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Rheumatology 2001; 40: 593-594
© 2001 British Society for Rheumatology
Letters to the Editor |
Bilateral cricoarytenoid joint involvement in rheumatoid arthritis: a case report
Department of Physical Medicine and Rehabilitation and
1 Department of Otorhinolaryngology, School of Medicine, Firat University, 23119 Elazi
, Turkey
SIR, The cricoarytenoid joint (CJ) is an interesting site of rheumatoid arthritis (RA) involvement [1]. This is the joint between the cricoid and arytenoid cartilages in the back wall of the larynx. The CJs are rotated by the vibration of vocal cords, thus changing the tone of voice [2]. In RA cases, CJ involvement of 17–70% has been reported [3–5]. However, obstruction of the upper respiratory system is a rarely seen complication of RA [6, 7].
In this report, the case of a 50-yr-old woman with bilateral CJ arthritis is presented. The patient had been diagnosed with RA 10 yr previously and had received irregular treatment. From her history, it was realized that she had had the disease for 25 yr. She had received weekly intramuscular gold therapy about 9 yr ago for 2.5 months (10 doses). In 1995, she was admitted to a hospital with hoarseness, and direct laryngoscopy showed that the CJs were inflamed and their movements were restricted. Steroid injections were applied around the CJs. After this treatment, the symptoms disappeared for 2 yr. The patient was admitted to our clinic in 1998 with symptoms of dyspnoea and hoarseness. Examination showed ulnar deviation, subluxation in the metacarpophalangeal joint, swelling, pain and sensitivity in the wrists and bilateral second, third and fourth proximal interphalangeal joints, and deformities of the metatarsophalangeal and ankle joints.
The erythrocyte sedimentation rate was 67 mm/h, the C-reactive protein concentration was 6.23 mg/dl and the rheumatoid factor concentration was 232 IU/ml. Biochemical parameters were within normal limits.
Direct laryngoscopy showed that the vocal cords were open 1 mm in the paramedian position of the interarytenoid region. Emergency medication and parenteral steroid administration were carried out and her condition was monitored closely. The gap between the vocal cords increased to 2 mm.
The patient was considered to be RA-active according to the American Rheumatism Association criteria. She received prednisolone (20 mg/day)+NSAID. One month later, glottis width was found to be 1.5–2 mm and the arytenoids were stable by indirect laryngoscopy. Supportive tissues in the oropharynx and infrahyoid muscles were seen to be asymmetrical by computed tomography. Following tracheostomy, the vocal cords were endoscopically seen to be open (1.5–2 mm) and the arytenoids were fixed. One-third of the posterior vocal cord was removed by left arytenoidectomy. Steroids were injected into the right arytenoid joint. Post-operative improvement was seen in dyspnoea and hoarseness. Glottis width was 3 and 4 mm on days 7 and 15 after operation respectively. The tracheostomy cannula was removed and the wound healed spontaneously.
Symptoms of dyspnoea and hoarseness were significantly improved after the operation and the patient followed up with methotrexate (7.5 mg/week) and prednisolone (15 mg/day), and she was followed up. At present she has mild hoarseness with no dyspnoea.
Cricoarytenoid arthritis (CA) is a typical feature of rheumatoid synovitis. The symptoms include hoarseness, a sense of pharyngeal fullness in the throat when speaking and swallowing, pain in the ears and dyspnoea. Infection of the upper respiratory tract may occur and tracheostomy may be required [6–8].
Involvement of the CJ has been reported in RA [3–5]. In addition, gout, mumps, tuberculosis, syphilis, gonorrhoea, Tietze's syndrome, lupus erythematosus and trauma have also been reported to cause arthritis of the CJ [7]. CA may be seen in children with chronic stridor and laryngeal obstruction [9].
In RA patients, laryngeal symptoms usually depend on synovia in the CJs. These joints, which are quite flexible, are always used during the production of the voice and in respiration. Hoarseness is the most frequently encountered symptom. Odynophonia and odynophagia are frequently seen in acute episodes. Voice deficiency occurs in the chronic form, while stridor and dyspnoea also occur, depending on the unilateral or bilateral fixation of the arytenoid cartilage [2].
The relationship between the severity of RA and of laryngeal involvement is controversial. Laryngeal involvement has been reported to occur frequently in severe cases [10]. However, obstruction of the airways is rarely seen. In severe and prolonged RA, involvement of the CJ is increased, as in our case. Obstruction of the upper respiratory system in infections of this system is a serious complication in acute cases of severe RA. Endotracheal intubation is dangerous in the presence of ankylosis and infection as it causes acute respiratory obstruction. A fibre-optic bronchoscope may be more useful [1, 2, 7, 10]. Surgery is a radical therapy [8].
In conclusion, involvement of the CJ should be considered in the presence of symptoms such as dyspnoea, voice deficiency, change in the tone of voice and sore throat in severe and prolonged RA cases, and the therapeutic approach should be adapted accordingly. Immobilization of the vocal cords may block the passage of air in bilateral CJ ankylosis; this must be considered and investigated further in the differential diagnosis when breathing problems are present. In addition, studies on the relationship between the incidence of CJ involvement in RA and activity of disease in large patient groups may be useful.
Notes
Correspondence to: A Kamanli, Firat Universitesi, Firat Tip Merkezi, 23119 Elazi, Turkey. 
References
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- Geterud A, Bake B, Berthelsen B et al. Laryngeal involvement in rheumatoid arthritis Acta Otolaryngol (Stockh)1991;111:990–8.
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- Charlin B, Brazeau-Lamontagne L, Levesque RY. Cricoarytenoiditis in rheumatoid arthritis: Comparison of fibrolaringoscopic and high resolution computerised tomographic findings. J Otolaryngol1985;14:381–6.[Medline]
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- Fried MP, Shapiro J. Acute and chronic laryngeal infections. In: Paperella MM, Shumrick DA, Gluckman JI, Meyerhoff WL, eds. Otolaryngology, edn 3. Philadelphia: W. B. Saunders, 1991:2245–56.
- Willatt DJ, Stell PM. Vocal cord paralysis. In: Paperella MM, Shumrick DA, Gluckman JI, Meyerhoff WL, eds. Otolaryngology, edn 3. Philadelphia: W. B. Saunders, 1991:2289–306.
- Bertoloni MF, Bergamini BM, Marotti F et al. Cricoarytenoid arthritis as an early sign of juvenile chronic arthritis. Clin Exp Rheumatol1997;15:115–6.[Medline]
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