Case Report: Upper airway obstruction due to rheumatoid arthritis

Rheumatoid arthritis (RA) is a common autoimmune disease characterized by inflammation of small joints. Small synovial joints in the larynx can also become affected, and laryngeal involvement is seen in more than half of patients with RA. As most patients have subtle symptoms and indolent course, they are either misdiagnosed or undiagnosed. The acute worsening of cricoarytenoid arthritis can cause sudden upper airway obstruction and may require emergency intubation or tracheostomy. This life-threatening condition is described in only a handful of cases in the medical literature. Physicians should be aware of this rare but life-threatening consequence of RA. We present a case of sudden and severe upper airway obstruction secondary to laryngeal involvement in a patient with long-standing RA.

Disorders of the thoracic cage and diaphragm

Disorders of the thoracic skeleton can lead to a severe restrictive ventilatory defect, the risk of respiratory failure being highest with (1) scoliosis—particularly if the following characteristics are present: early onset, severe angulation, high in the thorax, respiratory muscle weakness, low vital capacity; (2) kyphosis—but only if of very sharp angulation (gibbus), most commonly seen following tuberculous osteomyelitis; and (3) after thoracoplasty—historically performed as treatment for pulmonary tuberculosis. While not a disorder of the skeleton, a similar pathophysiological pattern is seen in extreme obesity, and this is the fastest growing cause of referral to home ventilation centres. Arterial blood gases and quality of life can both be readily improved with non-invasive ventilation, usually using a nasal or face mask. Survival in most skeletal disorders after starting ventilation leads to apical bullae, pleural thickening/effusions, and cricoarytenoid arthritis, but rarely causes respiratory failure in the absence of other comorbidities.