Introduction
Rheumatoid arthritis is a systemic, chronic and progressive autoimmune condition that is characterised primarily by inflammation and destruction of joint spaces.Reference Firestein1 It is one of the most common autoimmune conditions, affecting approximately 1 per cent of the global population, with a predilection for women between the ages of 30 and 50 years.Reference Bértolo, Brenol, Schainberg, Neubarth, Lima and Laurindo2–Reference McInnes and Schett4 The exact pathogenesis of rheumatoid arthritis remains unknown, but it is believed to involve complex interactions between genetic and environmental factors that facilitate an autoimmune response.Reference McInnes and Schett4 Although synovitis of small, peripheral joints in the upper extremities is the typical pathophysiology highlighted when discussing rheumatoid arthritis, there are joints in the head and neck area that are not immune to this disease process. Respiratory involvement has been documented as early as 1880 by Mackenzie in a study of cadavers, and laryngeal involvement, specifically, has been described starting in 1960.Reference Beirith, Ikino and Pereira5, Reference Voulgari, Papazisi, Bai, Zagorianakou, Assimakopoulos and Drosos6
Rheumatoid arthritis can affect various laryngeal subsites, including the arytenoids, glottis and subglottis. While head and neck manifestations of rheumatoid arthritis vary depending on the exact site of involvement, emergent cases may arise when the cricoarytenoid joints are involved.Reference Dehghan, Ahmadi, Yousefghahari, Kiakojouri and Gholinia7 The cricoarytenoid joint is a diarthrotic joint that, like other articulations in the body, is composed of a joint cavity, synovial lining and a fibrous capsule.Reference Foggia and Hoffman8, Reference Montgomery9 Compromise of these joints can hinder vocal fold abduction, narrowing the glottic inlet with resulting dyspnoea in a manner mimicking neurogenic bilateral vocal fold paralysis. Hence, compromise of these joints presents a dangerous complication of rheumatoid arthritis.
The prevalence of rheumatoid arthritis of the cricoarytenoid joint ranges widely from 31 per cent to 75 per cent in rheumatoid arthritis patients, but it remains underreported in the literature and underdiagnosed in patients.Reference Takizawa, Suzuki, Sawada, Ohsaka, Inoue and Yamada10 Furthermore, clinical detection and diagnosis is significantly less prevalent compared with as high as 90 per cent detection in post-mortem histopathological studies.Reference Hamdan and Sarieddine11 Clinical manifestations also range broadly from cough to dysphonia to respiratory distress, making this diagnosis difficult to detect early on and differentiate from other pathologies.
Various treatment modalities have been used to manage rheumatoid arthritis of the cricoarytenoid joint symptoms, including high-dose corticosteroids and surgical abduction procedures.Reference Takizawa, Suzuki, Sawada, Ohsaka, Inoue and Yamada10, Reference Farah Izati, Wong and Che Maraina12, Reference Hamdan, Khalifee and Berjawi13 However, in acute airway obstruction, a tracheostomy is the ‘gold standard’ alleviating treatment.Reference Iacovou, Vlastarakos and Nikolopoulos14
As rheumatoid arthritis of the cricoarytenoid joint can present with acute airway obstruction and respiratory distress, identifying management strategies is important for preventing life-altering outcomes. Regardless of presentation, a tracheostomy-free survival is the ideal result. As there is limited literature on rheumatoid arthritis of the cricoarytenoid joint, the objective of this systematic review was to comprehensively compare patient survival and tracheostomy decannulation outcomes between surgical and medical interventions in patients with the conditions.
Methods
Data sources and search strategy
A systematic review of published English language literature was performed in December 2023 in accordance with the 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis (‘PRISMA’) guidelines.Reference Page, Moher, Bossuyt, Boutron, Hoffmann and Mulrow15 PubMed, Web of Science, Scopus, Embase and MEDLINE databases were each queried to find all reported cases of rheumatoid arthritis of the cricoarytenoid joint from inception to the present day. The following search string was used: (rheumatoid arthritis OR rheumatoid) AND (cricoarytenoid joint OR crico-arytenoid joint OR cricoarytenoid OR cricoarytenoiditis).
