Key points to compose the concept and components parts.
Rheumatoid arthritis is the most common inflammatory disease of joints. It is described as symmetric, persistent and destructive polyarthritis which is often followed by positive rheumatoid factor and/or positive results on anticyclic citrulined peptide immunoglobulins. 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 larynx is a part of upper respiratory system and an aerodigestive crossroads and is, therefore, often affected by pathological changes specific for rheumatoid arthritis. 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. Patients with progressive symptoms and signs of rheumatoid arthritis in the larynx do not get routine examination by otorhinolaryngologists, but this disease is usually diagnosed only when breathing and/or swallowing are very compromised.One patient with rheumatoid arthritis in its terminal phase was treated at the ORL Clinic of the Clinical Center in Kragujevac. 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.
\n\t\tRheumatoid 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. In RA, the larynx is affected in 25% of the patients (Dockery, 1991). Symptoms and signs of rheumatoid arthritis in the larynx must be noticed and treated adequately in its earliest phase. This is necessary for preventing the progress of the disease and manifestation of the symptoms and signs that are life threatening, while the ultimate effect would be bringing back the quality of life to a satisfying level.
\n\t\t\tThe 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. The larynx extends from the third to the fourth cervical vertebrae. 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. Upper larynx border is presented by a free edge of epiglottis and aryepiglottic plicae. Lower edge of the cricoid cartilage makes the lower larynx border, Figure 1.
\n\t\t\t\t\n\t\t\t\tTopographically, 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. It follows the head and neck movements and it rises and descends while swallowing. 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. Muscles move cartilages one to another. Submucous layer is made of fibroelastic membrane and the interior is encased by mucosa with blood vessels and nerves. Epiglottis bends backwards and closes the opening of the larynx while swallowing. 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. plicae vocales spuriae. Inferior mucous plicae or true vocal cords or plicae s. chordae vocales close the vocal gap or rima glottidis and it presents the entrance into the lower, subglottic floor of the larynx called cavum infraglotticum. Vocal cord is in its anterior, longer part, membranous and that part is called pars intermembranacea s. ligamentum vocale and in its posterior, shorter part it is cartilagenous and that part is called pars intercartilaginea s. processus vocalis. 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. ventriculus laryngis Morgagni. 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. Mucosa of the larynx ventricle external wall is full of glands or glandulae laryngis.
\n\t\t\t\tAnterior view of larynx.
Coronal section of larynx.
The 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. Pedicle of epiglottis or petiolus is tied along the posterior side of the thyroid angle. Petiolus makes a bump on its mucosa, which covers the anterior commissure and, therefore, it can hardly be seen by indirect laryngoscopy. Mucosa of the epiglottic laryngeal side is tightly connected with its base. Vocal cords stretch from the back side of the thyroid angle and backwards to the vocal ending of the arytenoid cartilage, Figure 3.
\n\t\t\t\t\tInternal view of larynx.
They present triangular prismatic plicae. 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. When seen microscopically, they are whitish with vertical capillaries. Vocal ligament makes elastic skeleton of the vocal cord. Length of the vocal cord is changeable and it depends on its position and tighteness. When calm, it is about 30mm in men and 20mm in women. Subglottic space extends from the vocal cords down to the inferior edge of the cricoid cartilage and it has a conical shape. Its mucosa is tightly connected to the cartilage and they are separated only by elastic membrane.
\n\t\t\t\t\n\t\t\t\tSkeleton 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. The first three are hyaline and the fourth one is fibrocartilagenous. The thyroid cartilage is the gratest cartilage of the larynx. It has a shape of a shield or a shape of a book opened backwards, Figure 4.
\n\t\t\t\t\tLateral view of laryngeal cartilages.
