RA can affect any diarthrodial joint. The temporomandibular and cricoarytenoid joints and ossicles of the ear may be among those affected. The temporomandibular joint (TMJ) is symptomatic in over half of patients with RA, and radiographic evidence of involvement may be even more common. The TMJ may be tender to palpation and crepitus may be present. Patients may experience an acute onset of pain and be unable to fully close the mouth. Over time, an overbite may develop if the mandibular condyle and temporal bone surfaces are eroded. In children with RA, TMJ growth centers may fail to develop normally, with resultant micrognathia (Fig. 9). Cricoarytenoid involvement may lead to hoarseness, aspiration and, if severe enough to immobilize the joint, inspiratory stridor. Rheumatoid nodules have been reported to occur on the vocal cords, mimicking laryngeal
carcinoma. Keratoconjunctivitis sicca leads to symptoms of dry eyes and is commonly seen in RA, along with dry mouth.
Although not seen commonly today, vasculitic complications can take place in RA patients and have produced nasal septal perforations and even ulcerations on the external ear surfaces. Fortunately, these complications are rarely present in the modern era.
Cervical spine involvement in RA is of particular importance because of the potential for catastrophic neurological consequences. Extension of inflammation into the discover-tebral area can lead to bone and cartilage destruction, with malalignment and subluxation. Early involvement may lead to occipital headache. However, the course of neck pain and myelopathy or other neurological symptoms do not always run parallel. Alternate presentations include progressive spastic quadriparesis with painless sensory loss in the hands or transient episodes of medullary dysfunction. Spinal cord compression can occur; and radiographs, including flexion and extension views of the cervical spine, should routinely be performed in any RA patient undergoing surgery with general anesthesia, particularly those with longstanding disease.
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