What is the treatment for cricoarytenoid arthritis?

Treatment of Cricoarytenoid Arthritis

Corticosteroid therapy is the first-line treatment for cricoarytenoid arthritis, with remarkable effectiveness in resolving respiratory obstruction and inflammation. 1 This approach should be prioritized due to its demonstrated efficacy in reducing acute inflammation and preventing potentially life-threatening airway compromise.

Clinical Presentation and Diagnosis

Cricoarytenoid arthritis is a potentially serious complication of rheumatoid arthritis that affects the cricoarytenoid joints in the larynx. Key clinical features include:

• Hoarseness and voice changes
• Odynophagia (painful swallowing)
• Throat pain
• Sensation of a foreign body in the throat
• Inspiratory stridor in severe cases
• Potential for acute upper airway obstruction

Diagnostic Approach

• Laryngoscopy: Reveals arytenoid fixation (typically in adduction), signs of active arthritis, and reduced vocal cord mobility 1, 2
• Low voltage radiography: Can show erosive changes in the cricoarytenoid joints 1
• Laryngeal electromyography (LEMG): May be useful for diagnosis of vocal fold paresis related to cricoarytenoid arthritis 3

Treatment Algorithm

Acute Phase Management

1. Corticosteroid Therapy

   • Systemic high-dose prednisone for acute inflammation 4
   • Produces complete resolution of laryngeal symptoms in many cases
   • Consider intra-articular steroid injection directly into the cricoarytenoid joint for targeted relief 5

2. Airway Management

   • Monitor for signs of respiratory distress
   • Emergency tracheostomy may be life-saving in cases of severe obstruction 6, 2

Maintenance Therapy

1. Disease-Modifying Antirheumatic Drugs (DMARDs)

   • Methotrexate (7.5-15mg weekly, escalating to 20-25mg) as first-line DMARD 7
   • Consider combination therapy with methotrexate and hydroxychloroquine for better disease control 7

2. Biologic DMARDs

   • For patients with inadequate response to conventional DMARDs
   • Options include TNF inhibitors, abatacept, rituximab, or tocilizumab 7

3. Physical Conservative Methods

   • Physical therapy focused on neck and laryngeal exercises
   • Voice therapy to optimize function with limited joint mobility 6

Surgical Interventions

For cases with persistent obstruction after medical management:

• Arytenoidectomy
• Mobilization and lateral fixation of the vocal cord 6

Monitoring and Follow-up

• Regular assessment of disease activity every 1-3 months until remission 7
• Periodic laryngoscopic examination to evaluate joint status and vocal cord mobility
• Adjustment of DMARD therapy based on response

Important Considerations

• Cricoarytenoid arthritis can be asymptomatic or have subtle symptoms that are overshadowed by other rheumatoid arthritis manifestations 6
• Bacterial infections of the larynx can trigger dangerous respiratory tract obstructions in patients with underlying cricoarytenoid arthritis 6
• Prompt recognition of airway obstruction due to cricoarytenoid arthritis is essential for appropriate management 2
• The condition has been reported in other autoimmune diseases beyond rheumatoid arthritis, including dermatomyositis 4

Treatment Pitfalls to Avoid

• Delaying corticosteroid therapy in acute presentations
• Failing to consider cricoarytenoid arthritis in rheumatoid arthritis patients with voice changes or respiratory symptoms
• Inadequate monitoring of disease activity
• Relying solely on NSAIDs, which may provide insufficient control of inflammation 7
• Chronic glucocorticoid use without appropriate DMARD therapy 7

By implementing this treatment approach, most patients with cricoarytenoid arthritis can achieve significant symptom improvement and avoid serious complications such as airway obstruction.