|Year : 2015 | Volume
| Issue : 1 | Page : 33-36
Efficacy of voice therapy in patient with arytenoid dislocation as a complication of tracheal intubation
Md Noorain Alam1, Deepanshu Gurnani2, Vikas Sinha2, Nehal Patel2, Sachin Jindal2, Pawan Sharma2
1 Department of Speech Therapy, C. U. Shah Medical College, Surendranagar, Gujarat, India
2 Department of Otolaryngology and Head and Neck Surgery, M. P. Shah Government Medical College, Jamnagar, Gujarat, India
|Date of Web Publication||10-Mar-2015|
Prof. Md Noorain Alam
Department of Speech Therapy, C. U. Shah Medical College, Surendranagar, Gujarat
Source of Support: None, Conflict of Interest: None
Introduction: Tracheal intubation is the placement of a flexible plastic tube into the trachea to maintain an open airway or to serve as a conduit through which certain drugs are administered. Arytenoid dislocation is one of the rare reported complications of tracheal intubation. Decreased volume and breathiness are the most common voice symptoms. Need for the Study: There is lack of prospective and systemic study of the incidence of arytenoid dislocation and efficacy of voice therapy in such cases. Aim of the Study: Present study was carried out to find out the efficacy of voice therapy as independent management option in persons with arytenoid dislocation as a consequence of tracheal intubation. Materials and Methods: The study was based on a case study of a 37 year old male patient who reported to C U Shah Medical College and Hospital, Surendranagar with complaint of breathy and soft voice quality post laparotomy as a consequence of intubation. ENT examination revealed both vocal cord bowing with ? subclinical sublaxtition of arytenoid. Pre and post voice therapy assessment was done using GRBAS scale (for perceptual analysis), Praat software (for acoustical analysis) and VHI scale (for measuring the effect of voice disorder on the quality of life). Voice therapy was given for two months and pre and post findings were compared. Results: Significant improvement was observed on all the measures. Conclusion: Although arytenoid cartilage dislocation following the use of intubation is a rare event, it is important to be aware of its occurrence and to conduct diagnostic tests as early as possible in case of persistent hoarseness. Voice therapy may be used as an adjunct to phonosurgery or independently an effective intervention.
Keywords: Intubation, Anesthesia, Complication, Voice therapy
|How to cite this article:|
Alam MN, Gurnani D, Sinha V, Patel N, Jindal S, Sharma P. Efficacy of voice therapy in patient with arytenoid dislocation as a complication of tracheal intubation. Indian J Otol 2015;21:33-6
|How to cite this URL:|
Alam MN, Gurnani D, Sinha V, Patel N, Jindal S, Sharma P. Efficacy of voice therapy in patient with arytenoid dislocation as a complication of tracheal intubation. Indian J Otol [serial online] 2015 [cited 2022 Sep 26];21:33-6. Available from: https://www.indianjotol.org/text.asp?2015/21/1/33/152858
| Introduction|| |
Tracheal intubation is the placement of a flexible plastic tube into the trachea to maintain an open airway or to serve as a conduit through which certain drugs are administered. It is frequently performed in critically injured, ill or anesthetized patients to facilitate ventilation of the lungs, including mechanical ventilation, and to prevent the possibility of asphyxiation or airway obstruction. Although it is not the only means to maintain a patent airway during general anesthesia, intubation of the trachea provides the most reliable means of oxygenation and ventilation. 
Tracheal intubation can be associated with minor complications such as broken teeth or lacerations of the tissues of the upper airway. Potentially fatal complications include pulmonary aspiration of stomach contents which can result in a severe and sometimes fatal chemical aspiration pneumonitis, or unrecognized intubation of the esophagus which can lead to potentially fatal anoxia. Because of this, the potential for difficulty or complications due to the presence of unusual airway anatomy or other uncontrolled variables is carefully evaluated before undertaking tracheal intubation. Alternative strategies for securing the airway must always be readily available.
| Arytenoid Dislocation|| |
The reported incidence of arytenoid cartilage dislocation is low. This may be due to the wide range and orientation of motion allowed by the cricoarytenoid articulation and the laxity of its joint capsule. Arytenoid cartilage dislocation is an infrequently diagnosed cause of vocal fold immobility. Intubation is the most common origin, followed by external laryngeal trauma. Rethi  reported three cases of arytenoid cartilage dislocation, which each followed a single instance of endotracheal intubation. In all three cases, painful swallowing was the main presenting symptom.
Decreased volume and breathiness are the most common presenting voice symptoms of arytenoid dislocation. Hoarseness after tracheal intubation is reported in 14-50% of the patients who receive general anaesthesia.  In most cases, the symptoms are temporary and improve within several days.  However, in the case of arytenoid cartilage dislocation hoarseness persists.
Although reestablishing joint mobility is difficult, endoscopic reduction is considered to align the heights of the vocal processes. This process may result in significant voice improvement even long after the dislocation. In patients with arytenoids dislocation early operative reposition results in fair prognosis, whereas delayed diagnosis may lead to ankylosis of the cricoarytenoid joint with permanent impairment of voice quality and possibly compromised airway protection.  Late arytenoid subluxation can also be treated by vocal cord medialization procedures. 
