Acquired laryngeal deviation associated with cervical spine disease in erosive polyarticular arthritis. Use of the fiberoptic bronchoscope in rheumatoid disease.

Cervical spine disease in patients with erosive polyarticular arthritis often presents difficulties in endotracheal intubation at the time of surgery. After extensive experience with the use of the fiberoptic bronchoscope in such situations, the authors have identified a previously unrecognized and unanticipated tri-plane deviation in which the larynx is displaced caudally, deviated to the left, rotated to the right, and anteriorly angulated. A review of 710 consecutive fiberoptic intubations identified 15 arthritis patients with laryngeal deviation. Documentation was available in seven patients showing that the larynx was initially in a normal position, but was progressively displaced as the cervical spine disease worsened. Vertical penetration of the dens was the most significant underlying pattern of cervical spine disease. Computerized tomography with multiplanar reconstruction elucidated two patterns of deformity but was not necessary to detect the laryngeal deviation. One cause of the deviation was a scoliotic deformity of the trachea and larynx secondary to shortening of the neck resulting from the vertical penetration. The second mechanism was a rotational deformity of the cervical spine occurring from asymmetric bony erosions. Knowledge of this deformity permits it to be easily predicted preoperatively so that appropriate management can be planned.