|Year : 2019 | Volume
| Issue : 1 | Page : 54-61
Laryngeal assessment of patients with rheumatoid arthritis using laryngeal photodocumentation
Mohamed Baraka1, Hossam El-Dessouky2, Alaa Labeeb3, Eman Ezzat4, Asmaa El-Dessouky4
1 Phoniatrics Unit, Department of Otorhinolaryngology, Ain Shams University, Cairo, Egypt
2 Phoniatrics Unit, Department of Otorhinolaryngology, Cairo University, Cairo, Egypt
3 Department of Physical Medicine and Rehabilitation, Menoufia University, Menoufia, Egypt
4 Phoniatrics Unit, Department of Otorhinolaryngology, Menoufia University, Menoufia, Egypt
|Date of Submission||25-Jul-2018|
|Date of Acceptance||09-Oct-2018|
|Date of Web Publication||17-Apr-2019|
Phoniatrics Unit, Department of Otorhinolaryngology, Faculty of Medicine, Menoufia University, Menoufia
Source of Support: None, Conflict of Interest: None
The aim was to assess the prevalence of dysphonia and laryngeal changes upon videolaryngoscopic examination of patients with rheumatoid arthritis (RA).
RA effects on larynx vary from mild asymptomatic effect to life-threatening conditions. Many authors have emphasized the need of studies in different communities on its effect. In Egypt, the knowledge regarding its manifestations on the larynx, as well as its laryngeal alterations, is limited.
Patients and methods
A total of 79 patients diagnosed as having RA in Menoufia University Hospitals from March 2015 to March 2017 were assessed by taking history and asking about different laryngeal complaints followed by telescopic videolaryngeal examination.
The estimated prevalence of laryngeal complaints in patients with RA was 57%. The most frequent complaints were globus pharyngeus in 53.2% of patients followed by phonasthenic symptoms in 32.9% of the patients. Dysphonia prevalence was 25.3%. Regarding videolaryngoscopic findings, the prevalence of changes was present in 86.15% of the patients. Most common finding has been posterior laryngitis, which was found in 78.5% of patients, followed by glottic gap in 34.2% and vocal folds rheumatoid nodules in 26.6% of them.
Laryngeal complaints and videolaryngoscopic morphological findings are prevalent among patients with RA, with a prevalence rate of 57 and 86.15%, respectively. The most frequent complaints were globus pharyngeus in 53.2% of patients followed by phonasthenic symptoms in 32.9% of the patients. Most common videolaryngoscopic findings have been posterior laryngitis, which was found in 78.5% of our patients, followed by glottic gaps in 34.2%.
Keywords: bamboo nodules, laryngeal complaints, rheumatoid arthritis, videolaryngoscopic alterations
|How to cite this article:|
Baraka M, El-Dessouky H, Labeeb A, Ezzat E, El-Dessouky A. Laryngeal assessment of patients with rheumatoid arthritis using laryngeal photodocumentation. Menoufia Med J 2019;32:54-61
|How to cite this URL:|
Baraka M, El-Dessouky H, Labeeb A, Ezzat E, El-Dessouky A. Laryngeal assessment of patients with rheumatoid arthritis using laryngeal photodocumentation. Menoufia Med J [serial online] 2019 [cited 2019 Jul 17];32:54-61. Available from: http://www.mmj.eg.net/text.asp?2019/32/1/54/256091
| Introduction|| |
Rheumatoid arthritis (RA) is a chronic, autoimmune disease, of unknown cause, which affects mainly women between 30 and 50 years of age. The world prevalence in the adult population is ∼0.5–1%, and the incidence is of 20–50 cases per 100 000 people annually . RA represents articular as well as extra-articular manifestations, which may potentially happen to any small synovial joint, including the laryngeal joints . Because of unique anatomical and physiological characteristics of the larynx, its effect on the larynx has a great importance to exclude bad sequelae that can reach to be life threatening . Laryngeal involvement in RA was described as early as in 1880 by Mackenzie , by means of studies in cadavers. Since then, several case reports and studies have been published trying to describe the laryngeal symptoms often reported by the affected patients and what are the most common endoscopic laryngeal and radiological findings that the caring physician should be aware of . The condition is, however, rather uncommon, and the precise diagnosis is difficult to settle. The presentation may be dysphonia and airway obstruction as described by interesting Egyptian case report that described the atypical laryngeal presentations in different rare diseases including RA . Although videolaryngoscopy is a standard technique in otolaryngology, there is little information on using it for laryngeal involvement in patients with RA. In Egypt, the knowledge regarding RA manifestations in the larynx, as well as its respective statistical data, is limited. The aim of this study was to assess the prevalence of dysphonia and laryngeal changes upon videolaryngoscopic examination of patients with RA.
