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Anesth Analg 2001;92:1347-1348
© 2001 International Anesthesia Research Society

CASE REPORT

Arytenoid Dislocation While Using a McCoy Laryngoscope

Tadashi Usui, MD*, Shigeru Saito, MD{dagger}, and Fumio Goto, MD{dagger}

*Department of Anesthesia, Asahi Chuoh Hospital, Asahi, Chiba; {dagger}Department of Anesthesiology, Gunma University School of Medicine, Maebashi, Gunma, Japan

Address correspondence to Tadashi Usui, MD, Department of Anesthesia, Ashikaga Red Cross Hospital, Honjou 3-cho-me Ashikaga City, Tochigi-ken, 326-0808 Japan.


   Introduction
Top
 Introduction
Case Report
 Discussion
 References
 
Arytenoid dislocation (AD) involves either a complete disruption of the cricoarytenoid joint or a malpositioning of the arytenoid cartilages (AC) with reference to other laryngeal cartilages. In this report, we present a case of AD while using a McCoy laryngoscope. Although McCoy laryngoscope is recognized as a useful option for the cases of difficult endotracheal intubation, we are concerned that AD is likely with this device.


   Case Report
Top
 Introduction
 Case Report
Discussion
 References
 
A 26-year-old man was admitted to our hospital because of a sudden onset of headache. He had no history of laryngeal disorders. His height was 165 cm and his weight was 60 kg. Brain angiography revealed an aortic aneurysm and he was scheduled for emergency cerebral aneurysm clipping. Anesthesia was induced with propofol 150 mg, fentanyl 0.2 mg, and vecuronium 10 mg IV. On the first attempt to intubate with a tracheal tube using a No. 0.3 McCoy laryngoscope blade (1), we identified the vocal cords and classified the view as grade 3 in the Cormack’s scale (2). On the third atraumatic attempt, successful intubation of 7.5-mm spiral tube was performed with the aid of a stylet. Anesthesia was maintained with 1.0%–3.0% sevoflurane, 66% nitrous oxide, and oxygen. The patient tolerated the operation well, and his trachea was extubated 6 h after the tracheal intubation. On the first postoperative day, the patient gradually complained of a severe sore throat, dysphagia, and hoarseness. An otorhinolaryngologist performed a direct laryngoscopy that revealed the dislocation of the left AC to the anteromedial direction and dyskinesia of the left vocal cord. Because the symptoms persisted, reduction of the dislocation under local anesthesia was scheduled on the 28th postoperative day. Because all the symptoms disappeared, the operation was cancelled. To date, the patient has no laryngeal discomfort.


   Discussion
Top
 Introduction
 Case Report
 Discussion
References
 
AD is a rare event. Eighty cases have been described (3–6). Although AD can be caused by tracheal intubation or external injury to the neck, we usually ignore this when performing intubation, chiefly because of its infrequency. Concerning the underlying systemic disorders. Quick and Merwin (4) reported three cases of AD associated with chronic renal failure secondary to diabetes mellitus. Even ulcerative colitis (7) and laryngomalacia (8) have been associated with AD. However, these cases are rare. Furthermore, AD can occur in patients without any particular underlying diseases. In our case, the patient had neither a history nor underlying diseases.

As Talmi et al (5) suggested, a difficult or traumatic intubation is not always a prerequisite for incurring AD. Rather, many ADs are brought about by ordinary intubations. Therefore, we considered that the seemingly smooth intubation could have caused the AD. As a rare etiology for AD, use of a lighted stylet (9,10) and laryngeal mask airway (11,12) have been reported. The cause for the displacement of the arytenoid joint to the anteromedial direction after tracheal intubation may be a force generated by the laryngoscope that draws the AC to the anterior direction (5). In other words, the stretching pressure applied to the aryepiglottic folds produces an upward pulling force onto the AC. Furthermore, perhaps the tips of the AC are trapped in the tube while performing endotracheal intubation, resulting in forced displacement to the anteromedial direction (5,13). The merit of using a McCoy laryngoscope lies in its structural property, namely upwardly flexible tips (1), which enables anesthesiologists to intubate the trachea of patients in whom anatomical variation in the larynx makes the use of a Macintosh blade ineffective (14–18). McCoy et al. (19,20) compared the properties of the McCoy blade with those of Macintosh blades in terms of exerted force on the larynx and cardiovascular responses. The exerted force on the larynx was much smaller than with the Macintosh blade, and cardiovascular side effects were fewer. However, these authors only determined the total load exerted on the whole laryngopharyngeal region (21). The local load at the hinged tip during the levering action in the McCoy blade was not determined. Thus it is also possible that this instrument stretched the aryepiglottic folds as strongly as the Macintosh blade, resulting in a displacement of AC similar to that caused by the Macintosh blade. Therefore, although we appreciate the usefulness of the McCoy laryngoscope, it may be a risk factor for causing AD during endotracheal intubation.