Two thyroid quandrangle plates (lamine s. alae) are connected in their anterior middle part under the right angle in men and under 120 degrees in women. Plates become ossified around the age of 25 and the process ends around the age of 65. 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. There are many concaves on the epiglottic cartilage that are filled with lymph tissue. The epiglottic cartilage is elastic and never ossifies in contrast to others that are hyaline and therefore start to ossify right after the puberty. Cricoid or anular cartilage is placed in the inferior part of the larynx. It has a shape of a ring which is narrow in front and wider in the back. Ossifying of this cartilage begins around the age of 65. There are two small smooth surfaces for joining with arytenoid cartilages on both sides on the superior edges of cricoid lamina. The anterior cartilage is made of an arch or arcus. There are round surfaces for joining with inferior horns of the thyroid cartilage on the joining of the arch and lamina. Arytenoid cartilages are paired and they are placed in the posterior wall of the larynx. They have a shape of a triangular pyramid. 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. Musculus vocalis (m. thyroarytenoideus) attaches on vocal extension. Glottis adductors and abductors attach on the muscular extension. 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.
\n\t\t\t\t\n\t\t\t\tThere are two important joints on every side. They are synovial and enforced by a capsule. Articulatio cricothyreoidea is located between cornu inferior of the thyroid cartilage and cricoid cartilage on the joint of the arcus and lamina.
\n\t\t\t\t\tJoints of the larynx.
Movements in this joint are rotation around the horizontal arytenoid axis and very restricted movements of sliding. Articulatio crycoarytenoidea is located between the arytenoid base and joint surfaces on superior edge of the cricoid cartilage. Movements in the joint are rotation around the vertical arytenoid axis and movements of sliding when arytenoids adduct or abduct, Figure 5.
\n\t\t\t\t\t\n\t\t\t\tMembranes and ligaments of the larynx are divided into three groups. The first group consists of ligaments of joints’ capsules, cricothyroid and cricoarytenoid. The second group consists of interior fibrous tissue made of memrane elastica laryngis. 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. Ligamentum vocale presents superior, free edge of conus elasticus. 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.
\n\t\t\t\t\tMembranes and ligaments of the larynx.
Muscles of the larynx are divided into A. internal and B. external. A. Internal muscles (Figure 7) are placed between some of the cartilages and are divided into 1. abductors, 2. adductors, 3. tensors and 4. covers of the larynx lumen. 1. Laryngeal abductors are two muscles on each side of the larynx, m. cricoarytenoideus posterior s. posticus. Its function is to abduct vocal cords from the middle line and thus to open glottis. 2. Adductors adduct vocal cords to the middle line and close glottis. These are: a) m. cricoarytenoideus lateralis s. lateralis b) m. interarytenoideus s. transversus c) m. thyroarytenoideus or pars externa s. externus. 3. Laryngeal tensors are: a) m. cricothyreoideus s. anterior is external laryngeal tensor. It adducts the thyroid cartilage to the cricoid cartilage from the anterior side, and thus tights the vocal cords intermediately. b) m. thyroarytenoideus or pars interna s. internus s. vocalis is known as internal larynx tensor and forms a vocal cord. 4) covers of the larynx lumen: a) m. interarytenoideus – pars obliqua has a role of glottic sphincter, b) m. aryepiglotticus represents an extension of pars transversa muscles interarytenoidus into aryepiglottic plicae and has a function of a supraglottic sphincter. B. External laryngeal muscles: a) m. sternothyroideus is pulling the larynx downwards, b) m. thyrohyoideus is raising the larynx if hyoid is fixed, in other words, lowering hyoid bone if the larynx is fixed.
\n\t\t\t\t\tInternal laryngeal muscles.
Laryngeal mucosa encases the whole of its cavity. It is separated from cartilage and muscles by submucosa and elastic membrane. 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. There are many tubuloalveolar glands of serous or seromucous nature. 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. Otherwise, there aren’t mucous glands on the free edges of the vocal cords. Larynx mucosa epithelium can be: 1) placoid-layered; 2) cylindrical-ciliary, respiratory type and 3) transitory pseudo-layered cylindrical epithelium (transitory type). 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. There are 20 to 30 rows of cells in that region. 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.
\n\t\t\t\t\tIn 20 % of the cases, the anterior ends of the vocal cords are characterized by a narrow band of epithelium of transitory type. This epithelium is sometimes present in subglottis. 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. Macroscopically, there isn’t a point of joining mucosa with a vocal ligament.
