Arthritis back,quotes to live by steve jobs,create your own tattoo sleeve uk - Good Point

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All Home Remedies information on this site is intended for informational purposes only and is not meant as a substitute for professional medical advise. Turmeric, a yellow spice that contains a powerful compound called curcumin which helps to heal the inflammation.
Ginger has the ability to increase the blood circulation and also acts as anti inflammatory which remove the inflammatory chemicals away from the painful joints.
Apple cider vinegar is rich in calcium, magnesium, potassium and phosphorus which are very essential in relieving the joint pain. Green tea contains a chemical compound called quercetin, a powerful anti-inflammatory and anti-oxidant that prevent or ease the symptoms of RA. Capsaicin is a substance which gives the hot peppers heat to give relief and also to divert the brain to another topic rather than arthritis pain.
Cloves have an anti inflammatory chemical compound called eugenol which helps to heal the pain of arthritis. Boswellia is a natural anti-inflammatory which helps to give relief from the joint pain and inflammation. Cherries are rich in magnesium (natural pain killer) and potassium (acts as diuretic) that helps to reduce the inflammation by riding the tissue of fluid, this will efficiently treats the arthritis particularly gout.also helps to treat arthritis particularly gout.
Alfalfa is one of the herb which is rich in minerals and helps to regulate pH levels to heal the people who suffers from the arthritis.
Research says that SAM-e helps to relieve from the arthritis pain by increasing the blood levels of the proteoglycans, a molecule which seems to play an important role in preserving cartilage by helping to keep it well oxygenated. You can apply either heat or cold compress to the joints which are aching will definitely provides significant relief from its pain. Borage seed oil contains anti inflammatory property which helps to relieve arthritis and its symptoms. Planning perfect diet by including the essential vitamins and minerals will definitely helps to control the arthritis by removing the pain in your joints. Intake omega -3 fatty acids in your diet which helps to lessen the inflammation and pain that is caused by arthritis. Pomegranate juice, which contains both anti-inflammatory and antioxidant properties that helps to protect your cartilage.
Eat pineapple which contains bromelain (a protein-digesting enzyme) will helps to bring down some inflammation and reduces the pain of RA, osteoarthritis. Try these simple tips regularly to get relief from the arthritis now and also in future by following regularly.
Keep moving your joints as much as possible why because these movements will function your joints better for a longer period of time. Have some regular exercises like walking, gardening or even housekeeping which will helps to get rid of the problem. Playing in a pool will also helps you to get relief from the arthritis as it a simple exercise. Dona€™t over use over the counter creams or pain killers unless and until your doctor prescribed to you as these may give temporary relief but it activate the enzymes which will breakdown the cartilage in the joints when use continuously. Lose weight if youa€™re overweight as the excess weight will always puts it stress on the knee or joints. Prepare a plan everyday which is realistic, written schedule and do all the tasks by thinking that you have the essential energy and enthusiasm.
Try to avoid holding one position for a longer time as this will add to stiffness and discomfort.
Use eucalyptus oil or oil of winter green by taking few drops of this oil and rub it on the skin where your joints are paining.
Consume fish oil of 1 a€“ 2 teaspoons daily or take fish oil supplements in the morning on an empty stomach to get relief from the arthritis. They are many people suffering from this arthritis and also the number is increasing yearly. Science, Technology and Medicine open access publisher.Publish, read and share novel research. Laryngeal Manifestations of Rheumatoid ArthritisStevan Stojanovic1 and Branislav Belic1[1] Faculty of Medical Sciences, University of Kragujevac, Republic of Serbia1.
Research suggests that early intervention can delay the onset of the disease and may reduce the number of cases of osteoarthritis.
While there are about 100 forms of arthritis, the three most common causes account for 95% of all arthritis.
Then stop worrying, here are some effective natural home remedies to relieve the discomfort and pain. It is used especially to reduce the pain and swelling in the people who are suffering from the arthritis.
According to Iowa Womena€™s Health Study, ita€™s clear that women who drank three or more cups of this green tea per day are 60 percent less likely to develop RA and its symptoms rather than women who didna€™t drink this green tea.
Take either its pate or powder or any other supplement form and rub this on the joints where the arthritis pain is coming then it starts to irritate your nerve endings and also gives some relief from the pain also.
It also contains anti-oxidants which give relief from the pain and swelling that was caused by the arthritis. Research says that boswellia contains boswellic acid which are able to stop the formation of leukotrienes, the immune cells responsible for the inflammation. So, take it regularly either in the form of tinned, frozen, fresh or syrup (a strong, sweet drink obtained by boiling some cherries in water for about few minutes till the water came to half) to get relieve from the arthritis. You can make a tea by adding some alfalfa seeds to a cup of boiling water and let it stir and steep for few minutes.
Heat compress, you can apply either electric blanket, mitts, heating pads or hot packs, etc.
So, take few drops of this seed oil and massage it on the affected part to get heal tender and swollen joints. Omega -3 fatty acids are rich in salmon fish, flaxseeds, nuts, etc will helps to produce anti-inflammatory fats called resolvins, this helps a lot in healing the arthritis. This juice will lower an inflammatory chemical linked with over production of certain enzyme, this enzyme helps to replace cartilage but if take over then it wear away the cartilage.
However our body contains free radicals (unstable molecules that attack our healthy cells and causes arthritis) which destroys the cartilagea€™s ability to maintain and repair itself.
Eat this regularly between your meals but not with meals and also not to eat canned or its juice. You can also do some hand exercise in either a sink or bowl filled with warm water to get additional ease or comfort from the arthritis.
