revealed both vocal cords bowing with subclinical subluxation. The patient was then referred to Speech Language Therapy department for voice therapy.

Voice evaluation involved perceptual, acoustical and psychosocial impact assessment. Perceptual assessment was carried out using GRBAS scale (grade, roughness, breathiness, asthenia, and strain).⁶ Each parameter was rated on a four point scale ranging from 0 (normal), 1 (slight), 2 (moderate), and 3 (extreme).

Acoustic assessment was done using Praat software. Objective measurement of Pitch range, jitter, shimmer and harmonic to noise ratio (HNR) was carried out using this software.

The psychosocial impact of the change in voice was carried out using Voice Handicap Index (VHI),⁷ which is 30 items, five point scale (0-4). The impact of the voice disorder may be classified as mild, moderate or severe based on overall score.

Voice therapy schedule involved following techniques:1. Vocal hygiene; 2. Laryngeal manipulation exercise - Larynx of the patient was manipulated using the index finger and thumb of the clinician and patient was given practice to speak when the larynx was positioned so that it allowed optimal phonation; 3. Abdominal breathing exercise - The patient was asked to take abdomen out ward during inhalation and inward during exhalation.; 4. Head positioning - Head of the patient was adjusted at different position while the patient was phonating/a/ sound and was asked to speak with head positioned which allowed best phonation.; 5. Pushing and Pulling exercise - The patient was asked to push/pull a large object, e.g. a table while phonating/a/sound; 6. Hard glottal exercise - The patient was asked to produce vowels and words in a sudden plosive manner; 7. Increasing loudness exercise - The patient was asked to count 1-5 while increasing the loudness at each number so that number 1 is softest and number 5 is spoken with the loudest voice.

Voice therapy schedule consisted of two sessions per week and total duration was 2 months. At the end of therapy, perceptual, acoustical and psychosocial impact assessment was readministeredusing GRBAS scale, Praat software and VHI respectively. Pre and post voice therapy measurements were compared to find out the effect of voice therapy.

Following are the findings comparison of pre and of post voice therapy measurements.

Under perceptual analysis (GRBAS scale) pre voice therapy evaluation measurement was G2R2B3A2S3, which was abnormal while post voice therapy measurement was G0R0B0A0S0 i.e. voice was perceptually normal. Acoustical analysis (Praat software) showed improvement in most of the parametersin post voice therapy measurements. Pitch range increased from 13 Hz to 65.94 Hz. All Jitter values decreased like jitter local decreased from 5.87% to 2.41%. All shimmer values also decreased like shimmer local (dB) decreased from 20.88 dB to 15.89 dB.Harmonic to Noise Ratio value increased from mean HNR 1.62 dB to 5.96 dB.Under psychosocial impact analysis VHI measurements showed improvement in each of three domains i.e. functional (17.15 to 3.94), physical (22.7 to 19.9) and emotional component (19.9 to 5.99). Thus post voice therapy there was improvement in most of components of perceptual, acoustic and psychosocial domains of voice.

Principal theories which have been proposed to explain the mechanism of arytenoid dislocation as a rest of tracheal intubation include incomplete neuromuscular blockage, motor reactions during endotracheal intubation, or direct trauma to the cricoarytenoid joints leading to joint cavity hemorrhage or serosynovitis.

In the literature, a case has been reported as a complication of the uneventful and apparently straightforward endotracheal intubation and anesthesia.⁹ In our patient, the cause ofarytenoid dislocation was unclear, as the intubation was not traumatic. Results from the present study suggest that voice therapy helps.

Voice therapy may be used as an adjunct to phonosurgery or independently as an effective intervention to reduce breathiness and hoarseness in patients with arytrenoid dislocation which also in turn improves overall quality of life.