\n\t\t\t\tArterial vascularization of the larynx comes from: a) a. thyreoidea superior (branch a. carotis externa) via its branches aa. thyreoidea superior et media. These arteries go into the larynx on the posterior part of the thyrohyoid membrane, b) a. thyreoidea inferior (branch arteria subclavia) that follows n. recurrens on its way into the larynx. Veins of the larynx follow arteries of the same name. The larynx is innervated by the branch n. vagus: 1) n. laryngeus superior which has two laryngeal branches, internal and external (Figure 8). The internal branch is often sensitive and gives sensory innervation for the whole larynx lumen till the vocal cords height. It goes through the thyrohyoid membrane with superior laryngeal artery and vein. The external branch is motor and innervates the anterior cricothyroid muscle and goes along the inferior edge of superior pharynx constrictor; 2) n. laryngeus inferior s. recurrens which is on the left side much longer than on the right side. 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. It enters the larynx right behind the lower cricothyroid muscle and then divides into two branches: motor or anaetreolateral branch which innervates all internal muscles of the larynx, except the front cricothyroid muscle; and sensitive or postmedial branch for subglottic space. Nerve fibres n. recurrens that are on one side don’t go on the opposite side. 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. The vocal cords practically don’t have their lymph vessels.
\n\t\t\t\t\tBlood vessels, nerves and lymph vessels of the larynx.
Functions of the larynx can be primary and secondary. 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.
\n\t\t\t\tGlottis 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. frenicus. It is led across the respiratory centre as the activity of n. frenicus, it increases with hypercapnia and ventilatory obstruction, and it decreases with artery hyperoxygenation and hyperventilation. This activity is deleted by tracheotomy, as a result of lowered ventilation resistence. 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.
\n\t\t\t\tNormal 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. laryngeus recurrens, ramus communicans and n. laryngeus superior. These fibres go through the larynx into the deep tissue near thyroid plates and they are stimulated when the larynx is dilated.
\n\t\t\t\tAlmost 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. Sphincter mechanism. 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. Respiration ceases while swallowing. This is a reflex which results from stimuli coming from the pharynx when food enters, and they transfer via n. glossopharyngeus and n. vagus. Receptors are the richest in mucosa of the laryngeal side of epiglottis, aryepiglottic and plicae ventricularis and interarytenoid area; 3. Cough reflex is weak or it doesn’t exist in newborn children. Reflex centre is in medulla oblongata, and n. vagus is both afferent and efferent part of the reflex arch. 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. In this way, matters that initiated this reflex also go out. 4. Phonatory function is secondary adapted to respiratory and swallowing organs. 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. More subtle changes are a consequence of thyroarytenoid muscles action. 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. The result of such repeated cycles of glottis opening and closing is freeing of small clouds from subglottic air column which forms sound waves.
\n\t\t\t\tWhen 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.
\n\t\t\t\tDifferent mental conditions are expressed over the voice or they cause disorder in it.
\n\t\t\t\tThis 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. Production of voice is a very complex process and it depends on compliance in the body. 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. A system called ’’feed back’’ participates in forming and maintaining voice and speech. 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. Anterior capsular ligament restricts slanting of the arytenoid cartilage posteriorly and moving of the arytenoid cartilage laterally across joint surface of the cricoid cartilage (Wang, 1998).
\n\t\t\t\tRheumatoid arthritis (RA) is an inflammatory chronic systemic disease of unknown cause that affects peripheral joints symmetrically and permanently and is often connected to positive rheumatoid factor and/or positive results on anticyclic citrulined peptide immunoglobulins.. 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. Arthritis rate is from 5-6% in the Americans from Asian/Pacific islands, to 12% in Afro-Americans to 16% in white people. Etiology of rheumatoid arthritis includes more assumed theories. 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. RA has an important genetic predisposition and that is one more theory about RA. 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. RA rarely appears in women who use oral contraceptives. It is also described that hyperprolactinemia can be a risk factor for RA. 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). In RA patients, many other changed cells are found, such as numerous cytokines, hemokines. 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. Other predisposing factors are psychological stress and smoking. The so far known risk factors in RA are: female gender, positive family history, older age, exposure to silicates and smoking (Kuder, 2002). Drinking more than two cups of coffee a day, high intake of vitamin D, consuming of tea and oral contraceptives reduce risk for RA (Mikuls, 2002; Merlino, 2004).
