ANESTHESIA A N D ANALGESIA. . . Current Researches VOL. 54, NO. 6,Nov.-DEc.,1975
742
Rheumatoid Arthritis of the Cricoarytenoid Joints: An Airway Hazard DONALD FUNK, M.D.*
FRANK RAYMON, M.D.1. Chicago, Illinois$
The anesthesiologist must maintain a high index of suspicion for the presence of cricoarytenoid arthritis and vocal-cord fixation in the rheumatoid arthritic. He must be prepared to intubate the trachea blindly, attempting t o minimize trauma by using a smaller endotracheal tube. Indirect laryngoscopy, or direct laryngoscopy using a fiberoptic laryngoscope,
may be indicated as part of t h e preanesthetic evaluation. In some instances, preanesthetic tracheostomy or an alternative regional anesthetic technic may be appropriate. Unusually close vigilance in the postoperative period may be required to detect signs of postextubation airway obstruction.
A
and had been treated with salicylates, gold salts, chloroquine, phenylbutazone, and corticosteroids. He had experienced hoarseness and mild exertional dyspnea for the past 3 years and inspiratory stridor for the past 3 months.
management in the presence of an arthritic triad involving the larynx, the cervical spine, and the temporomandibular joints may tax the expertise of even the most experienced anesthesiologist. Arthritic disease of the cricoarytenoid joints occurs in as many as 26 percent of patients with rheumatoid arthritis.' This insidious involvement can cause serious upper-airway obstruction. IRWAY
On admittance, the patient was found to have mild kyphosis, mild exertional dyspnea, and swollen and deformed wrists, hands, feet, and knees. He could not extend his Some excellent discussions of this prob- head and could open his mouth only slightlem have been published,2-j but few cases ly. Chest expansion was limited to 3.75 cm, have been described in the anesthesia litera- and the expiratory phase of respiration was ture."-g The following case report illustrates prolonged. Although he was still hoarse, the anesthetic problems associated with this stridor was not present. There was a notable arthropathy . decrease in the distance from cricoid cartilage to sternal notch. Percussion and ausCASE REPORT cultation demonstrated no abnormalities of A 53-year-old man, 163 crn tall and weigh- his heart or lungs. The spleen and prostate ing 84 kg, was admitted for cholecystectomy were enlarged. and evaluation of lower urinary-tract symptoms. The last attack of cholecystitis had Hemoglobin was 13.2 gm/100 ml, hematooccurred 7 weeks before admission. He had crit 39 percent, and WBC count 3400, with a 10-year history of rheumatoid arthritis a normal differential. A latex agglutination "Assistant Professor of Clinical Anesthesia ?Associate Professor of Clinical Anesthesia tDepartment of Anesthesia, Northwestern University Medical School, Chicago, Illinois 60611. Paper received: 1/17/75 Accepted for publication: 4/10/75
Cricoarytenoid Joints.
. . Funk and Raymon
743 TABLE
Pulmonary Function Studies Observed
44
Maximum breathing capacity, L/min Maximum breathing capacity, af t er bronchial dilator Forced vital capacity, ml Forced expiratory volume at 1 sec, percent of forced vital capacity
Slow vital capacity, ml Residual volume, ml Total lung capacity, ml
Predicted
Percent*
177
25
46
177
27
4340
5470
79
58 %
75%
4390
5470
79
2710 7100
3060 8530
86 87
Residual volume/total lung capacity ratio, percent
38
36
Maximum midexpiratory flow rate, L/sec
2.1
2.2
*Percent of predicted normal value.
test was positive at a 1:2500 titer. Alkaline phosphatase was 585 units (normal 30 to 85 units). Serum electrolytes and ECG were normal. The chest roentgenogram showed a normal cardiac silhouette, with moderate emphysema and marked kyphosis. Cholecystograms verified the presence of gallstones. Lung volumes were considered to be within normal limits (table). The forced expiratory volume in 1 second was decreased, but not to a sufficient degree to explain the 25 percent maximum breathing capacity. These results were compatible with an extrathoracic fixed obstruction. Otolaryngologic consultation was not requested because this obstruction was thought to be due to fixation of the chest cage. Twenty-five minutes after the beginning of general anesthesia for diagnostic cystoscopy and needle biopsy of the prostate, using an inhalation induction and maintenance with N,O-0,-enflurane, airway maintenance by mask became extremely difficult, necessitating orotracheal intubation. Laryngoscopy was difficult. The glottis was not visualized, so an 8 mm tube was passed blindly under the tip of the epiglottis. The patient was extubated at the end of this l'/z hr procedure, and no further difficulty was encountered. On the following day, the patient experienced some dyspnea at rest, which was relieved by the use of a cervical orthopedic collar. On the 4th day, a transurethral resection of the prostate was performed under spinal anesthesia. The surgical, anesthetic, and postanesthetic courses were uneventful.
