Head and Neck Surgery

RHEUMATOID ARTHRITIS

Posted by headnecksurgery on March 10, 2009

Rheumatoid arthritis (RA) is an inflammation of synovial tissue with symmetric involvement of the peripheral joints as the dominant clinical feature. The course is variable, usually progressive, and may affect nonarticular tissues. RA occurs in 1% of the population, affecting women two to three times more often than men. Although it may occur at any age and there is a distinct juvenile variety, it is more common in the fourth to fifth decade. Its onset may be acute, but more frequently it is insidious, with progressive joint involvement. Morning stiffness lasting more than 30 minutes or stiffness after prolonged inactivity are common symptoms. Tenderness and inflammation in an inactive joint are physical findings specific to RA. Subcutaneous rheumatoid nodules aid in the diagnosis. Nonarticular manifestations include visceral nodules, vasculitis, pleural or pericardial effusions, and Sjögren syndrome.

Head and Neck Manifestations

Articular involvement predominates in the diverse head and neck manifestations of RA, affecting the ossicles, temporomandibular joints, cricoarytenoid joints, and the cervical spine. Temporomandibular joint dysfunction may be prominent. Most patients with RA have temporomandibular joint complaints. Pain or tenderness at the joint or in the masseter or temporalis muscles, crepitus, limited mobility, or deviation are commonly reported. Radiographic evidence of joint erosion is often present. Temporomandibular joint dysfunction in patients with RA may be severe and cause contractures of the muscles of mastication, producing an anterior open bite deformity.

Cricoarytenoid joint involvement in RA is the most frequent cause of arthritis in these joints. Histologic abnormalities of the cricoarytenoid joints are present in 86% of patients with RA. Clinically, however, only 30% of the patients with RA are hoarse. Cricoarytenoid arthritis may present with dyspnea on exertion, anterior neck or ear pain, fullness in the throat, dysphagia, and aspiration. Hoarseness in RA is usually the result of cricoarytenoid joint involvement but may be caused by rheumatoid nodules within the cords and ischemic recurrent nerve paresis or paralysis. The sudden onset of stridor and dyspnea in a patient with RA is an emergency requiring systemic steroids and possibly tracheostomy. The oral cavity usually is not involved with abnormalities related to RA unless there is associated Sjögren syndrome. In an uncommon variant of rheumatoid vasculitis, there are oral ulcers similar to those seen in polyarteritis nodosa.

The middle ear may be involved in severe cases of RA if synovitis develops in the ossicular joints, but this rarely result in a conductive hearing loss except during an acute RA flair. Stiffness in the incudomalleolar and incudostapedial joints does not impair sound conduction but results in stiffness abnormalities detected on tympanometric testing. Autoimmune inner ear disease has been related to RA, but no definitive mechanism has been proven.

Treatment

Salicylates, nonsteroidal antiinflammatory agents, gold salts, penicillamine, hydroxychloroquine, and immunosuppressive agents have been used to suppress the inflammation in RA. Additional treatment goals include maintaining joint function and prevention of joint deformities.

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