Involvement of cricoarytenoid joints in rheumatoid arthritis.

A 76-year-old man who was previously diagnosed with rheumatoid arthritis (RA) with juvenile onset and active polyarticular erosive arthritis involving hands, wrists, and metatarsal-falangeal joints came to our observation for bilateral paralysis of vocal cords. He was on treatment with deflazacort (7.5 mg/d) and indomethacin (25 mg/bid); methotrexate (12.5 mg/wk) was previously stopped after developing pulmonary fibrosis. He entered for acute respiratory failure with dyspnea and stridor which had never occurred before. A direct laryngoscopy evidenced bilateral paralysis of vocal cord, fixed in adduction with consequent insufficient glottic respiratory space. He underwent emergency tracheostomy. Laboratory analysis showed high levels of CRP (9.24 mg/dL), RF (568 IU/ml), and ESR (46 mm/h); he was also positive to anti-CCP (60 U.A.). High resolution CT (HRCT) scan of the larynx with bone algorithm was performed and revealed erosions of the arytenoid cartilage in correspondence of the cricoarytenoid (CA) joints surface (arrows). Cricoarytenoid arthritis secondary to RA with airway compromise was diagnosed. Leflunomide (20 mg/d) was added in therapy plan with significant improvement of clinical conditions. The CA joint is a true diarthrodial articulation formed by the cricoid and arytenoid cartilages. As in other diarthrodial joints, synovial membranes line the surfaces and synovial fluid fills the space enclosed by the fibrous joint capsule. Cricoarytenoid arthritis occurs most commonly in rheumatoid disease. Other etiologies include gout, disseminated lupus erythematosus, scleroderma, Tietze syndrome, upper respiratory tract infections, trauma, and vocal cord tumors. Clinical manifestations of rheumatoid arthritis in the CA joint are uncommon and symptoms can be vague (sensation of a foreign body, fullness or tension in the throat hoarseness, odynophagia, and pain with speaking or coughing), absent, or masked by concomitant joint involvement. The most common CT findings include the presence of cricoarytenoid erosion, luxation, prominence, and abnormal position of the true vocal cord. CT imaging plays an integral role in the assessment of the CA joint in patient with RA.