You can choose heated pool or whirlpool but take the advice of your doctor whether to do or not if youa€™re pregnant or suffering from any chronic health problems. If you are allergic to down blanket then use electric blanket which gives relief from the pain and discomfort.
Ita€™s better and recommended to be in perfect wait and lose the weight as early as possible if youa€™re over weight. But make to check or consult doctor before rubbing the oil as it causes some skin reaction to some people. It became a common problem that wona€™t get cured but luckily there are many natural home remedies and tips listed in this article which will alleviate its symptoms and relieve its pain and inflammation whenever you try these remedies. There are many different forms of arthritis and there is no cure for it but there is a chance to control it and make our life go smoothly. So, take turmeric regularly either in capsule form or turmeric water or turmeric in cooked food or turmeric mixed in warm milk and drink this milk before going to bed to get control over the pain. Take half teaspoon of ginger powder or 30 grams (approximately 6 teaspoons) of fresh ginger once in a day.
Mix this in water and drink this daily in the morning to remove the buildup toxins in the joints and connective tissues. Mix these two in a cup of warm water and drink this regularly in the morning on an empty stomach. Then strain the tea and drink this twice a day for about 2 a€“ 3 weeks to reduce the inflammation. First of all consult your doctor and then proceed to work with your physical therapist or massage therapist who have experience in massaging to the people who are suffering from the arthritis. Acupuncture is the process of inserting thin needles in certain pressure points to get relief from the pain.
Or you can simply drink a teaspoon of borage seed oil every day for quick relief from the pain, as this oil wona€™t harm your body but make sure that not to ingest seeds or other parts directly. So regular intake of vitamin C (citrus fruits), antioxidants and vitamin E (green leafy vegetables, etc.) will helps a lot in healing the joints pain.
But make sure that not to overdo the exercise if it makes your pain worse, then you can lessen the frequency or the amount of exercise. Or you can wear electric gloves with battery operated mitts at night while you go to sleep. And also remember that not to apply this under heating pad or hot compress as this action will cause the skin to burn or irritate the skin. Even though, if you cana€™t find any relief from the pain and discomfort then consult doctor as it can lead to any other health problem.
Or you can make a paste of cinnamon and honey and apply it on the painful area by massaging gently.
The larynx is rarely considered affected, and the patients come at terminal phase of rheumatoid arthritis when the changes are so progressive and irreversible and the treatment is very difficult. The causes for such inflammation may the daily wear and tear, some disease, hard and forceful movements, injury or hereditary factors. Osteoarthritis (breakdown and loss of joint cartilage depending on the age), Rheumatoid Arthritis (synovial lining of joint became inflamed and results in pain of joints), Gout (here uric acid crystals forms at the joints and mainly occurs in over weighted people), Lupus (bodya€™s own immune system attacks healthy cells and mainly common in women). Or you can simply eat the ginger regularly either in the raw or in cooked or in tincture, ale forms to get relief from the joint pain and inflammation. Then coming to cold compress as it will also works well in removing the pain from arthritis (joints).
The larynx is a part of upper respiratory system and an aerodigestive crossroads and is, therefore, often affected by pathological changes specific for rheumatoid arthritis. Pain, stiffness, swelling, redness, decreases range of motion are some of the symptoms of arthritis. For this you have to wrap an ice cubes in a wash cloth or towel and try to hold and press this on the sore joint or you can use the frozen tea bags, peas or corn, etc. Damage of its anatomical structures and physiological functions happens in the early phases of rheumatoid arthritis, as many authors have written about it (Hart, 1966), which is manifested by different pathoanatomical and pathophysiological changes.
Sequence and intensity of the symptoms’ appearance depend on the size, localization, spread and duration of pathological changes in rheumatoid arthritis. Clinical picture of laryngeal manifestations of rheumatoid arthritis is characterized by numerous and various symptoms.Because of the perplexity and length of the symptoms’ manifestations of this disease on other localizations of a human body, it is rarely thought about the laryngeal symptoms and signs when they are in the initial phase and of weak intensity. The disease was diagnosed by techniques of indirect laryngoscopy, microlaryngoscopy with the use of laryngoscopic claws, computered endovideostroboscopy and multislice scanner larynx examination. Previously, the patient underwent surgical tracheotomy because of asphyxia and very reduced breathing space.
Modern diagnostics recommended by other authors include electromyography of the larynx with the aim of differential diagnostics of cricoarytenoid joint immobility because of the paralysis of nervus reccurens of other etiology.With the aim of timely diagnostics of pathological changes in the larynx in the patients with the rheumatoid arthritis, a routine indirect laryngoscopy is necessary to be carried out.
When otorhinolaryngologists notice reduced mobility of one half of the larynx, laryngomicroscopy, electromyography of the larynx, multislice scanner neck examination are recommended in these patients. In diagnosed laryngeal changes, the therapy of intra-articular injection of corticosteroids in every affected cricoarytenoid joint should be considered as a possibility.
Larynx and rheumatoid arthritisRheumatoid arthritis is a generalized disease, but because of anatomical, physiological and pathoanatomial characteristics of the larynx, this disease has its manifestations in the larynx. Clinical picture, diagnostics and therapy of rheumatoid changes in the larynx have their characteristics to which every clinician must pay attention when treating clinical manifestations of this disease on other localizations and organs. Symptoms and signs of rheumatoid arthritis in the larynx must be noticed and treated adequately in its earliest phase.
