Rheumatology 2001; 40: 952-953
© 2001 British Society for Rheumatology
Letters to the Editor |
Dysphagia and stridor caused by laryngeal rheumatoid arthritis
Department of Rheumatology, Dudley Group of Hospitals NHS Trust, The Guest Hospital, Tipton Road, Dudley DY1 4SE, UK
SIR, A 52-yr-old man was admitted as an emergency with high dysphagia to liquids and stridor. He had complained of gradually deteriorating dysphagia for 6 months and some mild dyspnoea. His dyspnoea had deteriorated rapidly in the week preceding his admission and stridor was clearly audible. He had had severe erosive nodular rheumatoid arthritis for 10 yr and was on combination therapy with methotrexate 15 mg once weekly, folic acid 5 mg once weekly, cyclosporin 200 mg daily, hydroxychloroquine 200 mg daily and prednisolone 12.5 mg daily. He also suffered from non-insulin-dependent diabetes mellitus, hypertension and ischaemic heart disease for which he was being treated with mixtard insulin, metformin, atenolol, frusemide, simvastatin, aspirin and glyceryl trinitrate. He had undergone an upper gastrointestinal endoscopy for investigation of his dysphagia 8 weeks earlier; this had not revealed any significant abnormality. On admission he required insertion of an emergency tracheostomy. He had an urgent computed tomography scan of the neck which showed a large laryngeal mass situated posteriorly within the larynx extending from the base of the epiglottis to the level of the cricoid cartilage. The laryngeal lumen was severely compromised. There was destruction of the cricoid, arytenoid and thyroid cartilages. The anatomy of the neck was disrupted by the presence of extensive surgical emphysema due to breach of the laryngeal wall by the inflammatory mass and leakage of air into the surrounding tissues (see Fig. 1
). Laryngoscopy and biopsy of the mass was carried out. Biopsy of the left laryngeal ventricle revealed chronic inflammatory tissue infiltrating the subepithelial stroma associated with oedema and mild fibrosis consistent with rheumatoid synovial inflammation. Biopsy of the arytenoid area consisted of confluent rheumatoid nodules with total destruction of the arytenoid cartilage. He underwent further debridement of the inflammatory tissue with subsequent improvement in his stridor and dysphagia. His tracheostomy was removed 1 week post-operatively. When he was last seen his tracheostomy had healed well, he had no stridor and only minimal residual dysphagia. He continues on the anti-rheumatic medication listed above.
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Rheumatoid nodules and destructive inflammatory masses of the larynx and trachea have been described rarely in the literature. The cricoarytenoid joint in the larynx is a synovial joint and pathological descriptions of villous synovial proliferation and surrounding cartilage destruction characteristic of rheumatoid synovitis occurring at this joint were first made in the 1960s [1]. Symptoms of cricoarytenoid arthritis are frequently mild, consisting of intermittent dyspnoea and sore throat, although occasionally acute life-threatening stridor can develop due to fixation of the vocal cords in the midline [2–4]. Rheumatoid nodules can develop within the larynx and trachea in rheumatoid arthritis and can themselves erode through local structures [5]. If large, the nodules can cause dyspnoea, due to obstruction of the larynx, and dysphagia, due to extrinsic compression of the pharynx. Nodulosis occurs more frequently and more rapidly with methotrexate treatment, with 5–10% of patients treated with methotrexate developing nodules [6]. This gentleman was on treatment with methotrexate and had rheumatoid arthritis nodules elsewhere and therefore was at risk of developing laryngeal nodulosis. The inflammatory mass in this case appeared to be a mixture of synovitis and nodule formation; the exact origin could not be determined due to the extensive nature of the lesion at the time of diagnosis.
Endoscopy of the upper gastrointestinal tract is not good at detecting problems within the pharynx, as this area is frequently not visualized during the procedure, and this was almost certainly the cause of the negative upper gastrointestinal endoscopy report in this case. Rheumatologists should have a low threshold for referring rheumatoid arthritis patients with high dysphagia for laryngoscopy, particularly if dyspnoea or a sore throat accompanies it.
Notes
References
- Bienenstock H, Ehrlich GE, Freyberg RH. Rheumatoid arthritis of the cricoarytenoid joint: a clinicopathological study. Arthritis Rheum1963;6:48–63.
- Absalom AR, Watts R, Kong A. Airway obstruction caused by rheumatoid cricoarytenoid arthritis [letter]. Lancet1998;351:1099–100.
- Geterud A, Ejnell H, Mansson I, Sandberg N, Bake B, Bjelle A. Severe airway obstruction caused by laryngeal rheumatoid arthritis. J Rheumatol1986;13:948–51.[Medline]
- Bengtsson M, Bengtsson A. Cricoarytenoid arthritis—a cause of upper airway obstruction in the rheumatoid arthritis patient [letter]. Intensive Care Med1998;24:643.
- Sorensen WT, Moller-Andersen K, Behrendt N. Rheumatoid nodules of the larynx. J Laryngol Otol1998;112:573–4.[Medline]
- Combe B, Didry C, Gutierrez M, Anaya JM, Sany J. Accelerated nodulosis and systemic manifestations during methotrexate therapy for rheumatoid arthritis. Eur J Med1993;2:153–6.[Medline]
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