Post-intubation cricoarytenoid joint dysfunction
Parel, Mumbai, India
E-mail: jithesh_ak1{at}rediffmail.com
Editor—We read with interest the report by Mikuni and colleagues1 as we had a similar experience with a 20-yr-old female patient who had undergone anterolateral spinal decompression at T4–6. Tracheal intubation with a double-lumen tube was unremarkable except for the failure of the first attempt. After operation, the patient had hoarseness of voice. On the first postoperative day, the patient went into respiratory failure and required mechanical ventilation. A fibreoptic bronchoscopy revealed gross hyperaemia of the glottis and arytenoids. A diagnosis of glottic oedema was made. The patient was managed with steroids and on the fifth postoperative day again extubated. A few hours later, the patient had to be reintubated due to respiratory failure.
A CT scan of the neck was unremarkable. A repeat fibreoptic bronchoscopy revealed hyperaemia of glottis with swelling of the arytenoids. Bronchoscopy on the eighth postoperative day showed no hyperaemia in the glottic region, but the aytenoids were still swollen. A 70° scoping was done post-extubation, which showed sluggish movement of both vocal cords. A month later, the patient had some residual hoarseness.
This prompted the diagnosis of post-intubation cricoarytenoid joint dysfunction probably after haemarthrosis of cricoarytenoid joint. Laryngeal oedema was a strong possibility but the delay in onset of respiratory distress and the persistence of hoarseness for nearly a month favoured the diagnosis of cricoarytenoid joint dysfunction.
Asahikawa, Japan
* E-mail: subetenakusitamamani{at}yahoo.co.jp
Editor—Thank you for your interest in our report. Although the double-lumen tube is the main airway device for differential lung ventilation, our concern is that it can easily cause arytenoid cartilage dislocation because of its large outer diameter, which widens at the tracheal lumen orifice, and the rigidity of the material. The double-lumen tube may apply an external force to the arytenoid cartilage leading to dysfunction. Additionally, there is a possibility that the failure in the first attempt at tracheal intubation has an effect. It is important to investigate the possibility of arytenoid cartilage dysfunction early in the case with persistent hoarseness after the use of a double-lumen tube.
References
1 Mikuni I, Suzuki A, Takahata O, Fujita S, Otomo S, Iwasaki H. Arytenoid cartilage dislocation caused by a double-lumen endobronchial tube. Br J Anaesth (2006) 96:136–8.
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