Anatomy and embryology of the larynxThe larynx or voice box is located in the median line of the anterior neck. It is placed at the aerodigestive crossroads and is the beginning of lower respiratory system. It is a fibroelastic tube between the hyoid bone and trachea, whose external layer is made of cartilage and muscles, and internal layer is mucous. The larynx is tied by ligaments and muscles to the hyoid bone and, therefore, it follows its movements. From its aperture on the front wall of the inferior pharynx, the larynx comes down through the anterior neck and continues its way through the trachea.
Lower edge of the cricoid cartilage makes the lower larynx border, Figure 1.Topographically, hypopharynx with very mobile musculature is between the larynx and vertebral column at the back, while at the front, there is a gland thyroid on both sides of the larynx.
Its anterior is covered with thin infrahyoid muscles.Voice box is tied and strained to scull base and lower jaw indirectly over the hyoid bone, suprahyoid muscles and fibroelastic connections. Its angular prominence on the anterior neck is known as Adam’s apple in men, and is more prominent than in women. Structure of the larynx is such that firm part is made of cartilages connected mutually as well as with other organs by fibrillar connections-membranes and joints-ligaments. Submucous layer is made of fibroelastic membrane and the interior is encased by mucosa with blood vessels and nerves. Cavity of the larynx or cavum laryngis at its frontal section reminds of a sandglass or two vertical funnels connected with their narrow ends, Figure 2. Upper floor or vestibule of the larynx is vestibulum laryngis that extends from the larynx aperture to upper plicae, so called false vocal cords – plicae vestibulares s. Vocal cord is in its anterior, longer part, membranous and that part is called pars intermembranacea s.
Rima glottidis or just glottis consists of vocal cords and vocal extention of arytenoid cartilage. The median floor consists of a mucous recessus or invagination which arises between the true and false vocal cords and it is larynx ventricle or sinus s.
That recessus between the plicae ventricularis and vocal cords has a role of resonator and its length is approximately 20mm in men and 15mm in women. Epiglottis, plicae ventricularis and glottisThe anterior side of epiglottis or pars lingulais is free and covered with weakly adhered mucosa, which allows easy stretchening around edema. Its posterior side called pars laryngis completely belongs to the larynx and is bent above the larynx aperture.


Petiolus makes a bump on its mucosa, which covers the anterior commissure and, therefore, it can hardly be seen by indirect laryngoscopy. Their upper side is turned upwards and outside and continues its way laterally on the base of the ventriculus Morgagni, while their inferior side is turned downwards and inside and continues its way slopingly into the subglottic space. Subglottic space extends from the vocal cords down to the inferior edge of the cricoid cartilage and it has a conical shape. Laryngeal cartilagesSkeleton of the larynx consists of 16 cartilages: 6 paired and 4 unpaired. There are four large cartilages: thyroid or cartilago thyreoidea, cricoid or anular or cartilago cricoidea, paired arytenoid or cartilago arytenoidea and epiglottic or cartilago epiglottica. Its posterior edge extends upwards with the greater horn or cornu superior towards the hyoid bone and downwards with its interior side, little horn or cornu inferior is joined with the cricoid cartilage.
The epiglottic cartilage is located in the anterior wall of the larynx and has a shape of a rose leaf. Its superior, wider part is the larynx lid, and lower narrower part is pedicle or petiolus. The epiglottic cartilage is elastic and never ossifies in contrast to others that are hyaline and therefore start to ossify right after the puberty.
There are two small smooth surfaces for joining with arytenoid cartilages on both sides on the superior edges of cricoid lamina.
There are round surfaces for joining with inferior horns of the thyroid cartilage on the joining of the arch and lamina. The base of the pyramid is turned downwards and is located on the superior edge of the anular cartilage plate.
On the inferior part, near the base of this cartilage, there are two extensions and one of them is turned medially or processus vocalis and the other one is turned laterally or processus muscularis. The main extension of the arytenoid cartilage extends with an elastic connection (ligamentum vocale) which extends forward and ends on the interior side of the thyroid cartilage under its superior incesure. Right above the anterior joint of this connection, another connection or ligamentum vestibulare begins, and it continues backwards and ends on the anterior edge of the arytenoid cartilage on one small protuberance or colliculus. Articulatio cricothyreoidea is located between cornu inferior of the thyroid cartilage and cricoid cartilage on the joint of the arcus and lamina. Articulatio crycoarytenoidea is located between the arytenoid base and joint surfaces on superior edge of the cricoid cartilage.
Fibrous links of the larynx – membranes and ligamentsMembranes and ligaments of the larynx are divided into three groups.
The first group consists of ligaments of joints’ capsules, cricothyroid and cricoarytenoid.
Superior membrane supports aryepiglottic and plicae ventricularis, while inferior membrane or conus elasticus goes between the superior edge of the cricoid and inferior edge of the thyroid cartilage up to behind the vocal extension. The anterior part of the conus elasticus is tightly thickened in the middle and it makes ligamentum thyreoepiglotticum, which links epiglottis and thyroid cartilage. The third group consists of: membrane thyrohyoidea with the aperture for upper laryngeal artery and vein and internal branch of superior laryngeal nerve, cricotrachealis membrane lies between the inferior edge of the cricoid cartilage and the first tracheal ring and ligamentum hyoepiglotticum, which attaches epiglottis to hyoid bone, Figure 6. Internal muscles (Figure 7) are placed between some of the cartilages and are divided into 1.
It adducts the thyroid cartilage to the cricoid cartilage from the anterior side, and thus tights the vocal cords intermediately. On the superior larynx aperture, mucosa continues its way forward across the superior edge and anterior side of epiglottis into the mucosa of the root of the tongue, laterally and backwards into the pharynx mucosa, then it encases the external surface of the anterior wall of the larynx and it continues downwards into the trachea. Laryngeal mucosa is tightened very loosely to submucosa and elastic aperture, except at the front on the epiglottic cartilage and at the back on Santorini cartilages and superior ends of the arytenoid cartilages.
