B53-19 Silent Stridor: Rheumatoid Arthritis Presenting With Bilateral Vocal Cord Paralysis

Introduction Bilateral vocal cord paralysis is an uncommon but potentially life-threatening cause of respiratory distress. While etiologies such as surgical trauma, malignancy, and intubation are most frequently implicated, Rheumatoid arthritis (RA) can affect cricoarytenoid joints and vocal cords resulting in airway compromise. This case highlights the diagnostic and therapeutic challenges in RA-associated bilateral vocal cord paralysis. Case History A 68-year-old female with RA presented to the emergency room with acute respiratory distress progressing over the past year, with acute worsening over last 4 days. She reported frequent 10 to 15-minute episodes of hoarseness, dry cough, and shortness of breath, persisted despite oral steroids. She had never been intubated, had neck or chest surgery, or smoked. Her 30-year RA history involved bilateral metacarpophalangeal and wrist involvement. She trialed hydroxychloroquine without symptomatic relief, methotrexate complicated by elevated liver enzymes, and adalimumab with recurrent urinary tract infections. Over the past year, she had not been taking biologic therapy due to insurance barriers but continued low-dose prednisone with symptomatic relief. In ED, the exam revealed a quiet inspiratory stridor. Flexible fiberoptic laryngoscopy demonstrated bilateral vocal cord paralysis with approximately 4 mm glottic gap. CT of the head and neck and chest work-up was unremarkable. She was started on dexamethasone and subsequently transferred to the ICU for airway monitoring. Due to persistent oxygen requirement and failure to improve on high dose steroids with adjunctive heliox, she underwent right cordotomy and thyroarytenoid Botox injection with symptomatic resolution. Discussion Cricoarytenoid involvement in RA may remain clinically silent until critical airway obstruction develops. Progressive joint inflammation and fixation often evolve gradually, with early voice changes or exertional dyspnea easily misattributed to asthma or infection. Although under-reported, up to 50% of patients with RA have laryngeal involvement. Our patient persistent airway symptoms before the development of bilateral vocal cord paralysis highlights the need for routine assessment of airway symptoms and early referral for laryngoscopic evaluation. Once fixation occurs, medical therapy alone rarely reverses obstruction, and surgical intervention is often warranted. In our patient, vocal cordotomy was performed to enlarge the glottic airway, while thyroarytenoid Botox injection reduced adductor tone to temporarily improve airway patency. This case highlights that airway involvement in RA can progress silently yet present emergently, emphasizing multidisciplinary collaboration for timely diagnosis, airway management, and long-term disease control.