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Cricoarytenoid SubluxationPseudoasthma and Cricoarytenoid Subluxation: Another Cause of Pseudoasthma FREE TO VIEW

José-Aníbal Díaz-Tantaleán, MD; Mercedes Velasco, MD; Xavier Muñoz, MD, PhD
Author and Funding Information

From the Pneumology Department (Drs Díaz-Tantaleán and Muñoz), and Phoniatrics and Speech Therapy Unit, Rehabilitation Service (Dr Velasco), Hospital Universitari Vall d’Hebron; the Departament de Medicina (Drs Díaz-Tantaleán and Muñoz), and the Department of Cell Biology, Physiology, Immunology (Dr Muñoz), Universitat Autònoma de Barcelona; and Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES) (Dr Muñoz), Instituto de Salud Carlos III.

CORRESPONDENCE TO: Xavier Muñoz, MD, PhD, Pneumology Department, Hospital Universitari Vall d’Hebron, Passeig de la Vall d’Hebron, 119-129, 08035 Barcelona, Spain; e-mail: xmunoz@vhebron.net


FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(5):e182-e183. doi:10.1378/chest.14-1603
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Published online
To the Editor:

In clinical practice, approximately 5% of patients initially given a diagnosis of asthma present poor symptom control despite appropriate treatment, and the diagnosis must be reassessed.1 This reappraisal may detect other diseases in up to 55% of cases,2 including diseases of the upper respiratory tract. This is the case of the patient we describe here.

The patient was a 57-year-old woman with a history of hypertension, dyslipidemia, rhinitis, intolerance of antiinflammatory drugs, and appendectomy at the age of 15 years. She was referred to the Pneumology Service with a diagnosis of difficult-to-treat asthma. The patient reported two or three dyspnea and cough attacks per year since the age of 15 years, requiring emergency consultation. The attacks were generally self-limiting and remitted within 24 h.

Although asymptomatic between episodes, at the time of the visit she was receiving treatment with fluticasone, 500 μg/12 h; formoterol, 50 μg/12 h; montelukast, 10 mg/24 h; tiotropium bromide, 18 μg/24 h; and salbutamol on request. The lung function study showed FVC, 3.20 L (93%); FEV1, 2.67 L (102%); 83.5% FEV1/FVC; total lung capacity, 4.65 L (94.9%); diffusing capacity of the lung for carbon monoxide, 6.27 L (73.8%); diffusing capacity of the lung for carbon monoxide/alveolar volume, 1.53 L (77.1%); a negative bronchodilator test; and a negative bronchial challenge test with methacholine. No atopy was demonstrated. A subsequent interview revealed that the symptoms began after an appendectomy that required endotracheal intubation for 3 days because of complications. With the suspicion of likely upper airway pathology secondary to intubation, a laryngeal stroboscopy was performed in which no laryngeal lesions were observed, except for a hyperlaxity of the cricoarytenoid joints and risk of vestibular stenosis during forced inspiration (Fig 1). With the diagnosis of cricoarytenoid subluxation after tracheal intubation, all bronchodilator medication was discontinued, and speech therapy was recommended. During the 4 years of follow-up, although the patient has presented similar clinical episodes, she has been able to control them using the techniques learned during speech therapy and has not needed to consult the emergency services.

Figure Jump LinkFigure 1 –  Laryngeal stroboscopy. A, Glottal closure during phonation. B, Maximum glottal opening during normal inspiration. C, In forced inspiration, a forward movement toward the midline (subluxation) of the arytenoid cartilages (arrows) is observed, which obstructs the entrance to the vestibule.Grahic Jump Location

Subluxation of the arytenoid cartilage is a rare condition that occurs as a complication of treatment of injuries to the larynx and neck.3-5 The diagnosis is made by laryngoscopy or videostroboscopy to evaluate the position and movement of the vocal cords, and the arytenoids are evaluated, as in this patient.4 The treatment of choice is direct, early reduction and repositioning of the arytenoid cartilage.4 An alternative is the application of Teflon or gelfoam via surgery in the area affected.5 In our case, because of the time elapsed and because the airway was obstructed only in forced inspiration, we decided to perform conservative treatment with speech exercises, as described elsewhere.4 On observing satisfactory progress, surgery was definitively ruled out.

To our knowledge, this is the first report of a case of bilateral cricoarytenoid subluxation of long duration that for many years was mistaken for difficult-to-treat asthma. We believe that this entity should be included in the differential diagnosis of the various disorders of the upper airways that can mimic asthma.

References

Barnes PJ, Woolcock AJ. Difficult asthma. Eur Respir J. 1998;12(5):1209-1218. [CrossRef] [PubMed]
 
Robinson DS, Campbell DA, Durham SR, Pfeffer J, Barnes PJ, Chung KF; Asthma and Allergy Research Group of the National Heart and Lung Institute. Systematic assessment of difficult-to-treat asthma. Eur Respir J. 2003;22(3):478-483. [CrossRef] [PubMed]
 
Castella X, Gilabert J, Perez C. Arytenoid dislocation after tracheal intubation: an unusual cause of acute respiratory failure? Anesthesiology. 1991;74(3):613-615. [CrossRef] [PubMed]
 
Norris BK, Schweinfurth JM. Arytenoid dislocation: an analysis of the contemporary literature. Laryngoscope. 2011;121(1):142-146. [CrossRef] [PubMed]
 
Mendoza de la Vara HE, Figueroa y Segura E. Luxación del cartílago aritenoides izquierdo. Reporte de un caso. Rev Mex Anest. 1996;19(3):153-155.
 

Figures

Figure Jump LinkFigure 1 –  Laryngeal stroboscopy. A, Glottal closure during phonation. B, Maximum glottal opening during normal inspiration. C, In forced inspiration, a forward movement toward the midline (subluxation) of the arytenoid cartilages (arrows) is observed, which obstructs the entrance to the vestibule.Grahic Jump Location

Tables

References

Barnes PJ, Woolcock AJ. Difficult asthma. Eur Respir J. 1998;12(5):1209-1218. [CrossRef] [PubMed]
 
Robinson DS, Campbell DA, Durham SR, Pfeffer J, Barnes PJ, Chung KF; Asthma and Allergy Research Group of the National Heart and Lung Institute. Systematic assessment of difficult-to-treat asthma. Eur Respir J. 2003;22(3):478-483. [CrossRef] [PubMed]
 
Castella X, Gilabert J, Perez C. Arytenoid dislocation after tracheal intubation: an unusual cause of acute respiratory failure? Anesthesiology. 1991;74(3):613-615. [CrossRef] [PubMed]
 
Norris BK, Schweinfurth JM. Arytenoid dislocation: an analysis of the contemporary literature. Laryngoscope. 2011;121(1):142-146. [CrossRef] [PubMed]
 
Mendoza de la Vara HE, Figueroa y Segura E. Luxación del cartílago aritenoides izquierdo. Reporte de un caso. Rev Mex Anest. 1996;19(3):153-155.
 
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