|LETTER TO EDITOR
|Year : 2015 | Volume
| Issue : 2 | Page : 47-48
Laryngeal involvement in osteoarthritis: An interesting finding on video-laryngoscopic view
Uma Hariharan1, Shagun Bhatia Shah2, Ajay Kumar Bhargava2
1 Specialist, Anesthesia and Intensive Care, Bhagwan Mahavir Hospital, Delhi Government Health Services, Pitampura, Delhi 110 085, India
2 Department of Anesthesia and Oncosurgical Intensive Care, Rajiv Gandhi Cancer Institute and Research Centre, Sector 5, Rohini, Delhi 110 085, India
|Date of Web Publication||13-Jun-2016|
Dr. Uma Hariharan
(MBBS, DNB, PGDHM, Fellowship Oncoanesthesia) BH 41 East Shalimar Bagh, New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Hariharan U, Shah SB, Bhargava AK. Laryngeal involvement in osteoarthritis: An interesting finding on video-laryngoscopic view. J Laryngol Voice 2015;5:47-8
A 60-year-old ASA Grade 2, Mallampati Class 2, male patient was posted for elective robotic radical prostatectomy. He had a history of long-standing osteoarthritis (OA), for which bilateral knee replacement was done previously under regional anesthesia. He had no history of rheumatoid arthritis (RA) or gastroesophageal reflux disease (GERD) or upper respiratory tract infection (URI). He also complained of the occasional mild sore throat, with voice change (3-6 months). In view of anticipated difficult airway (presence of beard, short neck, irregular dentition, and two fingers mouth opening), C-MAC™ (Karl Storz, Tuttlingen, Germany) guided intubation was planned to secure, as well as to view the airway. Difficult airway cart was prepared preoperatively, including fiberoptic-bronchoscope (FOB). After standard monitoring and anesthesia induction with intravenous midazolam, propofol, and fentanyl citrate, video laryngoscope was inserted orally for real-time visualization of the upper airway. The laryngeal cartilages were found to be swollen and enlarged. The arytenoids were rounded, and the aryepiglottic folds were thick [Figure 1] and [Figure 2]. The true cords were normal with sluggish movements, and the trachea was intubated with a 7.5 mm cuffed endotracheal tube (Portex) under vision. After confirming correct tube placement, muscle relaxant was given for the surgery and circuit connected to the anesthesia machine ventilator. The entire perioperative course was uneventful, and all vitals were within normal limits. Intravenous steroid (dexamethasone 8 mg) was given. Postsurgery, the video laryngoscope was inserted again to visualize the larynx. The corniculate and arytenoids were still swollen as before [Figure 3]. After extubation over a tube exchanger device, he was shifted to onco-surgical Intensive Care Unit for observation and monitoring.
|Figure 2: Photo taken in the C-MAC video laryngoscope of the laryngeal involvement|
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|Figure 3: Video-laryngoscopic view of the swollen laryngeal cartilage taken after extubation|
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RA is known to cause laryngeal edema and cricoarytenoid arthritis.  But, our patient was suffering from OA (and not RA) for the past 10 years. He had undergone bilateral knee replacement 5 years back under combined spinal epidural block, which was uneventful. He had a history of mild hoarseness of voice and occasional sore throat. There was no history of URI or acid reflux. About half of cricoarytenoid joints in patients more than 40 years can have degenerative changes of varying intensity in their joint surface structure.  In fact, a rare case of stridor  due to OA of the larynx has been reported as early as 1917. The laryngeal changes visualized were not due to reflux laryngitis, as our patient did not have GERD or gastritis or symptoms suggestive of acid reflux disease. The C-MAC  is an excellent tool for real-time visualization of the airway and can help in difficult intubations, in the same way as an FOB. We had repeated the use of the video laryngoscope blade for securing the airway in two other chronic OA patients coming for surgery under general anesthesia, and similar findings were noted. Degenerative alterations in diarthrodial joints resembling OA can occur in laryngeal joints with similar structural changes. It may lead to impaired movements of the arytenoids causing negative consequences during voice production, such as impaired vocal quality and reduced vocal intensity. Our patient had subtle voice changes since 3 months.
This case highlights that many OA patients can have an affliction of the larynx and proper evaluation with appropriate preparation must be made preoperatively. OA is basically wear and tear of joint cartilage, and hence involvement of cartilages other than the major joints must be suspected in their assessment. Laryngeal involvement in OA was considered rare.  Gentle handling with an emphasis on avoiding trauma during intubation and extubation is the key concern. Video laryngoscopes and FOB may be utilized to document the findings and otorhinolaryngologist consultation may be sought during the preanesthetic assessment in chronic OA patients.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]