Upper Airway Obstruction? Could Be Rheumatoid Arthritis
Elizabeth Guardiani, MD, an assistant professor of otorhinolaryngology, and a team of researchers from University of Maryland Medical Center are the first to describe cases of rheumatoid arthritis that initially presented as acute upper respiratory obstruction. The researchers describe subtle symptoms that could be mistaken for other etiologies, in an effort to raise the profile of unique RA presentation among otolaryngologists.
In the American Journal of Otolaryngology,1 Guardiani and colleagues outline two distinct cases. Both demonstrate how RA can present with synovitis in cricoarytenoid joints and lead to severe airway narrowing.
- The first case, a man in his 80s with a history of sleep apnea, had been experiencing months of dyspnea, noisy breathing, voice change, and dysphagia. A CT scan revealed soft tissue thickening of the supraglottic larynx. In the emergency department, laryngoscopy showed significant arytenoid swelling. He was intubated and received a tracheostomy. Biological samples revealed no infectious disease or malignant cause. Two months later, he experienced a similar episode of recurrent laryngeal edema and felt improvement after 24 hours of corticosteroids. This history, combined with a test for elevated rheumatoid factor and new onset bilateral shoulder pain, ultimately led to an RA diagnosis.
- The second case, a man in his 60s with end-stage renal disease and a 45 pack-year smoking history, presented to the emergency department with similar, progressive symptoms. He, too, received a tracheostomy, after neck CT revealed supraglottic fullness concerning for malignancy or abscess. Laryngoscopy showed bilateral arytenoid swelling. Biopsy was negative for malignancy. Symptoms improved in seven days with antibiotics and dexamethasone. However, two months later, cricoarytenoid joint swelling persisted combined with painful joint swelling in his hands. A serologic workup revealed elevated cyclic citrulline peptide, yet normal rheumatoid factor. Low-dose prednisone led to symptom improvement under rheumatology care.
Both patients received a RA diagnosis per a scorecard developed by the American College of Rheumatology/European League Against Rheumatism collaborative initiative. Points are assigned based on the type and duration of symptoms. The scorecard can help clinicians make sense of presentations that do not initially include overt symptoms such as peripheral joint pain or elevated rheumatoid factor. In the two University of Maryland Medical Center cases, initial RA presentations were limited to severe upper airway obstruction due to cricoarytenoiditis.
Wrote the researchers, "It is essential for otolaryngologists to recognize this possible presentation of RA to ensure more timely and appropriate diagnosis and treatment."
- Bhatnagar K, Meenan K, Guardiani E. Rheumatoid arthritis presenting as acute upper airway obstruction. Am J Otolaryngol. Nov-Dec 2020;41(6):102545. doi: 10.1016/j.amjoto.2020.102545. Epub 2020 May 16.