On the 13th day, a cholecystectomy was scheduled. Anesthesia was induced with thiopental. Succinylcholine was then given, but attempts at laryngoscopy were unsuccessful. After the relaxant effect wore off, the trachea was intubated blindly with a nasal tube, passed as the patient breathed spontaneously. Anesthesia was maintained with N,O-0, and muscle relaxant, supplemented with intermittent doses of fentanyl. The d-tubocurarine (66 mg) used was adequately reversed with neostigmine and atropine at the conclusion of the operation. The patient was extubated in the recovery room and given humidified O2 by face tent. There were no airway problems during the early recovery period, but 25 minutes later, the patient complained of inability to inspire and quickly became cyanotic. Establishment of the airway and ventilation with bag and mask were accomplished with considerable difficulty. He was reintubated with a nasotracheal tube and respiration was supported by a mechanical ventilator. Within 2 hours, artificial ventilation was no longer required, and humidified 0, (40 percent) was administered via a Briggs adapter. Blood-gas analysis revealed a pH of 7.44, Paco, 43 torr, and Pao, 124 torr. The patient was extubated the following morning. Indirect laryngoscopy by a consultant in otolaryngology revealed that the vocal cords were adducted and fixed, with a 4 mm glottic opening on inspiration. Both arytenoidopexy and tracheostomy were considered, but neither procedure was needed as he continued to improve with steroid therapy.
744
ANESTHESIA AND ANALGESIA . . . Current Researches VOL.54, No. 6, Nov.-DEc.,1975
DISCUSSION At the time of his initial physical examination, this patient had neither stridor nor a remarkable degree of voice alteration, which would have called attention to the degree of difficulties seen at subsequent laryngoscopy. The history of stridor was probably not taken as seriously as it might have been. No effort was made to have the patient hyperventilate to unmask incipient stridor. Clinical examination of the chest clearly showed restricted mobility, with less than 4 cm expansion in inspiration. Consequently, the pulmonary-function test abnormalities were ascribed to this restriction. Although this fixation may have contributed significantly to the test results, the sources of extrathoracic airway obstruction obviously include sites other than the chest wall. The possibility that the larynx might have been such a site was not entertained seriously. Had it been, a consultant in otolaryngology might have recommended an elective tracheostomy prior to the administration of anesthesia. Even if this were not done, a better appreciation of the serious degree of compromise in this patient would have made management of his subsequent problems easier. It might, for example, have been possible, by a therapeutic dose of steroids given prior to extubation, to avoid the episode of postoperative airway obstruction. Thus, this patient showed several airway problems which accompany rheumatoid arthritis. Involvement of the cricoarytenoid joints produces progressive narrowing and fixation of the vocal cords in adduction, thus compromising the airway.10 This anatomic alteration, plus immobility of the cervical spine and of the temporomandibular joints, often make visualization of the glottis impossible. The basic problem is twofold: narrowing of the airway and inability to expose the glottis for intubation.
It is difficult to determine which rheumatoid patient will present an airway problem. Limitation of motion of the head and neck and of the extent to which the mouth can be opened can be readiIy evaluated. Arthritic involvement of the larynx is not so easily assessed. Certain clinical signs and symptoms4~10~l1 should arouse suspicion, and their presence should be a strong indication for indirect laryngoscopy as part of the preanesthetic work-up. These include the following:
1. Persistent fullness in the throat while speaking. 2. Tenderness of the larynx. 3. Inspiratory stridor. 4. Dysphagia. 5. Dysphonia and hoarseness. 6. Pain radiating from the larynx to the ears.