| Patients and Methods|| |
This was a descriptive case series study conducted on 79 patients with RA attending the outpatient clinic of Physical Medicine, Rehabilitation and Rheumatology in Menoufia University Hospitals in the period from March 2015 to March 2017, to assess the prevalence of dysphonia and laryngeal changes upon videolaryngoscopic examination. To be enrolled in the study, patients had to be definitely diagnosed as having RA according to the American College of Rheumatology criteria 2010  [Table 1]. Moreover, the patients must be at least 20 years old at the time of symptom onset and under medical treatment for at least one year. Exclusion criteria included previous orotracheal intubation for 24 h or more, documented head and neck cancer, laryngeal surgery, neck trauma, head and neck radiotherapy, central or peripheral neurologic disorders, and having collagen disease other than RA. The study protocol was approved by the local ethical committee of Menoufia University hospital. All patients gave written informed consent before inclusion into the study. Every patient has been subjected to both subjective and objective phoniatric assessment as follows. Subjective phoniatric examination was carried out on the basis of precise phoniatric interview including the following: identification data including name, age, sex, marital status, occupation, vocal demand, special habits as smoking. Laryngeal complaints, such as dysphonia, cough, difficulty of breathing or swallowing, phonasthenic symptoms or globus pharyngeus, were assessed. Voice capacity self-assessment questionnaire using Arabic version of Voice Handicap Index (VHI)  was used to assess the participants' self-perception of his/her voice. Moreover, subjective assessment was done by rheumatologist, including data of RA as time of onset of the disease, duration, extra-articular manifestations, and data on previous and current therapy. Videolaryngoscopy was performed using a digitalized videolaryngoscopic system manufactured by Italian Inventis company (Padova City, Italy M-900-01003-0001-highlight model plus-LED stroboscope), which consists of Invisia's Highlight Plus light source with light intensity 2000 lumens, Invisia's Medi Cam plus camera with Charge-Coupled Device (CCD) sensor with high sensitivity 1280 × 960 pixels, two interchangeable microphones (one contact microphone and one clip-on), rigid oral 90° angle telescope model Hipp E 2690, dual foot switches to start and end the recording, fiber-optic light cable 4.8 × 1800 mm, autoclavable with Storz adapters on both sides, colored laser printer, and the used software (Inventis Daisy software system 3.6.3B3 with Visia module), developed by Inventis company. All participants completed videolaryngoscopic examination of the larynx while seated. A 90° rigid endoscopic examination was performed, during which participants were asked to sustain the vowel/i/in their chest register at a comfortable intensity then similarly while phonating in their highest register. The following structures were examined and photodocumented: valleculae, epiglottis, vocal folds, pyriform fossae, arytenoids, interarytenoids region, anterior commissure, ventricular folds (VFs), aryepiglottic folds, and postcricoid region. The items to be noticed were the mucous membrane (regarding color, luster, transparency, and vascular markings), vocal folds configuration, vocal folds gross mobility (adduction and abduction), loss of tissue or atrophy, symmetry of the glottis, ventricular bands girth, and position on phonation and glottic closure (shape and size of glottal gap at maximal width). The parameters of every patient were rated by two phoneticians and one otolaryngologist who rated their findings according to the aforementioned parameters. To ensure the quality of data, each rater did the laryngoscopic examination review on two separate sessions 2–4 weeks apart to assess the intrarater reliability.
Results were collected, tabulated, and statistically analyzed by an IBM compatible personal computer with SPSS statistical package version 23 (IBM corporation Version 23, Armonk, New York city, United States of America) . Two types of statistical analysis were done: (a) descriptive statistics, which was expressed in number, percentage, mean, and SD, and (b) analytic statistics, for example, Student's t-test is a test of significance used for comparison of quantitative variables between two groups of normally distributed data, whereas Mann–Whitney's test was used for comparison of quantitative variables between two groups of not normally distributed data. χ2-Test was used to study association between qualitative variables. Whenever any of the expected cells were less than 5, Fischer's exact test was used, and two-sided P value of less than 0.05 was considered statistically significant.
| Results|| |
Regarding the demographic data in the current study, the mean value of age was 47.11 years. Most of our patients were females (female/male ratio was 78/1) and 97.5% of them were married. Overall, 88.6% of the patients were housewives, 6.3% were teachers, and 5.1% worked in other jobs [Table 2].
