1

Introduction

Rheumatoid arthritis (RA) is a chronic systemic disease that, acting together with complex genetic and environmental factors, causes inflammation and damage prevalently diarthrosis joints but may also involve extra-articular tissues and organs. The prevalence of RA ranges from 0.5% to 1.0% in many populations, and females are 1 to 3 times more likely to develop the disease than males. Peak onset of the disease is at 30 to 55 years, but it can occur at any age .

The disease primarily occurs in the synovial and joint tissues, with clinical features that include painful, swollen joints, and joint stiffness. Important extra-articular features include lung and cardiovascular diseases. Other organs may also be involved, and clinical features include anemia, skin nodules, neuropathies, ocular disease, splenomegaly, and vasculitis .

The cricoarytenoid joint (CAJ) of the larynx is rarely involved in RA . The CAJ is a diarthrosis because it consists of a synovial membrane that surrounds an articular cavity and articular cartilaginous surfaces. An articular capsule completely surrounds the diarthrosis. During RA, the synovial membranes are thickened and are covered with “the cloth,” which is granulation tissue that develops inside the articular space and invades the articular cartilage and articular capsule. In addition, synovial liquid increases substantially, and swelling occurs, which is typically followed by the erosion of the cartilage and luxation of the joint.

Laryngeal involvement in RA can be asymptomatic. Symptoms can be nonspecific, such as hoarseness, dysphagia, odynophagia, ear pain, and a sense of fullness of the throat, often during swallowing or speaking. Complications such as obstruction of the upper respiratory tract with dyspnea and inspiratory stridor are rarely observed . Respiratory deficiency results when the inflammatory process in RA affects the CJAs . Cricoarytenoid joint involvement in 17% to 70% of RA Otolaryngology cases has been reported . Therefore, either acute inflammation or chronic ankylosis of the joint can impair vocal cord movement.

The aim of our study is to demonstrate the utility of high-resolution computed tomographic (HRCT) scan in the diagnosis of arthritic rheumatoid lesions of CAJ.

2

Case report

We present a case of a 47-year-old woman who was previously diagnosed with juvenile onset RA and active polyarticular erosive arthritis. The patient was taking 25 mg of prednisolone and 20 mg of Leflunomide daily. In April 2011, she presented with acute respiratory distress and inspiratory stridor. A fibreoptic laryngoscope examination showed bilateral impairment of vocal fold abduction and paradoxical vocal cord movement without any mass, laryngeal obstruction, or laryngeal inflammation.

An emergency tracheostomy was performed, and endoscopic examinations were repeated after 2, 4, and 6 months. These examinations revealed bilateral impairment of the vocal folds, abduction distress, and inspiratory stridor when she closed her stoma.

A neck HRCT scan with enhancement was performed. The imaging, together with the patient’s clinical history, indicated RA localized to both CAJs. The arytenoid and cricoid cartilages showed prominent hyperdense intra-articular sclerotic foci. We also observed an increased distance of articular cartilage due to an increased production of synovial liquid and/or to the apposition of the synovial membranes in the intra-articular space ( Fig. 1 ).

High-resolution computed tomography: CAJ with RA; arytenoid and cricoid cartilages with prominent intra-articular sclerotic foci (A) and increased density and spacing of the articular cartilage (B).