Prolapse of the arytenoid mucosa in bilateral vocal cord paralysis: A rare cause of obstructive sleep apnea

A 64-year-old male patient initially presented to an external center with complaints of snoring during sleep, waking up with a sensation of choking, morning fatigue, daytime sleepiness, and hospital and intensive care admissions due to hypoxic episodes during sleep over the past six months. Polysomnography testing revealed severe obstructive sleep apnea syndrome (OSAS). The patient was then admitted to the pulmonary clinic, where three CPAP (continuous positive airway pressure) titration tests were conducted with benefit from the devices. Additional investigations, including neurology and otorhinolaryngology consultations, bronchoscopy, and head, neck, and thorax computed tomography imaging, did not lead to a conclusive diagnosis or treatment, apart from bilateral vocal cord mobility limitation. Seeking surgical treatment, the patient presented to our clinic. An otorhinolaryngology specialist experienced in sleep surgery found that while the patient's speech was normal, the exercise capacity was reduced. Indirect laryngoscopy and sleep endoscopy revealed that bilateral vocal cord paralysis and hypertrophic arytenoid mucosa prolapsing into the laryngeal inlet were causing airway obstruction and apnea. Surgical mucosal resection of the arytenoids was performed using a laser, and airway security was ensured with a tracheotomy. Following these procedures, the patient's life-threatening apnea and desaturation episodes improved and voice quality was preserved. A detailed otorhinolaryngological examination, including indirect laryngoscopy and sleep endoscopy, should not be overlooked in such complex sleep apnea cases in collaboration with relevant department consultations. This very rare condition poses a life-threatening risk. The anesthesia for sleep endoscopy and the surgical procedure is also crucial, and tracheotomy may be life-saving.