Diagnosis may be enhanced by indirect laryngoscopy, or alternatively, direct laryngoscopy utilizing a fiberoptic laryngoscope. Lateral x-rays of the larynx may reveal arytenoid mucosal edema.10 Once the diagnosis is established, the airway management will largely depend upon the degree of laryngeal involvement. If this is minor, the use of a smaller-than-normal endotracheal tube may be all that is required. Difficulty in exposing the larynx should be anticipated and a blind nasal intubation should be considered. Muscle relaxants and control of ventilation should be avoided until after intubation. Special care should be taken to avoid trauma, as airway obstruction may occur following extubation. Extubation should be delayed until the patient is alert. Close observation, availability of trained personnel, and adequate equipment for reintubation are essential to safeguard the patient in the postanesthetic period. Steroids and humidified 0, are used in some centers to reduce laryngeal edema.11,12 The use of narcotics should be reserved for treatment of severe pain and kept to the minimum dosage required to alleviate this distress.0 In the presence of severe arthritic involvement of the larynx, endotracheal intubation should be avoided; the airway is already compromised, making impossible an atraumatic intubation. A presurgical tracheostomy under local anesthesia may safely establish an airway and avoid these problems. The judicious use of a regional anesthetic technic when possible may prove to be a safer alternative.
REFERENCES 1. Lofgren RH, Montgomery WW: Incidence of laryngeal involvement in rheumatoid arthritis. New Eng J Med 267:193-195, 1962 2. Woldorf NM, Pastore PN, Terz J: Rheumatoid arthritis of the cricoarytenoid joint. Arch Otolaryng 93:623-627, 1971
3. Grossman A, Martin JR, Root Hs: Rheumatoid arthritis of the cricoarytenoid joint. Laryngo-scope 71:530-544, 1961
Cricoarytenoid Joints.
. . Funk and Raymon
745
4. Polisar IA: T h e crico-arytenoid joint: a diarthrodial articulation subject to rheumatoid arthritic involvement. Laryngoscope 69: 1129-1164, 1959 5. Montgomery WW: Cricoarytenoid arthritis. Laryngoscope 73:801-836, 1963 6. Gardner DL, Holmes F: Anaesthetic and postoperative hazards in rheumatoid arthritis. Brit J Anaesth 33:258-264, 1961 7. Edelist G: Principles of anesthetic management in rheumatoid arthritic patients. Anesth & Analg 43:227-231, 1964 8. Phelps JA: Laryngeal obstruction due to cricoarytenoid arthritis. Anesthesiology 27:518-522,
12. Bienenstock H, Erlich GE, Freyberg RH: Rheumatoid arthritis of the cricoarytenoid point. A clinicopathologic study. Arthritis Rheum 6:48-63,
1966
1963
9. Jenkins LC, McGraw RW: Anaesthetic management of the patient with rheumatoid arthritis. Canad Anaesth SOCJ 16:407-415, 1969 10. Zizmor J , Noyek AM: Some miscellaneous disorders of the larynx and pharnyx. Seminars Roentgen 9:311-322, 1974 11. Copeman WSC: Rheumatoid arthritis and the cricoarytenoid joints. Brit J Clin Pract 22:421-422, 1968
Dose response effectiveness of propranolol for t h e treatment of angina pectoris. Alderman EL, Davies RO, Crowley JJ e t al: Cir 51:964-975, 1975 Propranolol (80, 160 and 320 mg) and placebo were administered during 4 doubleblind 6 week study periods t o 17 male patients with coronary a r t e r y disease. Angina frequency was reduced as compared to t h e placebo period in 35 percent of patients at t h e 80 m g propranolol dose, 59 percent at t h e 160 m g dose and in 76 percent when t h e dose w a s 320 mg. Exercise tolerance increased with increasing doses of propranolol and w a s significantly prolonged with t h e 320 m g dose. The degree of beta-adrenergie blockade f o r each propranolol dose was assessed during exercise testing b y measuring the h e a r t r a t e during maximum exercise as compared with t h e placebo study period. Propranolol blood levels were 24, 67 and 173 ng/ml respectively at t h e 3 increasing dose levels but a 10 fold range of serum levels was seen in different patients but at t h e same propranolol dose. These d a t a suggest t h a t a serum level of 30 ng/ml is necessary f o r a clinical response to propranolol. This clinical response is associated with a level of beta-adrenergic blockade which produces a 20 percent o r g r e a t e r reduction in the heart r a t e attained with maximum exercise.
