Severe laryngeal involvement in rheumatoid arthritis requiring permanent tracheostomy

A 72-year-old woman with severe rheumatoid arthritis developed atlantoaxial subluxation requiring surgery. Tracheal intubation was performed during the procedure. Gradually worsening dysphonia and dyspnea developed postoperatively. Laryngoscopy showed palsy of both vocal cords and coalescence of the arytenoid cartilages. Despite surgical treatment, permanent tracheostomy was required. There is evidence that laryngeal involvement is common but usually subclinical or mild in rheumatoid arthritis patients. Tracheal intubation can cause the laryngeal lesions to flare. Clinical manifestations are nonspecific and sometimes misleading (e.g., cough or pharyngeal and laryngeal pain). Direct laryngoscopy and computed tomography of the larynx allow evaluation of the lesions of the different components of the larynx. The case reported herein demonstrates that rheumatoid arthritis patients should be screened for laryngeal involvement by history and ENT examination and that any laryngeal abnormalities should be reported to the anesthesiologist if tracheal intubation is planned.