Apart from tiny glands that can be found almost everywhere in laryngeal mucosa, three main groups of glands are placed :a) on the top of laryngeal epiglottic side and in the root of the lingual side, b) in the wall of ventriculus Morgagni and c) in the plicae ventricularis. Placoid-layered epithelium encases the vocal cords, superior larynx aperture and it goes downwards into the vestibulum, free epiglottic edge, epiglottic plicae, internal side of the arytenoid and interarytenoid space.
This epithelium covers the whole glottis from the anterior commissure at the front and back to processus vocalis and interior side of arytenoid. It goes under the free edge of glottis and laterally towards the plicae ventricularis for 6 to 8mm. Under normal conditions, the isles of placoid epithelium can be found scattered in the zones of cylindrical-ciliary epithelium and in the larynx vestibulum. The passage between placoid-layered and ciliar epithelium in the level of the vocal cords and free edges of the larynx is manifested as transformation of superficial planocells into cylindrical cells. And opposite, in the level of placoid cells isle, these variations can continue one to another without the passage. The most important of all the layers is the superficial layer which is made of more planocells that desquamate but don’t keratinize.
Under the ifluence of toxins, chronic irritation and inflammation, this epithelium can show similar characteristics as horny layer and epithelium extensions go into the derm so that papillae become higher. Cylindrical-ciliary epithelium of respiratory type covers the remaining, largest part of the larynx surface.In 20 % of the cases, the anterior ends of the vocal cords are characterized by a narrow band of epithelium of transitory type. Mucosa of the vocal cords has one macroscopic characteristic of a special importance like Reink spaces which goes along the whole length of the vocal cords between mucosa and vocal ligament. Blood vessels, nerves and lymph vessels of the larynxArterial vascularization of the larynx comes from: a) a. The internal branch is often sensitive and gives sensory innervation for the whole larynx lumen till the vocal cords height.
The external branch is motor and innervates the anterior cricothyroid muscle and goes along the inferior edge of superior pharynx constrictor; 2) n. Left recurrens goes round the aortic arch and the right recurrens goes round the artery subclavia and then goes upwards in the gutter between the trachea and esophagus.
Lymph vessels of the larynx are divided into two parts, superior that are above the vocal cords or supraglottic and inferior, below the vocal cords or subglottic. Lymph vessels of the superior part flow into preepiglottic lymph nodes and superior deep neck lymph nodes. Lymph vessels of the inferior part flow into prelaryngeal lymph nodes and inferior deep neck lymph nodes.
Primary functions are phylogenetically the oldest and they contain the following functions: respirations, protection of airways, swallowing, thorax fixation.
Secondary functions are adapted to breathing and swallowing organs, ant the most important of them is phonation.
Respiratory function of the larynxGlottis opens one second before the air comes into it by lowering diaphragm. This opening is a consequence of cricoarytenoid muscle contraction which is innervated by nerve recurrens and it begins right before the motor activity of n. Hemoreceptor corpusculs are identified in supraglottic mucosa, so their stimulation during hypercapnia decreases laryngeal resistence during the inspiration and expiration.
Inspiratory dilation of the larynx isn’t distributed to glottis and it doesn’t depend on muscle activity. With inspiratory lowering of the larynx from hyoid downwards, true and false vocal cords contract, arytenoid cartilages go laterally and glottis opens. Passive opening of the larynx is still intensified also by the inspiratory phase, in other words activity of external laryngeal muscles.
The result of glottis opening size variation during respiration allows the larynx to contribute significantly to internal air resistance during the respiration time, so abduction of the vocal cords produces glottis dilatation and reduction of opening during the inspiration time, and adduction of the vocal cords with glottis constriction produces greater resistence to expiratory air, which influences the depth and level of respiration. These reflex changes are a consequence of reaction on presoreceptors in lungs and subglottic part of the trachea and can help in mixing the air in the lungs. After vagus deafferention, neither inflation nor deflation influence respiratory activity in posterior cricoarytenoid. Corrections of glottis opening compensate changes in total air resistance which increased in the nose and bronchi.
Circulatory function of the larynxNormal respiration, in other words normal air circulation through the larynx, allows normal functioning of the circulatory system, heart and blood vessels. Arrhytmia, bradycardia and periodical cardiac arrest, can result in stimulation of the larynx. The mechanism is connected to the nerve fibres stimulation that comes from aortal baroreceptors and goes to the central nervous system across n.
Protective function of the larynxAlmost at the same time with respiration, mechanism of protection of the inferior airways developed, protecting them from entering foreign bodies, and this protection is guided by following mechanisms: 1. There are three sphincters in the larynx and they are the vocal cords, ventriculous and aryepiglottic plicae so it comes to: adduction of the true vocal cords one to another, closing of the false vocal cords one to another and to the base of epiglottis, posterior commissure of the vocal cords is closed by rotation and adduction of the arytenoid cartilages, constriction of the false vocal cords by activity of internal laryngeal muscles, lifting and moving the larynx to the front, moving the base of epiglottis backwards and covering aditus, moving tyreoepiglottic ligamentum to the front. The previous movements, first of all the tongue base and aryepiglottic plicae, lead to direction of food bolus to peripheral sinus and thus allows the function of the larynx while swallowing; 2. Reflex inhibition mechanism of respiration starts when food bolus touches the posterior wall of the pharynx and because of that, breathing stops immediately.
