Airway Management of a Patient with Juvenile Rheumatoid
Arthritis
Jorge Palacios, MD and Michael E. Mahla, MD
Dept of Anesthesiology, University of Florida
Case Report
A 48 year old wheelchair-bound woman, ASA physical status IV,
with juvenile rheumatoid arthritis was scheduled for a posterior
fusion of her cervical spine for subaxial instability with
cervical myelopathy. The patient had a history of multiple
surgical repairs of different joints, which included bilateral
total knee arthroplasties and bilateral total hip arthroplasties
with subsequent revisions. During her last procedure – which was
done three years prior to this procedure – the anesthesia team
canceled the procedure once because of multiple unsuccessful
attempts to intubate using a fiberoptic bronchoscope to
visualize the vocal cords. During the second attempt to perform
this procedure, she was successfully intubated, but only after
difficulty that almost required an emergent surgical airway
secondary to airway obstruction at the glottic level. Two months
prior to this surgical procedure, the patient was admitted to
the surgical intensive care unit secondary to respiratory
distress characterized by stridor. Evaluation of the airway
revealed severe inflammation of the arytenoid cartilages with
significant anterior displacement. The patient had documented
atlantoaxial and subaxial subluxation with instability, cervical
myelopathy, temporomandibular joint disease with an oral opening
of 1.5 cm, a thyromental distance of 2.5 cm, and demonstrated
involvement of her cricoarytenoid without current active
inflammation, all secondary to juvenile rheumatoid arthritis.
Discussion
This presentation will review the preoperative assessment of the
airway and cervical spine in patients with rheumatoid arthritis
and make recommendations for management of a difficult airway
secondary to rheumatoid arthritis.
