Vocal Fold Fixation Caused by Penetration of a High-Velocity Steel Projectile

Abstract

Vocal fold fixation as a result of trauma caused by a foreign body is rare. We report a unique case of vocal fold fixation caused by traumatic penetration of a shard of steel in a 31-year-old steelworker. While the patient was at work, an airborne projectile suddenly pierced his neck and entered his larynx, causing progressive hoarseness and dyspnea. Flexible laryngoscopy detected no obvious foreign body, but it did reveal that the right vocal fold had become immobile. Computed tomography revealed that a 2.5-cm sliver of steel had become impacted in the right cricoarytenoid joint, which made the arytenoid cartilage unable to rotate. An emergency tracheostomy was performed with local anesthesia to construct a functioning airway, and then rigid laryngoscopy was performed with general anesthesia. The foreign body was removed with the assistance of a microscope and microscissors. Postoperatively, the patient immediately regained control of his right vocal fold, and he experienced no permanent injury.

Introduction

The vast majority of cases of vocal fold immobility are caused by recurrent laryngeal nerve paralysis.^1–7 To the best of our knowledge, only 2 cases caused by mechanical fixation have been previously reported in the literature.^8,9 As far as we know, no case of vocal fold fixation caused by traumatic penetration of a foreign body has been reported. In this article, we describe such a case.

Case Report

A 31-year-old man presented to us with worsening hoarseness and dyspnea. The patient reported that he worked in a steel mill and that he had sustained a neck injury on the job. An unidentified foreign body had suddenly penetrated the left side of his neck at very high speed.

Examination revealed the presence of a pinholesized wound and mild subcutaneous emphysema in the anterior part of the left side of the neck. Flexible laryngoscopy detected no foreign body, but it did identify immobility of the right vocal fold. At this point, the cause of the vocal fold fixation was unclear, but an occult foreign body was suspected. Urgent computed tomography (CT) (figure 1) and three-dimensional CT (figure 2) demonstrated a needle-shaped 2.5-cm foreign body in the right cricoarytenoid joint, which made the arytenoid cartilage unable to rotate.

Figure 1.

Axial CTs show the needle-shaped foreign body in the right cricoarytenoid joint.

Figure 2.

The shard is seen on three-dimensional CT.

Because the shard had penetrated the vocal fold, performing a direct intubation would likely have been fatal. Therefore, an emergency tracheostomy with local anesthesia was performed to secure a properly functioning airway. Next, rigid laryngoscopy was performed with general anesthesia. With microscopic enhancement of the surgical field, we pulled the right vocal fold aside and immediately spotted the foreign body, which was a steel sliver. The shard was located just below the right vocal fold. It was vertically oriented, and both ends were firmly stuck in the larynx (figure 3). We used microscissors to cut the sliver in two, and then we removed each piece separately.

Figure 3.

The steel sliver is found just under the right vocal fold, with both ends lodged in the larynx.

Postoperatively, the patient immediately regained control of his right vocal fold. His phonation and respiratory system also recovered, and he experienced no permanent damage.

Discussion

Of the 2 previously reported cases of recurrent laryngeal nerve paralysis secondary to mechanical fixation, the first was reported by Hanukoglu et al in 1986. ⁸ In that case, a 3-year-old boy had swallowed some unshelled sunflower seeds, and he subsequently lost his voice. Examination revealed that the shell of one of the seeds had become lodged lateral to the left vocal fold, causing restriction of vocal fold mobility. The second case was reported by Tsunoda et al in 2002. ⁹ Their patient was a 62-year-old woman who had swallowed a fish bone, which then became stuck in her right cricoarytenoid joint and prevented rotation of her arytenoid cartilage.

Our case is unique in that the foreign body did not enter through the patient's mouth. Rather, the steel sliver had entered the anterior part of the left side of the neck and had become lodged in the right cricoarytenoid joint. Laryngotracheal injuries sustained as a result of penetration are uncommon; those that do occur are often fatal. Another unusual aspect of our case is that a minimally penetrating wound had caused worsening hoarseness and dyspnea in addition to vocal fold immobility.

Given its complexity, laryngeal trauma needs to be diagnosed correctly and treated promptly. Emergency airway management options include endotracheal intubation, cricothyroidotomy, and tracheostomy. According to Grewal et al, however, selected patients with mild laryngotracheal injuries who did not undergo a tracheostomy experienced no increase in morbidity or mortality. ¹⁰ Nevertheless, physicians should approach all cases of laryngeal trauma as unique. In our case, the construction of a properly functioning airway by tracheostomy rather than intubation was the better option because it allowed us to avoid causing further injury.

Removing a penetrating foreign body from the larynx as soon as possible is of paramount importance. In our case, the steel sliver was removed with minimal invasion with the use of a rigid laryngoscope rather than via an external approach.

In conclusion, to the best of our knowledge, this is the first reported case of vocal fold fixation resulting from an occupational accident. It is our belief that in patients with a minimally penetrating wound, proper airway control together with a fully detailed CT will minimize mortality. Finally, workers should always be advised to wear appropriate personal protective equipment when carrying out potentially dangerous tasks.