In the current study, laryngeal complaints were present in 57% of the patients. Overall, 5.1% of them complained of cough, 25.3% complained of dysphonia (this symptom was persistent in 16.5% of the cases and intermittent in 8.9% of them), none of the patients had dyspnea, difficulty of swallowing in 3.8%, globus pharyngeus in 53.2%, and 32.9% of the patients had phonasthenic symptoms (throat dryness, throat tenderness, frequent throat clearing, and difficulty in swallowing sticky throat mucous). Regarding videolaryngoscopic findings, the morphological changes were present in 86.15% of the patients. Presence of VFs nodules, posterior laryngitis, diffuse laryngitis, and glottic gap was seen in 26.6, 78.5, 2.5, and 35.4%, respectively. These findings were absent in 73.4, 21.5, 97.5, and 64.6%, respectively. Concomitant findings such as ectasia, brownish discoloration of the mucous membrane of VFs, polyp, hemorrhagic spot, hypertrophy, sulcus vocalis, and cyst with reaction were present in 12.2, 2.4, 1.2, 2.4, 1.2, 1.2, and 1.2%, respectively. In our study, VF immobility was absent in all patients (100%) [Table 3].
|Table 3: Prevalence of different laryngeal complaints and different videolaryngoscopic findings|
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In the present study, vocal fold nodules were present in 26.6% of cases with all of nodules located at the junction between the anterior and middle thirds of VFs. Base of the nodule was 1, 2, and 3 mm in 13.9, 7.6, and 5.1%, respectively. The height of VF nodules was either 1 or 2 or 3 mm in 7.6, 5.1, and 13.9% of the studied cases, respectively. They extended laterally to one-fourth width of VFs in 20.3% of the patients and to half width and whole width in 5.1% and 1.3% of the patients, respectively. Overall, 5.1% of the patients had unilateral VFs nodule and 21.5% had bilateral nodules and covered by intact mucosa in 24.1%, whereas brownish discoloration of covering mucosa was noticed in 2.5% of the patients. Regarding the equality of vocal folds nodules, it was equal in 21.5% of the cases. We observed that the glottic gap was present in 35.4% of the cases, and it was at middle in 35.4% of them. Regarding its shape and size, it was either hourglass or fusiform or parallel in 21.5, 12.7, and 1.3% of the patients, respectively, with size less than or equal to 1 mm in 29.1% and greater than or equal to 1 mm in 6.3% of studied cases. VHI was normal in 74.7% and either mild or moderate in 19.0% and 6.3% of the patients, respectively. VHI interpretation was as follows: normal (0), mild (1–30), moderate (31–60), and severe (61–120) [Table 4]. Regarding the relation between the presenting laryngeal symptoms and the videolaryngoscopic findings in our patients with RA, we found that posterior laryngitis was related to both phonasthenic symptoms and globus pharyngeus, as patients with posterior laryngitis had significantly higher percentage of phonasthenia symptoms and globus pharyngeus than patients without posterior laryngitis [Table 5].
|Table 4: Description of vocal fold nodules, glottic gap, and Voice Handicap Index|
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|Table 5: Assessment of association between laryngeal symptoms and videolaryngoscopic findings|
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| Discussion|| |
Both dysphonia and RA may compromise an individual's quality of life. There are many papers in the Egyptian medical literature discussing laryngeal changes and dysphonia in patients with RA. The prevalence of laryngeal involvement in RA is highly variable depending on the series studied and the technique used; although well known, laryngeal involvement in RA is variable and its symptoms less obvious than its pathological manifestations . The rheumatoid nodules can present as submucosal and/or subcutaneous masses in patients with autoimmune diseases. At the glottic level, these are more likely to occur in the middle part of the vocal folds [Figure 1]a .
