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European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2018) xxx–xxx

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Original article

Arytenoid asymmetry in opera singers

P. Clarós ∗ , A. Clarós-Pujol , A. Clarós
Oto-Rhino-Laryngologie, Clínica Clarós, c/. Los Vergós, 31, 08017 Barcelona, Spain

a r t i c l e i n f o a b s t r a c t

Keywords: Introduction: Otolaryngologists commonly observe asymmetrical movements of the arytenoid cartilages,
Arytenoid asymmetry but few authors have described the clinical implications of this asymmetry, especially in singers.
Vocal symptoms Objectives: The aim of this study was to determine the epidemiological and clinical characteristics of
Opera singers
arytenoid asymmetry in adduction in a group of healthy opera singers and to evaluate the impact of this
asymmetry on the voice.
Patients and methods: The medical charts and laryngeal video recordings of 245 healthy opera singers
were retrospectively reviewed. Arytenoid asymmetry was defined in relation to the position of the
corniculate cartilages, cuneiform cartilages and aryepiglottic angle.
Results: The subjects had a mean age of 38.54 years (range: 18 to 85 years) and presented a male-to-
female sex ratio of 1.02. About 5% of subjects had a history of smoking. The most common vocal symptoms
were occasional dysphonia (4%), followed by vocal fatigue (2%) and pharyngeal dryness (2%). Arytenoid
asymmetry was slightly more common in males (50.6%) and predominantly affected the right side (64.5%).
The most common form of asymmetry was cuneiform asymmetry (37.5%), followed by aryepiglottic angle
asymmetry in 33.1% of cases and corniculate asymmetry in 29.4% of cases. Mild asymmetry was observed
in the majority of cases. No correlation was observed between arytenoid asymmetry and vocal symptoms.
Conclusion: Almost one out of two singers was likely to present arytenoid asymmetry in adduction. The
presence of this asymmetry does not appear to be correlated with any vocal symptoms.
© 2018 Elsevier Masson SAS. All rights reserved.

1. Introduction
The larynx plays an essential role in breathing, phonation and
deglutition. It is composed of several cartilages connected by
joints, ligaments, membranes and muscles. The key element for
maintenance of laryngeal integrity and function is an intact and
mobile cricoarytenoid joint. Arytenoid adduction is characterized
by anteroposterior tilting on the long axis of the arytenoid carti-
lages, lateral sliding and a small degree of rotation [1]. It is often
attributed to asymmetry of the laryngeal cartilages, as already
reported by several authors [2–5]. In their radiological study of
patients presenting with voice disorders, Friedrich et al. [2–4]
showed that asymmetry was common in dysphonic subjects and
was related to vocal symptoms. Hirano et al. [5] reported simi-
lar results by showing that the anteroposterior dimensions of the
thyroid cartilage were longer on the left side than on the right side.
The prevalence of arytenoid asymmetry varies as a function of
the type of asymmetry and the patient’s age and sex. In their study
of 109 subjects not presenting any voice disorders, Lindestad et al.
[6] reported a 70% incidence of arytenoid asymmetry. The most fre-
quent type of asymmetry (66% of patients), accounting for 92% of all
cases of asymmetry observed, consisted of lateral differences in the
anteroposterior position of the corniculate or cuneiform cartilages
[6]. These authors also reported that asymmetry was more fre-
quent in older people and singers. These results corroborate those
reported by Lacina [7] in a cohort of Milanese opera singers. Using
indirect mirror laryngoscopy, Lacina [7] reported a high incidence
of arytenoid asymmetry in singers compared to non-singers and
attributed these results to the fact that singers had to more accu-
rately compensate for anatomical variants of laryngeal cartilages in
order to more effectively align their vocal folds when singing.
Very few data on arytenoid asymmetry in adduction are avail-
able at the present time. The objective of this study was to
determine the epidemiological and clinical characteristics of ary-
tenoid asymmetry in a series of opera singers and to look for
a possible correlation between arytenoid asymmetry and vocal
symptoms.
2. Materials and methods

∗ Corresponding author. We conducted a retrospective, descriptive study on a series

E-mail address: clinica@clinicaclaros.com (P. Clarós). of 250 opera singers (professional singers, amateur singers and

https://doi.org/10.1016/j.anorl.2018.08.014
1879-7296/© 2018 Elsevier Masson SAS. All rights reserved.