Criteria for inclusion and exclusion
Inclusion criteria consisted of case reports, case series and retrospective reviews in the English language that described rheumatoid arthritis of the cricoarytenoid joint in the adult population. Exclusion criteria consisted of papers irrelevant to the topic, papers with no clinical information, cases with non-human subjects, cases with undiagnosed rheumatoid arthritis, cases that did not describe rheumatoid arthritis of the cricoarytenoid joint and cases describing juvenile rheumatoid arthritis.
Data collection and statistical analysis
Each article was initially screened by two independent reviewers by title and abstract for relevance to the topic. Articles that passed the initial abstract screening then underwent a full-text reading by two independent reviewers to assess for final inclusion in the study. During both levels of screening, a third author resolved conflicts between the screening authors. The remaining articles each went through a systematic data extraction process by one reviewer and a second reviewer reviewed each extraction for consensus.
Data extraction for each paper included demographic information, clinical presentation, laryngoscopy findings, treatments, final outcome and, if given a tracheostomy, decannulation status. Descriptive statistical analyses such as frequencies of pooled data compiled from individual patient information were utilised. Fisher’s exact tests were employed to determine the association between survivorship and tracheostomy-free outcomes with surgical versus medical management. Logistic regression analysis using MetaXL (version 5.3) software was used to determine the relationship between years of rheumatoid arthritis diagnosis and likelihood of tracheostomy-free outcomes for bilateral cricoarytenoid joint involvement.
Qualitative analysis
Two different reviewers analysed each study to assess for risk of bias using the Joanna Briggs Institute Checklist for Case Reports and the Joanna Briggs Institute for Case Series.Reference Munn, Moola, Lisy, Riitano and Tufanaru16, Reference Moola, Munn, Tufanaru, Sears, Sfetcu and Currie17 In each checklist, questions can be answered with ‘Yes’, ‘No’, ‘Unclear’ or ‘Not applicable’. The Joanna Briggs Institute Checklists for Case Reports and Case Series have 8 and 10 questions, respectively, and a higher score indicates higher quality.Reference Swisher, Singh, Debbaneh and Rivero18 For this paper, above 70 per cent was considered low risk of bias, between 50 per cent and 70 per cent was moderate, and between 0 per cent and 49 per cent was high (Supplementary Table S1).
Results
The ‘PRISMA’ workflow chart is displayed in Figure 1. A total of 744 studies were initially compiled from all databases using the search string. After removal of 289 duplicates, 455 studies were screened by title and abstract, which left 89 articles considered for full-text review. An additional 34 studies were then removed according to the inclusion and exclusion criteria for a final total of 55 articles to be included in the analysis.Reference Voulgari, Papazisi, Bai, Zagorianakou, Assimakopoulos and Drosos6, Reference Foggia and Hoffman8, Reference Montgomery9, Reference Hamdan, Khalifee and Berjawi13, Reference Abe, Mitsuka, Yamaoka, Yamashita, Yamashita and Norimoto19–Reference Yano, Kashiwada, Suzuki, Kasaba and Takasaki69 The included articles were published between 1957 and 2021 with a total of 83 patients. Data were extracted from 46 case reports and 9 case series. All the case reports were deemed low risk (97.8 per cent) except for 1 (2.2 per cent) that was moderate risk. All the nine case series were considered low risk.
Preferred Reporting Items for Systematic Review and Meta-Analyses (‘PRISMA’) flow chart. RA = rheumatoid arthritis.
Figure 1 Long description
The flowchart outlines the PRISMA process for selecting studies in a systematic review. It begins with ′Identification,′ where 744 studies are gathered from databases like Scopus, Embase, PubMed, Web of Science and MEDLINE. Additional references from other sources are noted but not quantified. Next, ′References removed′ shows 289 duplicates removed, with 21 manually and 268 by automation tools. The ′Screening′ phase shows 455 studies screened, with 347 excluded. In ′Studies sought for retrieval,′ 89 studies are considered, with none not retrieved. ′Studies assessed for eligibility′ includes 89 studies, with 34 excluded for reasons like no history of rheumatoid arthritis, incorrect patient age, or no full text found. Finally, ′Included′ shows 55 studies in the review, with ongoing studies and those awaiting classification noted separately.