742
Rheumatoid Arthritis of the Cricoarytenoid Joints: An Airway Hazard DONALD FUNK, M.D.*
FRANK RAYMON, M.D.1. Chicago, Illinois$
The anesthesiologist must maintain a high index of suspicion for the presence of cricoarytenoid arthritis and vocal-cord fixation in the rheumatoid arthritic. He must be prepared to intubate the trachea blindly, attempting t o minimize trauma by using a smaller endotracheal tube. Indirect laryngoscopy, or direct laryngoscopy using a fiberoptic laryngoscope,
may be indicated as part of t h e preanesthetic evaluation. In some instances, preanesthetic tracheostomy or an alternative regional anesthetic technic may be appropriate. Unusually close vigilance in the postoperative period may be required to detect signs of postextubation airway obstruction.
A
and had been treated with salicylates, gold salts, chloroquine, phenylbutazone, and corticosteroids. He had experienced hoarseness and mild exertional dyspnea for the past 3 years and inspiratory stridor for the past 3 months.
management in the presence of an arthritic triad involving the larynx, the cervical spine, and the temporomandibular joints may tax the expertise of even the most experienced anesthesiologist. Arthritic disease of the cricoarytenoid joints occurs in as many as 26 percent of patients with rheumatoid arthritis.' This insidious involvement can cause serious upper-airway obstruction. IRWAY
On admittance, the patient was found to have mild kyphosis, mild exertional dyspnea, and swollen and deformed wrists, hands, feet, and knees. He could not extend his Some excellent discussions of this prob- head and could open his mouth only slightlem have been published,2-j but few cases ly. Chest expansion was limited to 3.75 cm, have been described in the anesthesia litera- and the expiratory phase of respiration was ture."-g The following case report illustrates prolonged. Although he was still hoarse, the anesthetic problems associated with this stridor was not present. There was a notable arthropathy . decrease in the distance from cricoid cartilage to sternal notch. Percussion and ausCASE REPORT cultation demonstrated no abnormalities of A 53-year-old man, 163 crn tall and weigh- his heart or lungs. The spleen and prostate ing 84 kg, was admitted for cholecystectomy were enlarged. and evaluation of lower urinary-tract symptoms. The last attack of cholecystitis had Hemoglobin was 13.2 gm/100 ml, hematooccurred 7 weeks before admission. He had crit 39 percent, and WBC count 3400, with a 10-year history of rheumatoid arthritis a normal differential. A latex agglutination "Assistant Professor of Clinical Anesthesia ?Associate Professor of Clinical Anesthesia tDepartment of Anesthesia, Northwestern University Medical School, Chicago, Illinois 60611. Paper received: 1/17/75 Accepted for publication: 4/10/75
Cricoarytenoid Joints.
. . Funk and Raymon
743 TABLE
Pulmonary Function Studies Observed
44
Maximum breathing capacity, L/min Maximum breathing capacity, af t er bronchial dilator Forced vital capacity, ml Forced expiratory volume at 1 sec, percent of forced vital capacity
Slow vital capacity, ml Residual volume, ml Total lung capacity, ml
Predicted
Percent*
177
25
46
177
27
4340
5470
79
58 %
75%
4390
5470
79
2710 7100
3060 8530
86 87
Residual volume/total lung capacity ratio, percent
38
36
Maximum midexpiratory flow rate, L/sec
2.1
2.2
*Percent of predicted normal value.
test was positive at a 1:2500 titer. Alkaline phosphatase was 585 units (normal 30 to 85 units). Serum electrolytes and ECG were normal. The chest roentgenogram showed a normal cardiac silhouette, with moderate emphysema and marked kyphosis. Cholecystograms verified the presence of gallstones. Lung volumes were considered to be within normal limits (table). The forced expiratory volume in 1 second was decreased, but not to a sufficient degree to explain the 25 percent maximum breathing capacity. These results were compatible with an extrathoracic fixed obstruction. Otolaryngologic consultation was not requested because this obstruction was thought to be due to fixation of the chest cage. Twenty-five minutes after the beginning of general anesthesia for diagnostic cystoscopy and needle biopsy of the prostate, using an inhalation induction and maintenance with N,O-0,-enflurane, airway maintenance by mask became extremely difficult, necessitating orotracheal intubation. Laryngoscopy was difficult. The glottis was not visualized, so an 8 mm tube was passed blindly under the tip of the epiglottis. The patient was extubated at the end of this l'/z hr procedure, and no further difficulty was encountered. On the following day, the patient experienced some dyspnea at rest, which was relieved by the use of a cervical orthopedic collar. On the 4th day, a transurethral resection of the prostate was performed under spinal anesthesia. The surgical, anesthetic, and postanesthetic courses were uneventful.
