AM report PEARLS 4/12: approach to dysphagia, manifestations of rheumatoid arthritis, and ddx for vocal cord paralysis!

Approach to dysphagia:

  • Oropharyngeal vs esophageal? (ask patient if they can tell where food gets stuck)
    • Oropharyngeal: think about neuromuscular disease, myopathies, structural lesions, metabolic (eg thyroid), infections (eg CMV, candida esophagitis), iatrogenic (eg radiation, meds)
    • Esophageal: motility vs obstructive (ask patient if it’s solids, liquids, or both)
      • Motility (solids + liq): neuromuscular (eg achalasia, diffuse esophageal spasm, scleroderma, Chagas)
      • Structural (solids>liquids): intrinsic (tumors, strictures, webs, rings) vs extrinsic (left atrial/aortic enlargement, mediastinal mass, etc)
    • Most common oropharyngeal cause = neurogenic/myogenic, most common esophageal cause = mechanical/motility issue


Management of acute inspiratory stridor – Remember your ABCs! worry about upper airway obstruction and impending respiratory compromise!

  • Intubate if needed (will need to be intubated under direct visualization) (NIPPV is probably not helpful in these patients)
    • If lesion is above the vocal cords and hard to intubate, consider cricothyrotomy or tracheostomy
  • Urgent ENT eval for direct visualization/tx
  • Racemic epi to acutely reduce edema if that is the cause
  • Heliox may help reduce turbulent flow across obstruction but not routinely used


Manifestations of rheumatoid arthritis:

  • Symmetric synovitis is characteristic! Esp of small joints of the hands (PCP and PIP, not DIP!), wrist, and forefoot. Can lead to reduced grip strength!
  • Axial involvement – rare, except cervical (20-50%) – remember atlantoaxial (C1-C2) involvement! Rarely, can cause spinal cord compression
  • Cricoarytenoid joint – involved in 30%! Symptoms include hoarseness and inspiratory stridor!
    • Can’t be diagnosed with imaging! Need direct visualization with ENT (just like how you can see synovitis on exam of other joints!)
    • Great article from rheum of 3 cases of RA manifested as acute stridor: Peters JE et al., Clin Rheumatol 2011; 30(5): 723-7 (attached here!)
  • Other joints: Acromioclavicular, sternoclavicular, temporomandibular


Ddx for bilateral vocal cord paralysis – a short list, thanks to Anna!

  • Infiltrative – amyloid/sarcoid
  • Infectious – TB
  • Malignancy – esp SCC
  • Postsurgical/postprocedural – post-intubation, post-thyroidectomy
  • Neuro – myasthenia gravis, motor neuro diseases like ALS


Bonus #1: Ortner’s syndrome: hoarseness from massively dilated left atrium or left pulmonary artery leading to compression of left recurrent laryngeal nerve


Bonus #2: a nice diagram of flow loops on spirometry depending on where you have obstruction (upper airway vs COPD) and a few other scenarios 🙂

flow loops.jpg





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