The mean age at diagnosis was 60.1 ± 11.2 years old and the majority of patients were female (n = 52, 63.4 per cent) (Table 1). Most patients were already diagnosed with rheumatoid arthritis on presentation, with only 6.1 per cent of patients (n = 5) receiving the diagnosis of rheumatoid arthritis following presentation. Patients were also classified as having systemic or localised head and neck rheumatoid arthritis; localised rheumatoid arthritis was defined as symptoms confined to the head and neck area, whereas systemic involved any other joints outside of the head and neck anatomy. In addition, 67 patients (81.7 per cent) had systemic rheumatoid arthritis, 2 (2.4 per cent) had localised head and neck rheumatoid arthritis, and 13 (15.9 per cent) did not distinguish. Of 46 patients (56.1 per cent) with reported symptom duration, patients had an average of 20.8 ± 32.8 months of symptoms. For the 59 patients (72 per cent) with reported duration of diagnosed rheumatoid arthritis, the average duration was 20.5 ± 13.5 years, with the majority of patients (n = 46, 56.1 per cent) presenting with at least 10 years of a rheumatoid arthritis diagnosis.
Patient characteristics
Table 1 Long description
The table summarizes patient demographics and rheumatoid arthritis history. The gender distribution favored females, with about 1 male for every 1.7 females. Average age was about 60 years, with a standard deviation of about 11 years. Most patients were already diagnosed with rheumatoid arthritis at presentation, with 68 yes, 5 no, and 9 not reported. Among those with reported disease extent, systemic rheumatoid arthritis was far more common than local disease, with 67 systemic, 2 local, and 13 not reported. Average duration of rheumatoid arthritis was about 20 years, with a standard deviation of about 14 years. Several fields include not reported counts, which limits certainty about the full distribution.
* Local = confined to head and neck area. SD = standard deviation.
The most common symptoms at presentation were dyspnoea (n = 51, 62.2 per cent), dysphonia (n = 43, 52.4 per cent), dysphagia (n = 21, 25.6 per cent) and stridor (n = 19, 23.2 per cent). Laterality of joint involvement was specified in 70 cases (85.3 per cent), with bilateral involvement (n = 66, 80.5 per cent) by far the most common finding, and unilateral involvement was specified in 4 patients (Table 2).
Symptom presentation and joint involvement*
Table 2 Long description
The table summarizes how often specific airway and throat symptoms occurred among 82 patients and reports the side of laryngeal involvement. Dyspnoea was most frequent at 51 patients (62.2%), followed by dysphonia at 43 (52.4%). Less common symptoms included dysphagia at 21 (25.6%) and stridor at 19 (23.2%). Sore throat or throat pain occurred in 9 (11%), cough in 8 (9.8%), and cyanosis or hypoxia in 4 (4.9%). Wheezing and unconsciousness were rare, each reported in 2 patients (2.4%). Symptom information was not reported for 7 patients (8.5%). For larynx involvement, bilateral disease predominated at 66 patients (80.5%), while left-sided involvement was 3 (3.7%) and right-sided involvement was 1 (1.2%); laterality was not reported for 12 (14.6%). Missing symptom and laterality entries mean the true frequencies for some categories may be slightly different from what is listed.
* Average symptom duration = 20.8 ± 32.8 months.
Out of the patients with unilateral involvement, every patient presented with dysphonia (n = 4, 100 per cent), while 2 (50 per cent) had additional dyspnoea and cough, and just 1 patient (25 per cent) presented with stridor. Three out of 4 patients (75 per cent) had solely the left cricoarytenoid joint affected and 1 patient had right cricoarytenoid joint fixation. All four patients experienced impaired adduction of the affected vocal fold, resulting in incomplete closure. In terms of treatment, laryngeal procedures were performed in 2 patients (50 per cent), including arytenoid adduction and vocal fold injection. These patients were also treated with antibiotics and oxygen.
For bilateral involvement, 65 patients (98.5 per cent) had laryngoscopy descriptions reported and all patients had narrowing of the glottic inlet. With regard to the source of the narrowed glottis, 84.6 per cent of cases (n = 55) were due to fixation of the cricoarytenoid joint, 13.8 per cent (n = 9) were due to oedema and inflammation of the cricoarytenoid joints, and 1.5 per cent (n = 1) were due to a large rheumatoid nodule. These origins were determined by author descriptions of laryngoscopies and manual probing of the vocal folds. Other findings, such as vocal fold surface ulceration (n = 6, 9.1 per cent), vocal fold hypertrophy (n = 5, 7.6 per cent), vocal fold nodules (n = 3, 4.5 per cent) and calcifications (n = 2, 3.0 per cent), were more rarely reported (Table 3). Information regarding imaging (computed tomography, magnetic resonance imaging, X-ray) and inflammatory markers (erythrocyte sedimentation rate, C-reactive protein, anti-cyclic citrullinated peptide) were inconsistent and sparse across studies, and hence were not included in the final analysis.
