Arytenoid Sequestrum

A sequestrum refers to a piece of dead (necrotic) bone or cartilage that has separated from the main bony or cartilaginous structure. The separated piece (sequestrum) becomes isolated from viable bone or cartilage due to loss of blood supply through trauma or chronic infection.

Sometimes the sequestrum “spits” itself out after many months and the remaining bone or cartilage heals over. At other times, there must be surgical removal and curettage or excision of adjacent infected or devitalized cartilage or bone.

In the larynx, a sequestrum may occur due to radionecrosis after treatment for cancer, chronic intubation, or infection. It is reasonable to observe for a time, while covering with antibiotics as appropriate and even consideration of hyperbaric oxygen, if the larynx was radiated.

Sequestrum That the Patient Spit Out

Key Words: sequestrum, arytenoid, arytenoid perichondritis, intubation

In this patient, there was a poorly focused history of intubation for a long abdominal surgery approximately a year prior to presentation.

Three months later, (nine months prior) the patient experienced throat pain and examination elsewhere showed unexplained right arytenoid swelling. A CT scan, also obtained elsewhere, showed a “phglegmon” appearance of swollen soft tissue but no obvious abscess or sequestrum. She presented after nine months, having had a tracheotomy and several procedures to biopsy the swollen arytenoid, with tissue diagnosis only of inflammatory changes.

At the time of first presentation to Bastian Voice Institute, she was in severe pain. Distant examination showed only the arytenoid edema; closer examination revealed a spicule of apparent cartilage. Before surgery could be accomplished to remove this and debride the arytenoid apex from which the spicule appeared to originate, the patient coughed out a sequestrum. After some weeks, the right arytenoid swelling resolved, the patient’s pain resolved, and she was successfully decannulated.

This appears to have been an extreme example of arytenoid perichondritis. On a speculative basis, it may be that the intubation a year earlier abraded the anterior face of the arytenoid, setting up a festering arytenoid perichondritis.

At original examination (1 of 7)

At this typical examination distance, the primary finding is the inflammatory (erythematous) swelling of the right arytenoid mound, with preserved vocal cord movement. At this point the patient has already had at least two endoscopic procedures elsewhere for biopsy and culture.

Closer inspection (2 of 7)

Now the pointed spar of what appears to be a bony projection or foreign body is seen directed medially and inferiorly from the medial face of the arytenoid eminence. This is just above the level of the vocal process. Note as well the divot of the opposite cord which, along with the inflammation, may partly explain the patient’s pain.

Sequestrum at closer range (3 of 7)

The sequestrum appears to be originating at the base of the arytenoid body. Speculating, there could have been an endotracheal tube injury with tip of tube pressing on insertion into the posterior ventricle and wounding not only mucosa but also arytenoid perichondrium and setting up a festering infection that eventually led to this sequestrum. The plan at this point: Surgical removal and wider debridement of the adjacent cartilage and soft tissue.

Expectorated sequestrum (4 of 7)

Two weeks later, while awaiting microlaryngoscopy, the patient spit out the piece of cartilage above, measuring nearly 7mm in diameter.

Examination after sequestrum expectorated (5 of 7)

It appears that the arytenoid apical mucosa (star) is already less inflamed, though the vocal cords themselves are quite erythematous. The patient’s pain is already diminished, however.

Closer view (6 of 7)

The divot is trying to heal with granulation tissue forming. As expected, the projecting sequestrum is no longer seen.

The arytenoid apex is pale/uninflamed. — A month later (7 of 7)

The patient’s pain is gone. The arytenoid apex (star) is pale/uninflamed. The vocal cords are also no longer inflamed. With a clear explanation of her prior arytenoid swelling and relief of symptoms, her tracheotomy tube can be removed and no further treatment is needed. This is an example of healing that can sometimes occur unaided after a sequestrum “spits.”

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Arytenoid Sequestrum

Sequestrum That the Patient Spit Out

At original examination (1 of 7)

Closer inspection (2 of 7)

Sequestrum at closer range (3 of 7)

Expectorated sequestrum (4 of 7)

Examination after sequestrum expectorated (5 of 7)

Closer view (6 of 7)

A month later (7 of 7)

Voice, Swallowing, Airway Disorder?

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