Please cite this article in press as: Clarós P, et al. Arytenoid asymmetry in opera singers. European Annals of Otorhinolaryngology, Head
and Neck diseases (2018), https://doi.org/10.1016/j.anorl.2018.08.014
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Fig. 1. Normal larynx.

Fig. 2. Various types of asymmetry: a: right corniculate asymmetry due to overlap; b: right cuneiform asymmetry in an anterior position; c: aryepiglottic angle asymmetry;
d: left cuneiform asymetry.

singing students) attending our otorhinolaryngology clinic in
Barcelona, Spain. Inclusion criteria were all patients over the age
of 18 years presenting arytenoid asymmetry. The patients’ medical
charts and video recordings were examined. All patients with a his-
tory of surgery or laryngeal disease, such as nodules, polyps, cysts
and other tumours, were excluded from this study.
All patients were examined by an experienced otorhinolaryn-
®
gologist using a Karl Storz 90◦ rigid endoscope connected to
a camera. Videos were recorded during phonation and the var-
ious types of arytenoid asymmetry in adduction observed were
listed. Arytenoid asymmetry was classified into 3 types accord-
ing to the position of the corniculate and cuneiform cartilages, and
the aryepiglottic angle (angle between the aryepiglottic cartilage
and the epiglottis) compared to a normal larynx (Figs. 1 and 2).
Corniculate asymmetry was defined by the presence of promi-
nent corniculate cartilages or in an anterior position compared to
the contralateral side. Cuneiform asymmetry was defined by the
anterior position of the cuneiform cartilages compared to the con-
tralateral side. Aryepiglottic angle asymmetry was noted when a
more acute angle was observed on one side compared to the oppo-
site side. The various degrees of asymmetry were classified into
three groups: mild, moderate and severe. The side of asymmetry
was also specified (right or left).
The following variables were studied: age, sex, type, lat-
erality and degree of arytenoid asymmetry observed in each
subject. A history of smoking and vocal symptoms, such
as dysphonia, cough, hoarseness or vocal fatigue, were also
investigated.

Please cite this article in press as: Clarós P, et al. Arytenoid asymmetry in opera singers. European Annals of Otorhinolaryngology, Head
and Neck diseases (2018), https://doi.org/10.1016/j.anorl.2018.08.014
G Model
ANORL-812; No. of Pages 4 ARTICLE IN PRESS
P. Clarós et al. / European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2018) xxx–xxx 3