This is a reflex which results from stimuli coming from the pharynx when food enters, and they transfer via n. Receptors are the richest in mucosa of the laryngeal side of epiglottis, aryepiglottic and plicae ventricularis and interarytenoid area; 3. Closing of the false vocal cords is an important moment for this reflex, because adduction of the true vocal cords one to another can bring by itself to preventing the air to come out of the lungs.
When high subglottic pressure is reached, sphincter mechanism suddenly relaxes and the air under the accumulated pressure comes out. It developed later in phylogenetic development thanks to high differentiation of the central nervous system.
For proper accomplishment of all the activities that the larynx carries out, there has to be full coordination of both synergistic and antagonistic groups of muscles. During phonation, the vocal cords are in adduction near medial line by the action of cricothyroid muscles that present the vocal cords tensors. Medial movement of the vocal cords towards the false ones are caused by: a) tension in the vocal cords, b) lowering of subglottic air pressure with every vibrating aperture of glottis and c) aspirating the air that ran away which is known as Bernuli phenomenon.
Function of thorax fixationWhen the larynx is closed, thorax is fixed and serves as adminiculum when some activities connected to the effort are held out: climbing, lifting burden, defaecation, delivery. Phonation functionThis function of the larynx is philogenetically the youngest function which was adapted to breathing and swallowing organs and it developed thanks to high diferentiation of the central nervous system. It presents integral function in which peripheral and central phonatory organs take part in.
Peripheral organs are: voice activator (lungs, diaphragm), voice generator (larynx) and resonator (pharynx, mouth, nose and paranasal cavities). Central organs for voice and speech are located in the central nervous system (cortex, lower centres, reticular substance, cerebellum and others).
Voice and speech of the humans are under the influence of psyche, neurovegetative system and endocrine system. One of the most important preconditions for normal development of speech is preserved hearing. Besides hearing, its main elements are eyesight and sensibility, and main activities in the sense of creating voice and speech happen in the central nervous system.
Three-dimensional analysis of movements in cricoarytenoid joint shows that vocal ligaments, cricothyroid ligament and conus elasticus are the most important in the control of abduction, while posterior cricoarytenoid muscle and conus elasticus take part in restriction of adduction. Vocal ligament makes moving of the vocal arytenoid cartilage extension backwards impossible, while cricoarytenoid and posterior capsular ligament restrict movement of vocal extension forward.
Annual incidence of RA in the world is 3 patients out of 1000 people, and the prevalence is from 0,5 – 5%. The disease is mainly present in some groups of population like North American natives, while it is less present in some other groups like black people in Carribean region.
When gender is taken into consideration, the disease is three times more frequent in women than men.
It can start at any age but its greatest frequency is in the fourth and fifth decade and it grows in the old age so it is the highest in people at the age of 25 to 50. One of them says that obesity, weakness and morning rigidity are important in appearing of this disease. Apart from joints, RA can also have extra-articular localizations such as skin, heart, lungs and eyes.
Another etiological theory implies presence of infectious cause of rheumatoid arthritis (Mycoplasma, Epstein-Bar virus, parvovirus, rubella) but none of the mentioned micro-organisms has been proved. Some of the medications from the group of medications that modify the disease also have antimicrobical activity and they are gold salts, antimalarial medications and minocyclin.
In the joints of rheumatoid arthritis patients, bacterial DNA is found, which is also an indirect proof of the bacterial etiology.
Autoimmune processes, as one more theory out of the assumed etiological theories, are tightly connected to RA but it isn’t known if they appear as a primary or secondary process. In the RA patients, autoantibodies aren’t directed towards one immunoglobulin G but also towards other different antigens, such as nuclear antigens (RA 33, EBNA), citrulined proteins (anti-CCP antibodies), collagen and glucose-6-isomarase phosphate. About 60% of patients in the USA has a common epitope HLA-DR4 claster which consists of peptide connected place of the adequate HLA-DR molecule and it is joined with RA. As women suffer from RA about three times more often than men, sexual hormones explain one more etiological theory of RA.
Complaints almost completely disappear during pregnancy, but in the postmenopause period, recurrences of the disease appear. Hyperplasia of synovial cells and activation of endothelial cells are early occurences in the pathological process that lead to uncontrolable inflammatory process and consequent cartilage and bone damage.
Pathological production and regulation of both pro-inflammatory and anti-inflammatory cytokines are found in RA.
In tissue immunity, the most important are Th1 CD4 cells, mononuclear phagocytes, fibroblasts, osteoclasts and neutrophils.
B lymphocytes can serve as an antigen of the presenting cell and they create autoantibodies (for example rheumatoid factor – RF). One of the therapeutic possibilities is, therefore, the elimination of B lymphocytes population by mononuclear antibodies (for example rituximabR which is often used in combination with methrotrexate). Other mediators of inflammation are also described: tumor necrosis factor-alpha, interleucins 1 and 6, transforming growth factor – beta, interleucin 8, fibroblast growth factor, growth factor received from thrombocytes.
Finally, inflammation and uncontrolable synovial proliferation lead to damage of certain tissues, mostly cartilages, bones, strings, ligaments and blood vessels.
The so far known risk factors in RA are: female gender, positive family history, older age, exposure to silicates and smoking (Kuder, 2002). Pathoanatomy of rheumatoid arthritis and laryngeal rheumatoid arthritisDamage of joints in RA is caused by proliferation of synovial macrophages and fibroblasts, probably as a response to possible autoimmune and infectious triggers.


Therefore, it comes to lymphocyte proliferation of perivascular region and proliferation of endothelial cells which cause new blood vessels to multiply and ingrow. Furthermore, the progress of process leads to irregular growth (Firestein, 2005; Goldring, 2000).