Regarding the treatments of AD, previous reports found an excellent prognosis in cases in which reduction (3–5) by a laryngeal spatula was performed (4). Fortunately, AD spontaneously reduced in our case, although the trigger of the spontaneous healing was unknown. There are several reports describing the repositioning of AD by severe coughing or vomiting (3,13,22).

In conclusion, despite its usefulness in alleviating difficulty in intubation, this one case raises the possibility that AD is more likely when using the McCoy laryngoscope.


   References
Top
 Introduction
 Case Report
 Discussion
 References
 

  1. McCoy EP, Mirakhur RK. The levering laryngoscope. Anaesthesia 1993; 48: 516–9.[Web of Science][Medline]
  2. Cormack RS. Difficult tracheal intubation in obstetrics. Anesthesia 1984; 39: 1105–11.
  3. Sataloff RT, Bough ID Jr, Spiegel JR. Arytenoid dislocation: diagnosis and treatment. Laryngoscope 1994; 104: 1353–61.[Web of Science][Medline]
  4. Quick CA, Merwin GE. Arytenoid dislocation. Arch Otolaryngol 1978; 104: 267–70.[Abstract/Free Full Text]
  5. Talmi YP, Wolf M, Bar-Ziv J, et al. Postintubation arytenoid sublucation. Ann Otol Rhinol Laryngol 1996; 105: 384–90.[Web of Science][Medline]
  6. Prasertwanitch Y, Schwanz JJH, Vandam LD. Arytenoid cartilage dislocation following prolonged endotraceal intubation. Anesthesiology 1974; 41: 516–7.[Web of Science][Medline]
  7. Dudley JP, Mancuso AA, Fonkalsrud EW. Arytenoid dislocation and computed tomography. Arch Otolaryngol 1984; 110: 483–4.[Abstract/Free Full Text]
  8. Roberts D, Mcquinn T, Beckerman RC. Neonatal arytenoid dislocation. Pediatrics 1988; 81: 580–2.[Abstract/Free Full Text]
  9. Szigeti CL, Baeuerle JJ, Mongan PD. Arytenoid dislocation with lighted stylet intubation. Anesth Analg 1994; 78: 185–6.[Free Full Text]
  10. Debo RF, Colonna D, Dewerd G, Gonzalez C. Cricoartenoid sublucation: complication of blind intubation with a lighted stylet. Ear Nose Throat J 1989; 68: 517–9.[Medline]
  11. Rosenberg MK, Rontal E, Rontal M, Lebenbom-Mansour M. Arytenoid cartilage dislocation caused by a laryngeal mask airway treated with chemical splinting. Anesth Analg 1996; 83: 1335–6.[Web of Science][Medline]
  12. Cros AM, Pitti R, Conil C, et al. Severe dysphonia after use of a laryngeal mask airway. Anesthesiology 1997; 86: 498–500.[Web of Science][Medline]
  13. Gauss A, Treiber HS, Haehnel J, Johannsen HS. Spontaneous reposition of a dislocated arytenoid cartilage. Br J of Anaesthesia 1993; 70: 591–2.[Abstract/Free Full Text]
  14. Pritchard C. Comparison of the Macintosh and McCoy laryngoscope blades. Anaesthesia 1997; 52: 185–6.
  15. Ward M. The McCoy levering laryngoscope blade. Anaesthesia 1994; 49: 357–8.
  16. Faring PA. The McCoy levering laryngoscope blade. Anaesthesia 1994; 49: 358.
  17. Johnston HML, Rao U. The McCoy levering laryngoscope blade. Anaesthesia 1994; 49: 358.
  18. Tuckey JP, Cook TM, Render CA. An evaluation of the levering laryngoscope. Anaesthesia 1996; 51: 71–3.[Web of Science][Medline]
  19. McCoy EP, Mirakhur RK. Rafferty C, et al. A comparison of the forces exerted during laryngoscopy. Anaesthesia 1996; 51: 912–5.[Web of Science][Medline]
  20. McCoy EP, Mirakhur RK, McCloskey BV. A comparison of the stress response to laryngoscopy. Anaesthesia 1995; 50: 943–6.[Web of Science][Medline]
  21. McCoy EP, Austin BA, Mirakhur RK, Wong KC. A bew device for measuring and recording the forces applied during laryngoscopy. Anaesthesia 1995; 50: 139–43.[Web of Science][Medline]
  22. Chatterji S, Gupta NR, Mishra TR. Valvular glottic obstruction following extubation. Anaesthesia 1984; 39: 246–7.[Web of Science][Medline]
Accepted for publication January 23, 2001.




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Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press