Rheumatoid Arthritis (RA)

Atlantoaxial instability - Suspect C1-C2 instability, especially with neck pain or neurologic symptoms; obtain flexion-extension cervical imaging when indicated, keep the neck neutral with manual in-line stabilization, and favor video laryngoscopy or awake fiberoptic over vigorous direct laryngoscopy.

Cricoarytenoid arthritis - The glottis may be narrowed and stiff; anticipate a smaller endotracheal tube and watch for post-extubation stridor and airway obstruction.

Limited mouth opening - Temporomandibular disease restricts access; have alternative airway plans ready.

Fragile joints and positioning - Deformed, unstable joints and osteoporosis demand careful, well-padded positioning, ideally confirmed with the awake patient.

Steroids and immunosuppression - Give perioperative stress-dose corticosteroids for chronic steroid use, use strict asepsis, and account for delayed healing.

Systemic disease - Screen for anemia, pericardial effusion, and pulmonary fibrosis that affect the anesthetic.

A chronic, systemic autoimmune inflammatory polyarthritis causing symmetric joint destruction, with important extra-articular disease. Three airway concerns dominate: atlantoaxial subluxation (C1-C2 instability that can compress the cord when the neck is manipulated), cricoarytenoid arthritis (a narrowed, less mobile glottis), and temporomandibular involvement (limited mouth opening). Systemically there is anemia of chronic disease, pericardial and pulmonary involvement, and the immunosuppression and adrenal suppression that come with steroids, methotrexate, and biologic therapy.