Histological examinations of cricoarytenoid joints in RA have shown synovitis as the earliest change that leads to synovial proliferation, fibrinous deposit, forming of pannus on joint surfaces, erosion of the joint cartilage and finally obliteration and ankylosis of joints. Cricoid necrosis as the last phase of pathological changes on the cricoid cartilage can cause serious pathophysiological disturbances (Gatland, 1988).
Neural atrophy of laryngeal muscles and degenerative changes in laryngeal nerves caused by vasculitis, can follow the degree of affection of cricoarytenoid joint (Voulgari PV, 2005; Lofgren RH, 1962).
A few small nodules can be noticed microscopically in submucous layer, and each of them consists of fibrinous necrosis focus surrounded by histiocytes arranged like palisades. Pathophysiology of rheumathoid arthritis and laryngeal rheumatoid arthritisFactors joined with RA include the possibility of infectious trigger, genetic predispositions and autoimmune response.
CD4+T cells lead to immunological cascade reaction which causes secretion of cytokines such as tumor necrosis alpha and interleucin 1. Increased formation and expression of TNF-alpha cause inflammation of synovial membranes and joint destruction.
Joint deformations and working inability happen because of erosion and destroying of synovial membranes and joint surfaces.
Acute obstruction of the superior airways leads to inspiratory stridor, the use of subsidiary respiratory musculature which is manifested by entrainment in jugulum, intercostal spaces, supraclavicular pits and in epigastrium, respiratory weaknesses, peripheral cyanosis, state of shock and coma (Lehmann, 1997). 1) Pulmonary manifestations of RA are pleuritic effusion, pulmonary nodules, interstitial fibrosis, pneumonitis and arteritis.
2) Cardiovascular manifestations are coronary disease, inflammatory pericarditis and pericarditis with effusion, myocarditis, mitral valves disease, disorder in conducting.
3) Constitutional manifestations of RA can be high body temperature, asthenia, weight loss, exhaustion and loss of appetite.
6) Neurological manifestations of RA can be neuropathies such as carpal tunnel syndrome, multiple mononeuritis, cervical myelopathy, central nervous system diseases (stroke, hemorrhage, encephalopathy, meningitis).
7) Cutaneous manifestations in RA can appear as ulcus cruris, palmar erythema and skin vasculitis.
8) Hematological manifestations of RA appear as anemia, thrombocytosis, granulocytopenia, eosinophilia, cryglobunemia and hypertreaclines. 9) Renal manifestations can appear as glomerulonephritis, vasculitis and secondary amyloidosis.
American association of rheumatologists has set up the following criteria for RA clasification: 1. Rigidity in and around joints that lasts at least one hour before maximum improvement in the morning hours.
At least three joint regions have soft tissue swellings or liquid which was diagnosed by a clinician. Fourteen possible regions include left and right superior interphalangeal (GIF) joint, metacarpophalangeal (MCF) joint, wrist joint, elbow joint, knee joint, ankle and metatarsophalangeal (MTF) joints; 3. Symmetric arthritis, in other words simultaneous affection of the same joint region on both sides of the body. Rheumatoid nodules are subcutaneous nodules that are present above the osseus bumps or extensory surfaces or surfaces around the regions that are close to joints; 6. Radiographic changes typical for RA on postero-anterior radiographies of hand and carpus, that have to enclose erosions or disproportional decalcification of bones localized in or on the rims of the most common affected joints. Criteria from 1 to 4 have to be present at least 6 weeks, and the physician has to establish criteria from 2 to 5. RA is often manifested with constitutional symptoms such as myelalgia, weight loss, high body temperature, weight loss and exhaustion. Patients can have difficulties with every day activities (dressing up, getting up, walking, personal hygiene, the use of arms). It can start with systemic manifestations such as high body temperature, exhaustion, arthralgia and weakness before the appearance of swelling joints and inflammation.
In the lower percentage, the patients have abrupt start with acute development of synovitis and extra-articular manifestations. Laryngeal manifestations of rheumatoid arthritis were described for the first time in 1880.
Cricoarytenoid arthritis can be divided into two phases, acute and chronic, and it appears in 27-78% of RA patients (Tarnowska, 2004), and according to some authors in 17-70% when the research is done laryngoscopically, by computered larynx tomography and histopathological cadaveric examinations (Voulgari, 2005). Acute cricoarytenoid arthritis is manifested by feeling of a foreign body in the throat or a feeling of tension in neck or even feeling of burning , hoarseness, odynophonia, voice weakness, changes in voice tone, odynophagia or dysphagia, pain or the feeling of hardness that becomes worse while speaking, spreading of pain to ear, feeling of suffocating, coughing, dyspnea or the feeling of rigidity.
In the chronic phase of cricoarytenoid arthritis, patients often complain of hoarse speech, stridor that appears while making an effort, dyspnea, pain while speaking, neck swelling, hoarseness and these symptoms appear during an infection or during a dream (Braverman, 2007). Laryngeal symptoms during RA vary in their manifestations from 31-75%, while histopathological changes in the larynx are presented postmortem in 90% (Pearson, 1957; Copeman, 1957). According to some authors, stridor appears during exercising in 75% of the cases (Charlin, 1985) and can be the result of inflammation and swelling of arytenoid and posterior commissure during an acute affection of joint or because of joint ankylosis in the chronic RA phase.
The most frequent symptoms are the feeling of a foreign body in the throat (51%), hoarseness (47%) and voice weakness (29%) (Amernik, 2007). Hoarseness appears only in 5% of RA patients (Fisher, 2008), while some other researches have shown that it appears in 30% of RA patients (Segebarth, 2007). Hard RA can be manifested by laryngeal obstruction and can lead to heart, pulmonary and fatal complications.