|Figure 1: Videolarygoscopic images. (a) Bilateral vocal fold nodules in a 55-year-old woman with change of voice characteristic and globus pharyngeus 2 years ago (the patient has high activity with 15-year duration). (b) Rheumatoid bamboo nodules in a 44-year-old female patient with RA for 4 years and of moderate activity. (c) A 61-year-old female patient with 30 years of RA duration and in remission, demonstrating posterior laryngitis, arytenoids congestion, and bilateral early vocal fold nodules. RA, rheumatoid arthritis.|
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Laryngoscopic findings in RA may also include the presence of bamboo nodes. Endoscopic visualization shows transversally arranged cystic yellowish bamboo nodes in the submucosal space of the middle portion of the vocal folds [Figure 1]b . These lesions are seen more commonly in women with a history of phonotraumatic behavior and GERD [Figure 1]c . Histological examinations of laryngeal joints in RA have shown synovitis as the earliest change, which leads to synovial proliferation, fibrinous deposit, forming of pannus on joint surfaces, erosion of the joint cartilage, and finally, obliteration and ankylosis of joints with subsequent VF fixation. Ossification also may occur with long-standing fixation . Studies have shown that the CA joints are affected in 17–70% of patients with RA when assessed by laryngoscopy, computed tomography imaging, or postmortem histology . The laryngeal involvement in RA can be subclinical indeed ; laryngeal involvement was detected in 23 patients who were asymptomatic in our study. Many authors believed that the decreasing overall occurrence of symptomatic voice impairment in patients with RA may reflect the modern trend to suppress clinical synovitis optimally . Regarding the demographic data in this study, the mean value of age was 47.11 years. Most of our patients were female (female/male ratio was 78/1) and 97.5% of them were married. Overall, 88.6% of the patients were housewives, 6.3% were teachers, and 5.1% worked in other job. In agreement with our study, a study on 72 patients with RA showed that the group consisted of 54 (75%) female and 18 (25%) male patients, aged from 27 to 76 years (mean: 59.6 years) .
Similar age was reported in another series in which ages ranged between 33 and 76 years (mean age: 55.2 years) . Moreover, women with RA accounted for 70% of all the patients (n = 70) as reported in another study. Average age was 55.22 years, and more than half of their patients (53.1%) were married . In this study, laryngeal complaints were present in 57% of the patients. Overall, 5.1% of them complained of cough, 25.3% complained of dysphonia (this symptom was persistent in 13.9% of the cases and intermittent in 8.9% of them), none of the patients had dyspnea or stridor, 3.8% had difficulty in swallowing, 53.2% had globus pharyngeus, and 32.9% of the patients had phonasthenic symptoms (throat dryness, throat tenderness, frequent throat clearing, and difficulty in swallowing sticky throat mucous). Moreover, in agreement with our results, a study revealed that the most frequent laryngeal complaints were foreign body sensation in 51%, dysphonia in 47%, and voice weakness in 29% of the cases. In acute phases, patients may complain of burning, foreign body sensation in the throat, and difficulty in swallowing . Similar results were obtained by another study, in which laryngeal complaints were reported by 19 of the 27 patients (70.4%). The most common symptoms were dysphonia and sensation of a foreign body in the throat followed by vocal fatigue . In a recent study on a total of 82 participants, consisting of 42 patients with RA and 40 non-RA patients as the control group, concluded that there was a statistically significant difference in the prevalence of foreign body sensation, dryness, coughing, and dyspnea among patients with RA versus controls (42.9 vs. 17.5%, 31 vs. 2.5%, 28.6 vs. 7.5%, and 9.5 vs. 0%, respectively) .
Regarding videolaryngoscopic findings, morphological changes in laryngeal examination were found in 86.15% of the patients and absent in 13.9% of them. Presence of VF nodules, posterior laryngitis, diffuse laryngitis, glottic gap, was seen in 26.6, 78.5, 2.5, and 35.4%, respectively. None of our patients had VF immobility, with only one patient with rheumatoid bamboo-shaped nodules. In agreement with our findings, in a study on patients with RA, posterior laryngitis was the most prevalent videolaryngoscopy-related diagnosis (44.7%), with a percentage value higher than the one found in the control group (32.5%); however, there was no statistical significance . Regarding the high association between GERD Gastroesophageal reflux disease and RA, a recent study in 2018 was conducted, in which an alternative hypothesis other than the effect of anti-RA medications on the gastric acidity including NSAIDs has been recently proposed that gastrointestinal disorders may be part of the clinical spectrum and pathogenesis of RA disease and revealed a higher prevalence of GERD among patients with RA compared with the general population (24.6 vs. 11.5%) . The incidence of posterior laryngitis in our study was 78.5%, whereas in a previous recent study on 47 patients, it was 44.7%. Beirith et al.  also found that there is a statistically significant difference between the patient and control groups in symptoms of vocal fatigue and globus pharynges, with non-significant correlation regarding dyspnea and stridor.