Although it is a rare event (about 0.1% as reported by Kambic and Radsel, 1978),  it is important to diagnose arytenoid cartilage dislocation early because recovery becomes difficult if appropriate treatment is not started immediately, which can significantly affect the patient's satisfaction and activity after anaesthesia.  The present study was carried out as there is lack of prospective and systemic study of the incidence of this complication. The efficacy of voice therapy as independent management option in such cases was also measured in the study.
| Case Study|| |
A 37-year-old male patient underwent the intestine surgery (laprotomy in general aneathesia at C.U. Shah Medical College and Hospital). At the time of surgery the anesthetist inserted the tube for surgery. Postsurgery the patient developed breathy and soft voice. It affected his quality of life as he felt frustrated due to inability to communicate properly. He was referred to ENT for the change of voice. The detailed ENT evaluation was carried out and a direct laryngoscopic evaluation was done using a Hopkin's telescopic examination and findings showed both vocal cord bowing with? Subclinical sublaxtition of arytenoid. The patient was referred to the speech-language therapy department for voice therapy.
The perceptual and acoustical assessment was done in speech-language therapy department. The perceptual assessment was done with the grade, roughness, breathiness, asthenia, and strain (GRBAS) scale.  This scale evaluates voice on five scales - grade (G), roughness (R), breathiness (B), asthenia (A), and strain (S). Each parameter is rated on a four-point rating scale ranging from 0 (normal), 1 (slight), 2 (moderate), and 3 (extreme). Praat software (Developed by Paul Boersma and David Weenink of the University of Amsterdam) was used for acoustic assessment of voice. Praat is a software tool used to analyze, synthesize, and manipulate speech and has a built-in voice report tool.
The psychosocial impact of the change in voice was assessed with the voice handicap index (VHI).  It is a 30 items, five-point (0-4) scale, where 0 denotes "never" and 4 denotes "always." From the scores, the impact of the voice disorder may be classified as mild, moderate or severe. Low scores (<30) indicate that there is a minimal amount of handicap associated with the voice disorder. A score of 31-60 denotes a moderate amount of handicap and a VHI score from 60 to 120 represents a significant amount of handicap due to a voice problem. VHI is a useful instrument to monitor the treatment efficacy for voice disorders.
The patients underwent a voice therapy schedule with the following techniques:
- Vocal hygiene - The patient was asked to follow a vocal hygiene program for optimal voice production
- 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
- Abdominal breathing exercise - The patient was asked to take abdomen out ward during inhalation and inward during exhalation
- 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
- Pushing and pulling exercise - The patient was asked to push/pull a large object, e.g. a table while phonating/a/sound
- Hard glottal attack - The patient was asked to produce vowels and words in a sudden plosive manner
- 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 consisted of two sessions per week. The patient attended 2 months sessions. At the end of therapy, both the perceptual and acoustic assessment was again carried out using GRBAS scale and Praat software. The quality of life postvoice therapy was evaluated using VHI.
| Results|| |
On the GRBAS scale, the patient had abnormal scoring prevoice therapy that is G2R2B3A2S3 while postvoice therapy he had normal scoring that is G0R0B0A0S0.
As seen in [Table 1], on praat, postvoice therapy pitch range increased from 13 to 65.94 Hz. All Jitter measurements have decreased for example jitter local decreased 3.46% from 5.87% to 2.41%. All shimmer measurements improved for example posttherapy shimmer local (dB) has decreased 4.99 (dB) from 20.88 to 15.89 (dB). The posttherapy harmonic-to-noise ratio (HNR) value improved from mean HNR 1.62 (dB) to 5.96. [Table 1] shows acoustical analysis of pre- and post-voice therapy.
Psychosocial impact analysis
As seen in [Figure 1], on VHI, the average prevoice therapy for functional, physical and emotional component scores were 17.15, 22.7 and 19.9, respectively, while posttherapy scores were 3.94, 4.99 and 5.99, respectively. Voice handicap has reduced and significantly changes seen on the components of VHI as a result of voice therapy.
|Figure 1: Treatment result of voice therapy on voice handicap index subsets|
Click here to view
| Discussion|| |
Injuries of the larynx are a well-known complication of anesthesia and range from moderate to severe. Incidence of hoarseness is common, varying between 14.4% and 50%. Most cases are temporary and improve within several days. Endotracheal tube size, cuff design, and cuff pressure, as well as demographic factors such as sex or even the type of surgery are reported as risk factors. 
Research has been done to investigate the mechanism of arytenoid dislocation. The preferred theories are incomplete neuromuscular blockage, motor reactions during endotracheal intubation, or direct trauma to the cricoarytenoid joints leading to joint cavity hemorrhage or serosynovitis. After this, pathological process can be followed by adhesion of articular surfaces or periarticular structures that fix the arytenoid in an abnormal position. Delay in diagnosis and treatment can consequently lead vocal fold immobility to occur. The primary symptom is persistent hoarseness in adults and respiratory compromise in pediatric and neonatal cases.  In the literature, a case has reported as a complication of the uneventful and apparently straightforward endotracheal intubation and anesthesia.  In our patient, the cause of arytenoid cartilage dislocation was unclear, the intubation was not traumatic. Results from the present study suggest that voice therapy helps to reduce breathiness and hoarseness in patients with arytrenoid dislocation. Voice therapy helps to improve the overall quality of life as the self-perceived handicap in this population.
| Conclusion|| |
Although arytenoid cartilage dislocation following the use of intubation is a rare event, it is important to be aware of its occurrence and to conduct diagnostic tests as early as possible in case of persistent hoarseness. Voice therapy may be used as an adjunct to phonosurgery or independently an effective intervention.
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