Diagnosis of rheumatoid arthritis and laryngeal rheumatoid arthritisThorough anamnesis, careful examination of joints and periarticular soft tissue structures, as well as laboratory and imaging results are necessary for right diagnosis of RA.
A clinical examination can establish that mostly small wrists and ankles are affected relatively symmetrically. The most frequently affected joints, with decreasing frequency, are MCF, wrist joint, GIF, knee joint, MTF, shoulder joint, ankle, cervical spine, hip and temporomandibular joints. Joints and chordae damage can lead to deformities such as ulnar deviation, hammer like fingers and occasionally joint rigidity. Other muscle-skeletal manifestations that are usually found during the examination are tendosynovitis and joined chordae rupture during the ligament and chordae affection, the most often affected are chordae of the fourth and fifth finger extensor, periarticular osteoporosis during the localized inflammation, generalized osteoporosis during systemic chronic inflammation, changes connected to immobilization, or corticosteroid therapy and syndrom of carpal tunnel. Cutaneous changes in RA appear like subcutaneous nodules, often along the pressure points (for example olecranon), ulceration of feet cutis, rashes in vasculitis, palmar erythema, gangrenous pyodermia. Affection of lungs in RA can have several forms like pleural effusion, interstitial fibrosis, nodules (Caplan syndrom) and bronchiolitis obliterans, in other words ogranized pneumonia.
In gastrointestinal tract, the affection of intestines is a side effect of medication action, inflammation and other diseases.
Secondary kidney damage often happens during medicamentous therapy (nonsteroidal anti-inflammatory drugs, gold salt, cyclosporin), inflammation (amyloidosis) and joined diseases (Sjogren syndrom with kidney tubular disorders).
Vascular lesions can affect any organ, but are often found on cutis where they can be manifested as palpable purpura, cutis ulcerations or digital infarcts. Hematological disorders are often manifested by secondary anemia which is normochromic-normocytic type, thrombocytosis and eosinophilia. Vascular lesions, mononeuritis multiplex and cervical myelopathy can cause serious neurological prolapses. RA is manifested on eyes like keratoconjuctivitis sicca, as well as episcleritis, uveitis and nodular scleritis which can lead to scleromalacia.
American college for rheumatology has determined criteria for progression, remission and functional state of RA patient.
C) Functional status of RA patients: a) Category I – completely able to fullfil everyday activities, b) Category II – able to fullfil regular personal hygiene and activities connected to their profession but limited in other activities, c) Category III – able to fullfil the activities of regular personal hygiene but limited in activities connected to their proffession and other activities that aren’t connected to their profession, d) Category IV – limited to fulfill regular activities for personal hygiene, profession and activities that aren’t connected to their profession. American College of Rheumatologists (ACR) and European League Against Rheumatism (EULAR) have regulated new criteria for classification of early RA, which include joint affection, autoantibodies status, answer to acute phase and symptoms duration (Aletaha, 2010). RA can be diagnosed in patients if they have: a) atypical erosions or b) long lasting disease which fullfils the previous classification criteria. Large joints are defined as: shoulder joints, elbow joints, hip joints, knee joints and ankles.
Small joints are defined as: MCF, PIF, from the second to fifth MTF and interphalangeal thumb joints and carpus joints. The following laboratory tests are necessary to be carried out: complete blood count with differential count, rheumatoid factor, erythrocyte sedimentation, C-reactive proteins, fibrinogen, haptoglobin, alpha-1-acid glycoprotein, alpha-1-trypsin, S-amyloid-A protein and hematocrit (Guerra, 1992). Erythrocyte sedimentation and C-reactive protein give the best information about the presence of acute phase of RA, but thrombocytosis, low level of iron in the serum and low values of hemoglobin also point to active disease (Crassi, 1998).
It is also important to examine the function of liver and kidneys because of further choice of medicaments, which shows that it is necessary to carry out a complete biochemical blood analysis. Diagnosis of rheumatoid changes in the larynx includes anamnesis, clinical examination, videolaryngoscopy, computered tomography and electromyography (Amernik, 2007). Indirect laryngoscopy shows changes in the larynx in 32% of RA patients, unlike computered tomography where the changes are found in 54%, so indirect laryngoscopy reveals mucous and great pathoanatomical changes, and computered larynx tomography reveals structural lesions (Lawry, 1984). Cricoarytenoid arthritis can be asymptomatic because many RA patients have pathological changes in cricoarytenoid joint, proved by computered tomography, but they don’t have laryngeal difficulties (Brazeau-Lamontagne, 1986). Laryngoscopy in acute cricoarytenoid arthritis shows light red medially expressed swellings in the region of arytenoid, epiglottis, cricoarytenoid arthritis and vocal cords nodules that can look normal or very edematous. In chronic cricoarytenoid arthritis, we can find thickened mucosa in the region of arytenoid, interarytenoid pachydermia, uneven rima glottidis, called “bamboo nodules” because of their appearance that reminds of knots on the bamboo branch. During laryngoscopy of bamboo nodules, subepithelial sallow mass on upper surface of glottis is noticed, often mushroomlike shape and directed by its longer axis transversely to the vocal cords, and they are usually surrounded by hyperemic mucosa (Immerman, 2007; Hilgert, 2008). Direct fiber laryngoscopy can establish pathological changes in the larynx in 75% of RA patients (Brazeau-Lamontagne, 2005). The most frequent rheumatoid changes in the larynx are hyperemia of the mucosa in arytenoid subregion in 41% of the patients and edema of the same region in 28% of the patients (Amernik, 2007).