Bilateral cricoarytenoid joint involvement laryngoscopy findings (n = 66)
Table 3 Long description
The table reports laryngoscopy findings in 66 patients with bilateral cricoarytenoid joint involvement, listing each observed finding and the number and percentage of patients affected. A narrowed glottic inlet was present in 65 patients, making it the dominant finding. Among those with a narrowed inlet, cricoarytenoid joint immobilisation was most common at 55 patients, while oedema or inflammation occurred in 9 and a rheumatoid nodule in 1. Other vocal fold abnormalities were less frequent: surface ulceration in 6, hypertrophy in 5, nodules in 3, and calcifications in 2. One patient had findings not reported. Because the narrowed glottic inlet category includes subtypes, the subtype counts should be interpreted as breakdowns within that finding rather than separate totals.
In patients with bilateral involvement who had a procedure, tracheostomy was the most commonly utilised (92.2 per cent) and arytenoidectomy was second (15.7 per cent). For medical management, steroids (systemic or local) were the most commonly used treatment (63.6 per cent) and immunosuppressants were second (21.2 per cent) (Table 4).
Bilateral rheumatoid arthritis of cricoarytenoid joint treatment and outcomes (n = 66)
Table 4 Long description
The table summarizes treatments used and reported outcomes for 66 patients with bilateral rheumatoid arthritis affecting the cricoarytenoid joints. Procedural treatment was reported for 51 patients (77.3 percent), and among those, tracheostomy was most frequent (47 patients, 92.2 percent of procedural cases); arytenoidectomy was next (8 patients, 15.7 percent), while laterofixation, laryngectomy, and cordotomy were each reported once (2 percent each). Steroids were used in 42 patients (63.6 percent), with 14 of these patients reported as decannulated (33.3 percent); immunosuppressants were used in 14 patients (21.2 percent), with 3 decannulated (21.4 percent). Other medical therapies were less common, including antibiotics (13.6 percent), oxygen or positive-pressure ventilation (10.6 percent), salicylates (9.1 percent), bronchodilators (7.6 percent), gold salts and epinephrine (6.1 percent each), non-steroidal anti-inflammatory drugs (4.5 percent), and acetaminophen (1.5 percent). Outcomes were grouped by management approach: medical management only was most common (53 patients, 80.3 percent) and included 24 tracheostomy-dependent patients (45.3 percent), 9 decannulations (17 percent), 14 who never had a tracheostomy (26.4 percent), and 6 deaths (11.3 percent). Laryngeal surgery with medical management (7 patients, 10.6 percent) and laryngeal surgery only (3 patients, 4.5 percent) reported no deaths and higher decannulation proportions within those small groups. Some entries are marked not reported (2 patients for treatment and 3 patients for outcome), and treatment categories may overlap, so totals across treatments should not be interpreted as mutually exclusive.
The 54 patients (65.1 per cent) that reported duration of follow up were seen for an average of 19.6 ± 19.5 months (Table 1). For those who had bilateral cricoarytenoid joint involvement and a tracheostomy, there was a significant relationship between the use of a primary laryngeal surgery such as arytenoidectomy, with or without medical management, and overall survival and decannulation compared with those where only medical management was used (p = 0.0022). Out of the 47 patients who received a tracheostomy, 36 per cent (n = 17) were able to be decannulated and the remaining 63.8 per cent (n = 30) were tracheostomy-dependent or expired. Of those decannulated, 47.1 per cent (n = 8) were treated with laryngeal surgery, with or without medical management, whereas 52.9 per cent (n = 9) were decannulated with medical management only. Of the remaining 30 tracheostomy-dependent or expired patients, the majority received medical management only (n = 28, 93.3 per cent) and only 6.7 per cent (n = 2) received a laryngeal surgical procedure (Figure 2).
Bilateral cricoarytenoid joint patient outcomes based on treatment. MM = medical management.
Patients in all subdivisions had an average age similar to that of the mean of the patient population in this study. Logistic regression analysis results for those with bilateral cricoarytenoid joint involvement revealed that for each additional year of rheumatoid arthritis diagnosis, the odds of being tracheostomy-dependent were insignificantly associated (odds ratio = 1.03, 95 per cent confidence interval 0.99, 1.07, p = 0.19069) (Figure 3).
