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Article Excerpt
ABSTRACT: Patients with rheumatoid arthritis (RA) often have pulmonary manifestations, such as interstitial lung disease. The most common cause of upper airway obstruction is cricoarytenoid arthritis. Patients often complain of a pharyngeal foreign-body sensation or hoarseness, but some present with severe stridor. Bronchiolitis obliterans is characterized by a rapid onset of dyspnea and dry cough, with inspiratory rales and squeaks on examination. This presentation, particularly in middle-aged women with seropositive disease, distinguishes bronchiolitis obliterans from other pulmonary manifestations of RA. High-resolution CT may be more sensitive than pulmonary function tests for detecting small-airways disease, and it frequently shows moderate to severe air trapping on expiratory images. (J Respir Dis. 2008;29(8):318-324)
KEY WORDS: Rheumatoid arthritis, Interstitial lung disease, Bronchiectasis, Bronchiolitis obliterans
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Pleuropulmonary involvement in patients with rheumatoid arthritis (RA) is more common than has been believed. Although much of this involvement is asymptomatic, progressive disease can be disabling and even fatal. When patients present with respiratory symptoms, the diagnostic evaluation is complicated by issues such as increased risk of infection, use of drugs that have pulmonary toxicities, and the known frequency of lung disease related to RA itself.
In the July 2008 issue of The Journal of Respiratory Diseases, we reviewed RA-related pleural disease and interstitial lung disease (ILD). In this article, we discuss airway diseases such as bronchiectasis, drug-related lung disease, rheumatoid nodules, and pulmonary infections.
AIRWAYS DISEASE
Upper airway disease
The most common cause of upper airway obstruction in patients with RA is cricoarytenoid arthritis, which tends to be more common in women than in men. The cricoarytenoid joint is a true diarthrodial articulation. Inflammation, with eventual ankylosis of that joint may lead to symptoms referable to the head and neck. [1] On the basis of diagnosis by laryngoscopy or CT, the incidence of cricoarytenoid arthritis may be as high as 75%, but only about 25% of patients have laryngeal symptoms. [2-4]
Most commonly, patients complain of a pharyngeal foreign-body sensation or hoarseness, but dyspnea, pain radiating to the ears, stridor, dysphagia, odynophagia, and pain with speech have been described. [5] Sore throat and difficulty in drawing a full breath during inspiration predict mucosal and functional abnormalities seen on indirect laryngoscopy. [4]
Radiographic abnormalities of the joint may include cricoarytenoid erosion, cricoarytenoid luxation, cricoarytenoid prominence, and abnormal position of the true vocal cord. [2] Examination of flow-volume loops on spirometry may suggest upper airway obstruction.
In addition to chronic symptoms of upper airway obstruction, cricoarytenoid arthritis may present acutely, with severe stridor requiring emergent airway management and tracheostomy. Early diagnosis and management are ideal to avoid situations in which the diagnosis is made in the postoperative setting, with airway emergency associated with vocal cord trauma or laryngeal edema. [6] Management of chronic symptoms may include systemic or intra-articular corticosteroids. [1] Surgical management, including tracheostomy, arytenoidectomy, or arytenoidopexy, may be necessary in patients with progressive airway obstruction despite medical treatment. [5]
Other manifestations of RA in the head and neck may include rheumatoid nodules, which can present as submucosal masses mimicking squamous cell carcinoma, as well as subluxation of the atlantoaxial joint and arthritis of the temporomandibular joint, which lead to obstructive sleep apnea. [5,7]
Bronchiectasis
High-resolution CT (HRCT) often reveals bronchiectasis in patients with RA; the reported incidence is usually about 30%, but it has been observed to be as high as 58% in nonsmoking patients with RA. [8,9] The reasons for the increased frequency of bronchiectasis among patients with RA are not well understood. Theories include susceptibility to recurrent respiratory infections and genetic predisposition. [10]
It has also been suggested that heterozygosity for the [DELTA]F508 cystic fibrosis transmembrane conductance regulator gene may confer risk for diffuse bronchiectasis in RA. [11] Some hypothesize that bronchiectasis itself may be a risk factor for the development of RA....
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