Table 1 different positions, dimensions and shapes. However, arytenoid

Epidemiological characteristics of the singers.
asymmetry appears to be more frequent in abduction than in
Number of singers 245 phonation. When arytenoid asymmetry is observed in adduction,
Sex ratio (male/female) 1.02 otorhinolaryngologists are often unable to distinguish between
Age
normal and pathological appearances. Despite the importance of
Mean age 38.54 years
Range 18–85 years
the cricoarytenoid joint, very few studies have evaluated the preva-
Smokers 5% lence of arytenoid asymmetry in adduction, its clinical impact on
Associated symptoms phonation and its association with vocal symptoms, especially in
Occasional dysphonia 4% singers [5–7].
Pharyngeal dryness 2%
A slight male predominance of arytenoid asymmetry (M/F sex
Vocal fatigue 2%
ratio: 1.02) was observed in this study. Hirano et al. [5] also reported
no particular anatomical difference between the two sexes in their
Table 2 series. On the other hand, Hamdan et al. [8] and Husseini et al. [9]
Prevalence of arytenoid asymmetry (%).
reported a marked male predominance of arytenoid asymmetry in
Arytenoid asymmetry their respective series of singers.
Right asymmetry 64.5 Anatomical studies have shown a higher prevalence of laryngeal
Left asymmetry 35.5 asymmetry in older people [5]. The mean age of the patients in this
Women 49.4
Men 50.6
series was 38.54 years (range: 18 to 85 years), while Hamdan et al.
[8] and Husseini et al. [9] reported a mean age of 23.4 years and
24 years in their respective series. This difference can be explained
Table 3 by the fact that their subjects were younger with an age range of
Types of arytenoid asymmetry (%).
15 to 39 years and 16 to 38 years, respectively. The vocal symp-
Cuneiform asymmetry 37.5 toms associated with arytenoid asymmetry in the present study
Mild 67.4 were occasional dysphonia (4%), pharyngeal dryness (2%) and vocal
Moderate 25
fatigue (2%). Hamdan et al. [8] also reported vocal symptoms such
Severe 7.6
Corniculate asymmetry 29.4 as hoarseness (19%), breathlessness (2.7%), vocal fatigue (22.7%)
Mild 61.1 and inability to project the voice (0.9%) and they also reported the
Moderate 34.7 absence of any correlation between these various vocal symptoms
Severe 4.2 and arytenoid asymmetry.
Aryepiglottic angle asymmetry 33.1
Mild 38.3
Most of the studies published to date have shown that ary-
Moderate 55.5 tenoid asymmetry is predominantly observed on the right side.
Severe 6.2 In the present series, arytenoid asymmetry was predominantly
observed on the right side (64.5%) compared to the left side (35.5%).
These results are similar to those reported by Hamdan et al. [8]
3. Results and Husseini et al. [9], who also reported a marked predominance
of right arytenoid asymmetry in their studies (74.2 and 70%). This
3.1. Epidemiological data right-sided predominance can be explained by the asymmetrical
position of the cricoarytenoid joint and a long thyroid lamina tilted
A total of 245 singers with a mean age of 38.54 years (range: 18 towards the left. A compensatory mechanism may also be involved
to 85 years) and an M/F sex ratio of 1.02 (124 men and 121 women) to maintain symmetry of the vocal folds during phonation, as the
were included in this study. About 5% of subjects reported a history arytenoid cartilages slide from a posterosuperior midline position
of smoking. The symptoms associated with arytenoid asymmetry to an anteroinferior lateral position and vice versa during adduction
were occasional dysphonia (4%), pharyngeal dryness (2%) and vocal and abduction movements. Because vocal fold vibrations require
fatigue (2%) (Table 1). adequate glottic closure in singers, alignment of the vocal folds in
the vertical and horizontal planes is therefore crucial. If arytenoid
3.2. Arytenoid asymmetry asymmetry in adduction is a compensatory phenomenon due to
anatomical asymmetry, it would therefore be reasonable to sup-
In this study, arytenoid asymmetry was more frequent on the pose that singers who are able to compensate by more accurately
right side (64.5%) than on the left side (35.5%) and was slightly aligning their vocal folds would have a better quality voice than
more frequent in men (50.6%) than in women (49.4%) (Table 2). those who compensate less effectively.
The type of asymmetry most commonly observed was cuneiform Among the various types of arytenoid asymmetry observed in
asymmetry in 37.5% of cases, followed by aryepiglottic angle asym- this study, cuneiform asymmetry was predominant (37.5%), fol-
metry in 33.1% of cases and finally corniculate asymmetry in 29.4% lowed by aryepiglottic angle asymmetry (33.1%) and corniculate
of cases. Asymmetry was considered to be mild in the majority of asymmetry (29.4%). These results corroborate those reported by
cases (Table 3). Hamdan et al. [8] and Husseini et al. [9]. Bonilha et al. [10] also
reported similar results in their study in normal subjects.
4. Discussion

Phonation is a complex process that requires coordination and

stability between various body systems. Phonation consists of
adduction of the vocal folds during voice production. Adequate
adjustment of the horizontal and vertical positions of the vocal folds
is important, as poor alignment or incomplete closure of the vocal
folds can be responsible for voice disorders.
Laryngeal asymmetry is not rare. Like other paired organs of
the body subject to asymmetry, laryngeal structures can present
5. Conclusion
Arytenoid asymmetry is frequent in singers, as about one in
two singers may present arytenoid asymmetry in adduction. How-
ever, the presence of arytenoid asymmetry does not appear to be
correlated with any vocal symptoms.

Please cite this article in press as: Clarós P, et al. Arytenoid asymmetry in opera singers. European Annals of Otorhinolaryngology, Head
and Neck diseases (2018), https://doi.org/10.1016/j.anorl.2018.08.014
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ANORL-812; No. of Pages 4 ARTICLE IN PRESS
4 P. Clarós et al. / European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2018) xxx–xxx

Disclosure of interest
The authors declare that they have no competing interest.
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Please cite this article in press as: Clarós P, et al. Arytenoid asymmetry in opera singers. European Annals of Otorhinolaryngology, Head
and Neck diseases (2018), https://doi.org/10.1016/j.anorl.2018.08.014