A recent study, in agreement with our results, revealed that the prevalence of nasopharyngeal laryngoscopic alterations was 57.1% in patients with RA and 30% in the control group. Only one patient with RA revealed a rheumatoid nodule. Four of the 16 patients who were asymptomatic were detected to have findings . Many authors have suggested that morphological changes in the larynx observed in the course of RA can lead to vocal folds immobility . According to a study done using radiological evaluation of laryngeal joints revealed that erosive arthritis of the cricoarytenoid joint (CAJ) is present in 45% of patients with RA. Simultaneously, the authors noticed that the CA arthritis may be asymptomatic in 58% of patients . Many authors believe that the lower overall occurrence of symptomatic voice impairment in patients with RA may reflect the modern trend to suppress clinical synovitis optimally . In agreement with our results is a study on 47 patients with RA, which discovered vocal fold immobility in only one case among the patients . The laryngeal involvement in RA can be subclinical indeed ; laryngeal involvement was detected in 26 patients who were asymptomatic in our study. The mean duration of these cases has been 9.69 ± 7.47, whereas the mean duration of the symptomatic cases with discovered videolaryngoscopic alterations was 11.02 ± 7.77. Similar results were seen in another study in which laryngeal alterations were found in 4 of 16 patients who were asymptomatic . Another study reported that laryngeal involvement was present in 5 of 11 patients with RA at postmortem examination, and only two of them were symptomatic . The yield of imaging technique in the detection of CAJ involvement can go from 25 to 72% depending on the sensitivity of the technique used. In a study done by Berjawi et al.  on 19 patients with RA, 10 of them had evidence of structural anatomical abnormalities of the cricothyroid joint compared with none in the control group. There was a statistically significant difference in the prevalence of cricothyroid joint space narrowing among patients with RA versus controls (81.8 vs. 0%). With respect to the CAJ, the prevalence of narrowing was higher compared with controls, and also 27% of the patients with RA had vocal fold thickening using computed tomography (CT) study.
In 1987, the American Rheumatism Association had included submucosal nodules in the laryngeal tissue in its revised criteria for the classification of RA. The nodules can present as submucosal and/or subcutaneous masses in patients with autoimmune diseases . At the glottic level, rheumatoid nodules are more likely to occur in the posterior part of the vocal folds . In our study, vocal fold nodules were present in 26.6% and absent in 73.4%. All of the cases with VF nodules were located at anterior and middle third of VFs, and 5.1% of the patients had unilateral VF nodule (5.1% of them in right side) and 21.5 had bilateral nodule. Regarding the equality of vocal fold nodules, it was equal to 21.5% of the cases. According to a recent study, rheumatoid nodules occur most often at the midpoint of the vocal folds where contact forces are maximal during vibration, and dysphonia is the principal symptom . Regarding the presence of glottic gaps, similar results to our study were observed in another study, which found different types of glottic gaps in patients with RA: 10 (21.3%) patients had posterior triangular glottic gaps, three (6.4%) with posterior gap, one (2.1%) with a spindle-shaped gap. and one (2.1%) with a hourglass gap. One (2.5%) patient in the control group had a spindle-shaped gap . Regarding VHI, it has been of 0 score in 74.7% and either mild or moderate in 19.0 and 6.3% of the patients, respectively. Similar results were concluded by Voulgari et al.  regarding the index, suggesting the presence of dysphonia; they found that the mean VHI among patients with RA was 6.36 ± 10.82 points. In the control group, the mean was 13.15 ± 13.78 points. VHI was higher than 15 points, characterizing dysphonia, in six (12.8%) of the patients with RA, and in 12 (30.0%) of the patients in the control group (P = 0.064). Therefore, the ratio of dysphonia prevalence among patients in the RA group vis-à -vis the control group was 0.42.
Limitations of our study include limited number of the studied patients. This was the number of the cases referred to us by rheumatology unit in our hospital for assessment of laryngeal manifestations. Another limitation was the lack for CT assessment of cricoarytenoid joint. This was owing to noncompliance of the patients with refusal to do CT study. Lack of stroboscopic assessment in our study was owing the unfortunate incidence that the stroboscopic assessment system in our phonitrics unit at time of the study was not functioning during the study duration. The initial design of the study was a descriptive case series study (to study prevalence) without a control group. We recommend a further comparative study with a control group in the discussion section.
| Conclusion|| |
From the presented results, we concluded that laryngeal complaints and videolaryngoscopic morphological findings are prevalent among patients with RA, with a prevalence rate of 57 and 86.15%, respectively. The most frequent complaints were globus pharyngeus in 53.2% of patients followed by phonasthenic symptoms in 32.9% of the patients. Dysphonia prevalence was 25.3% of the patients. Most common videolaryngoscopic findings have been posterior laryngitis, which was found in 78.5% of our patients, followed by glottic gaps in 34.2% and vocal folds nodules in 26.6% of them.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]