INFO - Allergic and Immune Disorders of the Larynx

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Wake Forest University Baptist Medical Center

Center for Voice and Swallowing Disorders

Excerpt from " Allergic and Immune Disorders of the Larynx " :

Rheumatoid Arthritis

Rheumatoid arthritis is a systemic autoimmune disorder of unknown cause,

which can affect any organ in the body. Its most common manifestation is

symmetrical polyarthritis, but, it also can cause inflammation in nonjoint

structures, vasculitis, and pulmonary changes.3 Rheumatoid arthritis may

affect the larynx both directly and indirectly.

First, rheumatoid involvement of the cricoarytenoid joints may cause

hoarseness or airway obstruction. At post-mortem examination, up to 87% of

patients with rheumatoid arthritis have cricoarytenoid joint changes, but,

based on laryngoscopy, only 17-33% of such patients have clinical signs of

laryngeal involvement, namely posterior laryngeal inflammation and decreased

arytenoid mobility.4

Second, rheumatoid nodules may occur anywhere in the larynx or within the

substance of the vocal cord itself, leading to hoarseness. The gross

appearance of rheumatoid laryngeal nodules is variable. They may appear as

white submucosal nodules, as ulcerated friable polypoid lesions, or as

ill-defined masses deep within the substance of the vocal cords.

Occasionally, unsuspected rheumatoid nodules are discovered during direct

laryngoscopy by palpation of a nodule within the vocal cord.

Histologically, these lesions show a central area of fibrinoid necrosis

surrounded by histiocytes, plasma cells, and lymphocytes. They can be highly

vascularized and hyalinized; they may have a fibrous capsule. Frequently,

rheumatoid nodules of the larynx are misdiagnosed as pyogenic granulomas.5

Third, rheumatoid arthritis, like other collagen vascular diseases, often

involves the esophagus, causing esophageal dysmotility and reflux disease.

Thus, patients with rheumatoid arthritis may have reflux laryngitis, but it

is not known whether such reflux contributes to the arytenoid fixation.

The choice of treatment for rheumatoid airway obstruction secondary to

arytenoid fixation depends upon the patient's overall medical condition.

Usually surgical rehabilitation of arytenoid function is not possible, so

that endoscopic arytenoidectomy is often the treatment of choice. This

procedure leaves the patient with an adequate airway and a somewhat breathy,

dysphonic voice. Sometimes, the rheumatoid arthritis so severely affects the

neck that endoscopic exposure of the larynx is not possible. In such cases,

an open surgical procedure, or simply a tracheotomy, may be performed.

Because rheumatoid nodules of the larynx frequently lie within the substance

of the vocal cord and may be inflamed, the vocal cord may be scarred after

their removal. As a consequence, most patients with this type of rheumatoid

involvement have persistent hoarseness following nodule removal.

http://www.wfubmc.edu/voice/immune_disorders.html

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