Safe diagnosis of laryngeal RA is set in direct laryngoscopy by arytenoid palpation when mechanical restriction of movements in cricoarytenoid joint can be proved (Woods, 2007). Computered endovideostroboscopy allows examination of the way mucosa vibrates on the affected side, determination of lesion depth in mucous layer, confirming the unique characteristics of these lesions.
In this way, we can diagnose disorders of adduction and lateral torsion of the vocal cords when they are present. During the palpation of these lesions in general anesthesia, we can find tough fibroid masses tightened on the deep vocal cords structures.
Radiographic manifestations of the disease on wrists are characterised by swelling and mild juxta-articular osteoporosis.
Radiographic indicators of cricoarytenoid joint affection are cricoarytenoid prominention (46%), changes in thickness and volume of joint (46%), as well as cricoarytenoid subluxation (39,9%). Radiographic signs of erosive arthritis of cricoarytenoid joint are present in 45% of patients (Jurik 1984).
Computered tomography of the larynx is a method of choice in diagnosing cricoarytenoid thickness, erosions, arytenoid subluxations, glottic or aryepiglottic nodules asymmetry and by using this method, changes are found in 72% of RA patients (Brazeau-Lamontagne, 2005). Deviation of the larynx in three surfaces is a characteristic finding for RA in the advanced stage and it includes: 1) moving of the larynx anterio-laterally, 2) rotation of the vocal cords clockwise and 3) slantedness of the larynx forward while its front aspect is lowered caudally in relation to its front part (Keenan, 1983).
Also triplanar laryngeal deviation.Nuclear magnetic resonance, computered tomography and scintigraphy can give useful information about pathological changes and their extension in RA. Ultrasonography is accepted for examination of joints, chordae and bursa affection in RA and it can advance early clinical diagnosis and following of patients, showing details such as synovial thicknesses in finger joints (Grassi W, 1998). Complications of laryngeal rheumatoid arthritisComplications of RA can begin to develop within several months since the appearance of clinical symptoms, so timely refering to a rheumatologist or his consultation are necessary for the beginning of treatment with DMARD (disease-modifying antireumatic drugs).
A great number of acute respiratory insufficiency cases caused by rheumatoid arthritis in the larynx have been described (Chalmers, 1979; McGeehan, 1989). Acute respiratory insufficiency in RA patients can be provoked by bacterial infections of the larynx, mechanical larynx lesions or acute exacerbation of cricoarytenoid arthritis (Bolten, 1991; Geterud, 1986).
Tracheotomy is necessary in 10-25% of patients with chronic cricoarytenoiditis (Tarnowska, 2004). Acute obstruction of airways is often connected to cervical spine ankylosis and impossibility of its extension (Miller, 1994). Cervical spine ankylosis was also present with the patient that we treated, it can easily be seen in Figure 6.
Arrow indicates patological process of cervical spine.Vertical penetration of cerebral vertebra cusp was the most important manifestation of cervical spine disease, and one of the laryngeal deviation causes is the scoliotic trachea and the larynx deformation because of neck shortening as a consequence of the second cervical vertebra cusp penetration.
Another machanism is rotational deformity of cervical vertebra caused by asymmetric osseous erosions (Keenan, 1983). Besides cricoarytenoid and cervical vertebra ankylosis, treatment of RA patients is also difficult because of temporomandibular joint ankylosis (Okuda, 1992; McGeehan, 1989). These pathological changes of RA patients can make endotracheal intubation very difficult and dangerous, especially if there is a triploid deviation of the larynx on computered tomography (Bamshad, 1989).
Arthritis of cricoarytenoid joint is also caused by gout, mumps, tuberculosis, syphilis, gonorrhea, Tietz syndrom, lupus eritematodes and injuries (Fried, 1991). Rheumatoid nodules of the larynx as initial signs of systemic lupus eritematodes are described in the literature (Schwartz, 1980). Rheumatoid nodules of the larynx can be differentially diagnostic problem if they are mixed up with vascular lesions (Friedman, 1975). It is often important to distinguish by differential diagnosis asthma and psychoneurosis from cricoarytenoid joint arthritis which is rarely manifested by acute laryngeal obstruction and colapse (Leicht 1987; Absalom 1998). Secondary amyloidosis during rheumatoid arthritis or secondary Sjogren syndrom are rarely causes for laryngeal symptoms (Bayar, 2003).
The case of RA and systemic sclerosis union is also described, which led to mutual immobility of the vocal cords and was manifested by dysphonia and dyspnea as main symptoms and treatment by sphygmic doses of methylprednisolone led to slow improvement (Ingegnoli, 2007).
With other autoimmune diseases, transversal, white-yellow, striped lesions can be found, in the median part of membranous link of the vocal cords, mostly bilateral, but they aren’t symmetrical (Ylitalo, 2003). Rheumatoid cricoarytenoid arthritis should be distinguished from neurogenic disorders, traumatic changes, infections, neoplastic processes and psychosomatic illnesses (Bolten, 1991; Chen, 2005). Mutual immobility of cricoarytenoid joint and Hashimoto thyroiditis are next differentially diagnostic problem which requires multidiscipline approach (Stojanovic, 2010). Then normal electromyogram of vocal muscles and fixation of cricoarytenoid joints during laryngoscopy set by application of laryngoscopic claws, confirm the diagnosis of ankylosis. Treatment of rheumatoid arthritis and laryngeal rheumatoid arthritisThe aims of early prevention and early treatment of RA are to reduce pain, inflammation and inability, to prevent radiologically found damages and progression and to reduce the development of comorbidity.



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