[Cricoarytenoid arthritis diagnosed after tracheostomy in a rheumatoid arthritis patient]

A 65-year-old woman was scheduled for total knee replacement. She had been suffering from rheumatoid arthritis for 22 years. She also had a history of occasional acute dyspnea, which had been diagnosed as asthmatic bronchitis. Preoperative examinations of the airway revealed limited neck flexion, a small jaw, and normal mouth opening. After epidural catheterization, anesthesia was induced with propofol, and a #3 laryngeal mask airway (LMA) was inserted. However, her lungs could not be ventilated through the LMA. Despite repeated attempts, proper placement of the LMA could not be achieved. Hence, a 7.0 mm ID armored endotracheal tube was inserted through an intubating LMA. Anesthesia was maintained with nitrous oxide and sevoflurane in oxygen. The surgery proceeded uneventfully. Five minutes after extubation, inspiratory dyspnea occurred. The patient's trachea was re-intubated nasally with a bronchofiberscope. Since the bronchofiberscopy revealed remarkable laryngeal edema, percutaneous tracheostomy was performed. On the 3 rd postoperative day, cricoarytenoid arthritis that had caused occasional airway obstruction was diagnosed, although her laryngeal edema disappeared. She went home with a permanent tracheostomy. Although cricoarytenoid arthritis is a common occurrence in patients with rheumatoid arthritis, the diagnosis can be difficult. A scrupulous preoperative evaluation and awareness of cricoarytenoid arthritis are necessary for optimal anesthetic management.