Para-arytenoid cartilage pseudodiverticulum formation as a sequela of endotracheal intubation

• Context. - Laryngotracheal injury secondary to endotracheal intubation results from ischemic necrosis, which develops within hours of intubation, with injury severity increasing with duration of intubation. Postextubation and postmortem observations demonstrate that laryngotracheal injury still occurs in a large number of intubated patients. Objective. - To demonstrate laryngeal injury, specifically pseudodiverticulum formation, as a result of intubation. Design. - A total of 41 autopsy cases from February 1970 to February 2006 were retrospectively reviewed. All patients had been intubated during their hospital course and had an endotracheal tube in place at the time of death. Continuous endotracheal intubation ranged from several hours to 33 days. Results. - The earliest manifestations of laryngeal injury occurred within hours and included hyperemia, edema, and ovoid mucosal lesions over the arytenoid and inner posterolateral cricoid cartilages. Within 48 hours, superficial epithelial denudation progressed to mucosal ulceration, with inflammatory infiltrate into the submucosa. These ulcerations enlarged and deepened, and within 3 to 6 days they showed gross excavations and, in some cases, confluence with other ulcerations. Four cases had pseudodiverticulum formation in the area of the arytenoid cartilages, with deep, excavated lesions that extended to the underlying cartilage. Pseudodiverticulum formation occurred as early as 8 days of continuous intubation. Conclusions. - Although endotracheal intubation is required for airway maintenance in many patients with respiratory dysfunction, the procedure carries risks. Laryngeal injury from intubation is very common, and the severity of injury is directly related to the duration of intubation. We add para-arytenoid pseudodiverticulum formation to the list of possible complications of endotracheal intubation.