Bilateral cricoarytenoid joint patients’ years of diagnosis with rheumatoid arthritis and tracheostomy status. RA = rheumatoid arthritis.
Discussion
We present the first clinical systematic review of patients with rheumatoid arthritis of the cricoarytenoid joint comparing medical versus surgical treatment, assessing the ability to be decannulated after tracheostomy. Overall, the majority of patients in this study were older women with an extensive length of rheumatoid arthritis disease and long symptom duration. Most patients presented with dyspnoea and dysphagia, and on laryngoscopy a narrowed glottic inlet due to cricoarytenoid joint immobilisation was the most common finding. For bilateral joint involvement, a tracheostomy was almost always performed, and medical management usually included steroids. Most significantly, this study found a significant relationship between receiving a primary laryngeal surgery and overall survival and decannulation compared with those who just received medical management.
Laryngeal involvement of rheumatoid arthritis has been described as having two distinct stages: acute and chronic. The acute, active phase is described as a general inflammatory state, sensation of a foreign body and/or tenderness of the larynx. The chronic phase is defined as cricoarytenoid joint involvement.Reference Iacovou, Vlastarakos and Nikolopoulos14 The majority of patients in this study had chronic rheumatoid arthritis disease, indicating that patients with long histories of rheumatoid arthritis disease are, inherently, at a greater risk for development of rheumatoid arthritis of cricoarytenoid joint. Furthermore, this study found a positive yet insignificant relationship between years of rheumatoid arthritis of diagnosis and tracheostomy-dependence (p = 0.19069).
Rheumatoid arthritis of the cricoarytenoid joint may be an eventual development of severe, refractory rheumatoid arthritis, and as most of the patients had bilateral involvement, the pathology can be explained as an acute, systemic flare that compromises these joints. Overall, our findings suggest that rheumatoid arthritis of the cricoarytenoid joint tends to present with dyspnoea and impairment of the glottic opening in a high acuity manner. Although cricoarytenoid joint involvement in rheumatoid arthritis is classified as the chronic phase of laryngeal rheumatoid arthritis, patients will always be at risk for acute respiratory distress should the cricoarytenoid joints become impaired.
The majority of patients in this review presented with bilateral cricoarytenoid joint immobility, causing dyspnoea via a similar mechanism to neurogenic bilateral vocal fold paralysis. One key distinguishing feature between rheumatoid arthritis of the cricoarytenoid joint and bilateral vocal fold paralysis is the availability of non-surgical treatment options. Medical management and less invasive procedures such as botulinum toxin, laryngeal pacing and even gene and stem cell therapy are in their nascency as treatment options for bilateral vocal fold paralysis, whereas rheumatoid arthritis of the cricoarytenoid joint has the potential to be managed and monitored in the out-patient setting using anti-inflammatory medications or high-dose steroids.Reference Foggia and Hoffman8, Reference Li, Garrett and Zealear70 In a study by Foggia et al., the takeaway was that medications that manage rheumatoid arthritis are the mainstay treatment for rheumatoid arthritis of the cricoarytenoid joint; as stated before, rheumatoid arthritis of the cricoarytenoid joint is simply a severe manifestation of rheumatoid arthritis.Reference Foggia and Hoffman8 Our study therefore sought to determine if medical management alone was a viable option for this condition.
Surprisingly, we found that the vast majority of our patients (92.2 per cent) required a tracheostomy. This is contrary to a previous retrospective review of the management of bilateral vocal fold paralysis that found that 36.2 per cent of cases necessitated a tracheostomy.Reference Lechien, Hans and Mau71 This supports the general underdiagnosis of rheumatoid arthritis of the cricoarytenoid joint, leading to a more acute presentation with unexpected airway compromise. This highlights the need for close monitoring of patients with rheumatoid arthritis and aggressive medical management to prevent this complication from occurring. Hamdan et al. even recommend otolaryngological involvement in patients with rheumatoid arthritis during intubation for non-otolaryngological surgical procedures because prior authors have reported aggravation of laryngeal manifestations during intubation techniques.Reference Hamdan, Khalifee and Berjawi13
As patients with bilaterally involved cricoarytenoid joints often required a tracheostomy, the question then arises as to the appropriate treatment following tracheostomy that would lead to ultimate decannulation. In our study, continued medical management only led to decannulation in 19.1 per cent of patients, while primary laryngeal surgery was significantly associated with eventual decannulation and overall survival. For those who received a laryngeal surgery, arytenoidectomy was most often used, while other procedures, such as laterofixation and cordotomy, were also used.