On the 13th day, a cholecystectomy was scheduled. Anesthesia was induced with thiopental. Succinylcholine was then given, but attempts at laryngoscopy were unsuccessful. After the relaxant effect wore off, the trachea was intubated blindly with a nasal tube, passed as the patient breathed spontaneously. Anesthesia was maintained with N,O-0, and muscle relaxant, supplemented with intermittent doses of fentanyl. The d-tubocurarine (66 mg) used was adequately reversed with neostigmine and atropine at the conclusion of the operation. The patient was extubated in the recovery room and given humidified O2 by face tent. There were no airway problems during the early recovery period, but 25 minutes later, the patient complained of inability to inspire and quickly became cyanotic. Establishment of the airway and ventilation with bag and mask were accomplished with considerable difficulty. He was reintubated with a nasotracheal tube and respiration was supported by a mechanical ventilator. Within 2 hours, artificial ventilation was no longer required, and humidified 0, (40 percent) was administered via a Briggs adapter. Blood-gas analysis revealed a pH of 7.44, Paco, 43 torr, and Pao, 124 torr. The patient was extubated the following morning. Indirect laryngoscopy by a consultant in otolaryngology revealed that the vocal cords were adducted and fixed, with a 4 mm glottic opening on inspiration. Both arytenoidopexy and tracheostomy were considered, but neither procedure was needed as he continued to improve with steroid therapy.
744
ANESTHESIA AND ANALGESIA . . . Current Researches VOL.54, No. 6, Nov.-DEc.,1975
DISCUSSION At the time of his initial physical examination, this patient had neither stridor nor a remarkable degree of voice alteration, which would have called attention to the degree of difficulties seen at subsequent laryngoscopy. The history of stridor was probably not taken as seriously as it might have been. No effort was made to have the patient hyperventilate to unmask incipient stridor. Clinical examination of the chest clearly showed restricted mobility, with less than 4 cm expansion in inspiration. Consequently, the pulmonary-function test abnormalities were ascribed to this restriction. Although this fixation may have contributed significantly to the test results, the sources of extrathoracic airway obstruction obviously include sites other than the chest wall. The possibility that the larynx might have been such a site was not entertained seriously. Had it been, a consultant in otolaryngology might have recommended an elective tracheostomy prior to the administration of anesthesia. Even if this were not done, a better appreciation of the serious degree of compromise in this patient would have made management of his subsequent problems easier. It might, for example, have been possible, by a therapeutic dose of steroids given prior to extubation, to avoid the episode of postoperative airway obstruction. Thus, this patient showed several airway problems which accompany rheumatoid arthritis. Involvement of the cricoarytenoid joints produces progressive narrowing and fixation of the vocal cords in adduction, thus compromising the airway.10 This anatomic alteration, plus immobility of the cervical spine and of the temporomandibular joints, often make visualization of the glottis impossible. The basic problem is twofold: narrowing of the airway and inability to expose the glottis for intubation.
It is difficult to determine which rheumatoid patient will present an airway problem. Limitation of motion of the head and neck and of the extent to which the mouth can be opened can be readiIy evaluated. Arthritic involvement of the larynx is not so easily assessed. Certain clinical signs and symptoms4~10~l1 should arouse suspicion, and their presence should be a strong indication for indirect laryngoscopy as part of the preanesthetic work-up. These include the following:
1. Persistent fullness in the throat while speaking. 2. Tenderness of the larynx. 3. Inspiratory stridor. 4. Dysphagia. 5. Dysphonia and hoarseness. 6. Pain radiating from the larynx to the ears.
