Vocal Process Avulsion and Phonosurgical Treatment

Markus M. Hess, Anna-Katharina Licht, Susanne Fleischer

We present a case of vocal process avulsion in a 24 year old female hockey player. After blunt trauma of the larynx with a hockey stick she reported that she immediatedly was aphonic, but did not suffer from dyspnea. One day after the trauma rigid laryngoscopy revealed that the left vocal process (cartilage) protruded during phonation. Hematoma and swelling of the left arytenoid hump was also seen, but no signs of paresis or paralysis were encountered. Computer tomography did not reveal any fractures of the laryngeal cartilages.
Four days later and after swelling was reduced with steroids and antibiotics, suspension microlaryngoscopy was performed and the vocal ligament was fixed to the vocal process by suturing. The patient also received 60 MU Dysport^® (Botulinum toxin A) injected into the lateral cricoarytenoid muscle and the thyroarytenoid muscle to reduce postoperative vocal fold tension.
Three months later videostrobolaryngoscopic examination showed glottal closure and some vocal fold vibration of the left side.The voice was still slightly breathy. After 6 months the voice had become more resonant. The maximum phonation time was 16 seconds and the patient was satisfied with her voice.
Vocal process avulsion is a rare complication after laryngeal trauma. We suppose that detachment of the tip of the vocal process (avulsion), disconnecting the rest of the vocal process from the ligament, is the result of the embryologic development with different origins of the arytenoid body and the vocal process. If not seen soon after trauma, diagnosis is difficult to assess because of swelling and scarring. In the present case the pathomechanism of the trauma could be identified by immediated laryngoscopy, thus early and specific treatment was possible.

Markus M. Hess, Anna-Katharina Licht, Susanne Fleischer
Department of Voice, Speech and Hearing Disorders, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, D-20246 Hamburg, GERMANY