Posterior Arytenoid Cartilage Dislocation Despite Optimal Intubation During Prolonged Steep Trendelenburg Robotic Prostatectomy: A Potential Biomechanical Contributor.

Background: Arytenoid cartilage dislocation (ACD) is a rare but clinically significant complication of endotracheal intubation that may be misdiagnosed as transient vocal cord paralysis. The potential role of prolonged surgical positioning in ACD remains underrecognized. Methods: A 63-year-old male developed left posterior ACD following robot-assisted radical prostatectomy (RARP) performed in a steep Trendelenburg position for 3.5 h. Intubation was successfully achieved on the first attempt using a video laryngoscope with full glottic visualization and no apparent airway trauma. Postoperatively, the patient developed persistent dysphonia, dysphagia, aspiration, and tongue deviation. Initial flexible laryngoscopy suggested left vocal cord paralysis, whereas direct laryngoscopy on postoperative day 6 confirmed posterior arytenoid dislocation. Urgent closed reduction was performed, followed by structured voice therapy, which resulted in substantial functional recovery. Discussion: This case illustrates that ACD may occur despite technically optimal and atraumatic intubation and should be interpreted as reflecting a temporal association rather than a definitive causal relationship. Prolonged steep Trendelenburg positioning and extended operative duration may be considered potential contributing biomechanical factors, possibly mediated by venous congestion, mucosal edema, altered endotracheal tube dynamics, and cumulative shear stress on the cricoarytenoid joint. However, these mechanisms remain interpretive and hypothesis-generating. Conclusions: Prolonged steep Trendelenburg positioning and extended operative duration may represent possible contributing biomechanical factors in ACD, even in the setting of atraumatic intubation. Early laryngeal evaluation and timely reduction remain essential for optimal functional recovery.