\n\t\t\tDamage 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. In damaged joints, blood vessels become clogged by small clots or inflammatory cells. Furthermore, the progress of process leads to irregular growth (Firestein, 2005; Goldring, 2000). RA in the larynx can manifest in the following forms: 1) Arthritis of cricothyroid and/or cricoarytenoid joint (Ferdynus-Chromy, 1977; Gotze, 1973; Kubiak-Socha, 1973; Woldorf, 1971; De Gandt, 1969; Copeman, 1968), 2) Rheumatoid nodules (Bridger, 1980; Bonner, 1977; Abadir, 1974), 3) Laryngeal myositis, 4) Neuropathy of laryngeal nervus recurrens and 5) Postcricoid granulomas (Bienenstock H, 1963). 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). Rheumatoid nodules of different size in the larynx are mainly found with seropositive RA. Methotrexate can raise the development of nodules (Kerstens, 1992). Microtrauma, especially a repeated one, can create predisposition for RA. In the largest number of cases, nodules are found subcutaneously. 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. There is a progressive proliferation of endothelial cells and fibroblasts as well as the infiltration of plasma cells and lymphocytes in fibrous supporting tissue that surrounds nodules (Webb J, 1972).
\n\t\t\tFactors 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. Inflammation, proliferation and degeneration are typical for affected synovial membranes. 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). Chronic obstruction of the superior airways can lead to hypoxia, hypercapnia and respiratory acidosis which cause pulmonary hypertension and cor pulmonale (McGeehan, 1989).
\n\t\t\tClinical picture of RA can be divided into several groups of clinical manifestations of the disease, depending on the affected organs/systems: 1) Pulmonary, 2) Cardiovascular, 3) Constitutional, 4) Manifestations from rheumatoid nodules, 5) Eye manifestations, 6) Neurological, 7) Cutaneous, 8) Hematological, 9) Renal and 10) Hepatic manifestations. 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. 4) Rheumatoid nodules can manifest subcutaneously or in pulmonary parenchyma. 5) Eye manifestations are kretoconjuctivitis, episcleritis, scleritis and conjuctivitis. 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. 10) Hepatic manifestations of RA are characterized by high level of liver enzymes. 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. 2. Arthritis of three or more joint regions. 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. Arthritis of wrist joints; at least one region of carpus, GIF and MCF are swollen; 4. Symmetric arthritis, in other words simultaneous affection of the same joint region on both sides of the body. Mutual affection of GIF, MCF and MTF without absolute proportion is also accepted; 5. 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. Serum RF; 7. 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. Independent osteoarthritic changes are not a criterion for RA. Presence of four out of seven criteria are enough for diagnosis. 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). In most of the patients, RA has a perfidious start. 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. by Mackenzie M. and later, 1894. Mackenzie GH. (Mackenzie, 1880; Mackenzie, 1894). 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). In 55% of patients, cricoarytenoid arthritis is asymptomatic (Jurik, 1984). At the beginning of the disease, symptoms are mild but usually subclinical. 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. Rheumatoid nodules of the larynx are often manifested by hoarseness and coughing.
\n\t\t\tThorough anamnesis, careful examination of joints and periarticular soft tissue structures, as well as laboratory and imaging results are necessary for right diagnosis of RA. None laboratory test is specific for RA, so its diagnosis is primary clinical. 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. The patient whom we treated, had prominent changes on the wrists which can be clearly seen in the Figure 9.
\n\t\t\t\tHand changes of reumatoid arthritis.