Diagnosis may be enhanced by indirect laryngoscopy, or alternatively, direct laryngoscopy utilizing a fiberoptic laryngoscope. Lateral x-rays of the larynx may reveal arytenoid mucosal edema.10 Once the diagnosis is established, the airway management will largely depend upon the degree of laryngeal involvement. If this is minor, the use of a smaller-than-normal endotracheal tube may be all that is required. Difficulty in exposing the larynx should be anticipated and a blind nasal intubation should be considered. Muscle relaxants and control of ventilation should be avoided until after intubation. Special care should be taken to avoid trauma, as airway obstruction may occur following extubation. Extubation should be delayed until the patient is alert. Close observation, availability of trained personnel, and adequate equipment for reintubation are essential to safeguard the patient in the postanesthetic period. Steroids and humidified 0, are used in some centers to reduce laryngeal edema.11,12 The use of narcotics should be reserved for treatment of severe pain and kept to the minimum dosage required to alleviate this distress.0 In the presence of severe arthritic involvement of the larynx, endotracheal intubation should be avoided; the airway is already compromised, making impossible an atraumatic intubation. A presurgical tracheostomy under local anesthesia may safely establish an airway and avoid these problems. The judicious use of a regional anesthetic technic when possible may prove to be a safer alternative.
REFERENCES 1. Lofgren RH, Montgomery WW: Incidence of laryngeal involvement in rheumatoid arthritis. New Eng J Med 267:193-195, 1962 2. Woldorf NM, Pastore PN, Terz J: Rheumatoid arthritis of the cricoarytenoid joint. Arch Otolaryng 93:623-627, 1971
3. Grossman A, Martin JR, Root Hs: Rheumatoid arthritis of the cricoarytenoid joint. Laryngo-scope 71:530-544, 1961
Cricoarytenoid Joints.
. . Funk and Raymon
745
4. Polisar IA: T h e crico-arytenoid joint: a diarthrodial articulation subject to rheumatoid arthritic involvement. Laryngoscope 69: 1129-1164, 1959 5. Montgomery WW: Cricoarytenoid arthritis. Laryngoscope 73:801-836, 1963 6. Gardner DL, Holmes F: Anaesthetic and postoperative hazards in rheumatoid arthritis. Brit J Anaesth 33:258-264, 1961 7. Edelist G: Principles of anesthetic management in rheumatoid arthritic patients. Anesth & Analg 43:227-231, 1964 8. Phelps JA: Laryngeal obstruction due to cricoarytenoid arthritis. Anesthesiology 27:518-522,
12. Bienenstock H, Erlich GE, Freyberg RH: Rheumatoid arthritis of the cricoarytenoid point. A clinicopathologic study. Arthritis Rheum 6:48-63,
1966
1963
9. Jenkins LC, McGraw RW: Anaesthetic management of the patient with rheumatoid arthritis. Canad Anaesth SOCJ 16:407-415, 1969 10. Zizmor J , Noyek AM: Some miscellaneous disorders of the larynx and pharnyx. Seminars Roentgen 9:311-322, 1974 11. Copeman WSC: Rheumatoid arthritis and the cricoarytenoid joints. Brit J Clin Pract 22:421-422, 1968
Dose response effectiveness of propranolol for t h e treatment of angina pectoris. Alderman EL, Davies RO, Crowley JJ e t al: Cir 51:964-975, 1975 Propranolol (80, 160 and 320 mg) and placebo were administered during 4 doubleblind 6 week study periods t o 17 male patients with coronary a r t e r y disease. Angina frequency was reduced as compared to t h e placebo period in 35 percent of patients at t h e 80 m g propranolol dose, 59 percent at t h e 160 m g dose and in 76 percent when t h e dose w a s 320 mg. Exercise tolerance increased with increasing doses of propranolol and w a s significantly prolonged with t h e 320 m g dose. The degree of beta-adrenergie blockade f o r each propranolol dose was assessed during exercise testing b y measuring the h e a r t r a t e during maximum exercise as compared with t h e placebo study period. Propranolol blood levels were 24, 67 and 173 ng/ml respectively at t h e 3 increasing dose levels but a 10 fold range of serum levels was seen in different patients but at t h e same propranolol dose. These d a t a suggest t h a t a serum level of 30 ng/ml is necessary f o r a clinical response to propranolol. This clinical response is associated with a level of beta-adrenergic blockade which produces a 20 percent o r g r e a t e r reduction in the heart r a t e attained with maximum exercise.