In a small retrospective cohort study, Dispenza et al. concluded that ideal treatment of bilateral vocal fold paralysis from recurrent laryngeal nerve (RLN) injury post-thyroidectomy is a combination of arytenoidectomy plus posterior true and false cordectomy.Reference Dispenza, Dispenza, Marchese, Kulamarva and Saraniti72 Other reviews have also found that procedures such as arytenoidectomy, cordotomy, laterofixation and arytenoid abduction are preferred for immediate improvement of breathing.Reference Li, Garrett and Zealear70 We therefore suggest that similar procedures should be considered for treatment of bilateral cricoarytenoid joint immobility due to rheumatoid arthritis.
In summary, the patients included in this study had extensive history of rheumatoid arthritis disease and developed severe, acute manifestations of laryngeal rheumatoid arthritis. In accordance with literature, the definitive treatment for acute respiratory distress when the cricoarytenoid joints are immobilised is a tracheostomy with hopeful decannulation via laryngeal surgery. Cricoarytenoid joint dysfunction in rheumatoid arthritis should not be dismissed, especially in patients with long histories of rheumatoid arthritis disease, because the consequences of acute respiratory compromise can be fatal.
• This is the first systematic review specifically comparing surgical and medical management outcomes (including decannulation and survival) in rheumatoid arthritis-related cricoarytenoid joint involvement
• The study demonstrates a significant association between laryngeal surgery and improved decannulation and survival rates compared with medical therapy alone
• The high prevalence of bilateral cricoarytenoid joint fixation and the importance of early recognition and intervention are highlighted
• A paradigm shift toward surgical intervention (e.g. arytenoidectomy) as a key factor in achieving tracheostomy-free survival is suggested
• The literature lacks consensus on optimal treatment strategies for severe bilateral cricoarytenoid joint involvement and existing data are limited to case reports and small series
Limitations
Although this study followed the standardised ‘PRISMA’ guidelines for a systematic review, there are nevertheless limitations that affect these results. The study was restricted to articles written in the English language, introducing a selection bias and preventing a fully comprehensive sample of this pathology. Additionally, with large prevalence of rheumatoid arthritis but inclusion of only 83 patients, this study may significantly underrepresent the true burden of cricoarytenoid joint involvement. This limitation may stem from selection criteria that excluded patients with rheumatoid arthritis and vocal fold immobility or other disorders of vocal motion or glottic closure, potentially leading to an underestimation of the prevalence of cricoarytenoid joint involvement.
There may also be a reporting bias, as authors tend to publish the findings of patients presenting in a unique manner, which could skew our study population toward more acute manifestations of the disease. Even though a consistent search strategy was employed to identify all clinical cases of rheumatoid arthritis of the cricoarytenoid joint, the patient population nonetheless remains small. Furthermore, inconsistent reporting among papers created heterogeneity between studies, which may limit the conclusivity of these findings. Despite these limitations, this study remains the first systematic review of rheumatoid arthritis of the cricoarytenoid joint to comprehensively discuss patient presentation and associations between treatment and outcomes.
Conclusions
Rheumatoid arthritis of the cricoarytenoid joint is a clinically insidious pathology that has severe consequences if abduction of the vocal fold is impaired. While general rheumatoid arthritis of the larynx can present as more mild symptoms such as hoarseness and coughing, involvement of the cricoarytenoid joints creates potentially life-threatening situations if not addressed acutely and appropriately. Although a tracheostomy is a life-altering and disabling condition for those with already limited dexterity, laryngeal surgical procedures are significantly associated with eventual decannulation. Although severity of rheumatoid arthritis does not necessarily correlate with severity of laryngeal manifestations, it is critical that those with long histories of rheumatoid arthritis are monitored for laryngeal symptoms and managed with the appropriate rheumatoid arthritis treatments to avoid progression and acute phases of disease.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/S0022215126105040.
Data availability statement
The datasets generated and analysed during the current study are available from the corresponding author on reasonable request.
Competing interests
None declared.