Joints show inflammation with swelling, painfulness, locally high temperature and restricted movement. Atrophy of interosseus muscles of hands is a typical early sign. 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. Vascular lesions of cutis can be manifested as palpable purpura or cutis ulceration. Cardial changes in RA lead to increased cardiovascular morbidity and mortality. Myocardial infarction, myocardial disfunction and constrictive pericarditis are rare. 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. Kidneys are usually intact by direct action of RA. Secondary kidney damage often happens during medicamentous therapy (nonsteroidal anti-inflammatory drugs, gold salt, cyclosporin), inflammation (amyloidosis) and joined diseases (Sjögren 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. Affection of nerves is often as in nervus medianus syndrom in the carpal tunnel. 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. A) RA progression (clinical and radiological stages): Stage 1 (early RA) is characterized by: a) absence of destructive changes during the roentgenography examinations and b) possible radiography presence of osteoporosis; Stage 2 (advanced progression): a) radiography evidence of periarticular osteoporosis with or without light subchondral destruction of bones, b) possible light destruction of cartilage, c) possible restriction of joint movements, without joint deformities, d) joined myatrophy, e) possible soft tissue extra-articular lesions (for example nodules, tenosynovitis). Stage 3 (very advanced progression): a) radiographic evidence of cartilage and bone destruction followed by periarticular osteoporosis, b) joint deformities (for example subluxation, ulnar deviation, hyperextension) without fibrous or osseus ankylosis, c) massive myatrophy, d) possible extra-articular lesions of soft tissue (for example nodules, tenosynovitis); Stage 4: a) fibrous or osseus ankylosis and b) criteria for stage 3. B) RA remission ( ≥ 5 below induced states that last at least two months constantly): a) morning rigidity that doesn’t stop for 15 minutes, b) without weakness, c) without pain in joints, d) without cracking in joints or pain while moving, e) without soft tissue swelling in joints or chorda wraping, f) erythrocyte sedimentation lower than 30 mm/h in women or lower than 20mm/h in men. 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). ACR/EULAR 2010 criteria: A) Joint affection (0-5): one median to large joint (0), two to ten median to large joints (1), one to three small joints (large joints aren’t included) (2), four to ten small joints (small joints aren’t included) (3), more than ten joints (at least one small joint) (5); B) Serology (0-3): negative RF and negative cell-Purkinje antibodies (APCA) (0), Light positive RF or light positive APCA (2), high positive RF or high positive APCA (3); C) Reactants of acute phase (0-1); normal CRP and normal percentage of erythrocyte sedimentation (ESR) (0), Abnormal CRP or abnormal ESR (1); D) Symptoms duration: a) shorter than 6 weeks (0), 6 weeks and more (1). Cut point for RA is 6 weeks or more. 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. Course of disease can be short and limited or progressive and hard. 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). Similar changes on multislice scanner larynx examination in the woman patient treated at our clinic and triploid deviation of the larynx can clearly be seen in Figure 10.
\n\t\t\t\tSclerosis of the right arytenoid due the cricoarythenoid rheumatoid involvement. 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). In RA patients, electromyographic examinations of internal thyroarytenoid muscles show mutually normal bioelectric stimulation of thyroarytenoid muscles during phonation, while at rest there is no denervation activity (Tarnowska, 2004).
\n\t\t\tComplications 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). Laryngeal obstruction required surgical tracheotomy of RA patients (Takakura, 2005; Jol, 1997; Daver, 1994; Ten Holter, 1988; Peters, 2011; Bossingham, 1996; Funk, 1975). 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. and it can threaten surgical tracheotomy (Yonemoto, 2005).
\n\t\t\t\tAtalantoccipital joint ankylosis. 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). Rheumatoid cricoarytenoid arthritis was complicated by ulcerous necrosis of cricoid esophagostenosis and therefore the patient underwent total laryngectomy (Montgomery, 1980).
\n\t\t\tDifferential diagnosis is directed to artropathies caused by infection, seronegative spondyloartropathies and other connective tissue diseases such as systemic lupus eritematodes (Harris, 2005; Akil, 1995; Nanke, 2001).
\n\t\t\t\tRA should be distinguished from a wide range of diseases that are characterized by clinically prominent synovitis, such as viral, reactive and psoriatic arthritis as well as enteroarthritis and we can come to differential diagnosis by eliminating, because there isn’t a specific test for RA (Grassi, 1998). 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 Sjögren 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). The most difficult differential diagnosis is in cricoarytenoid ankylosis and bilateral paresis/paralysis of recurrent laryngeal nerves. 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. Differential diagnosis of these two conditions is possible by using electromyography and laryngoscopy, and mutual fixation of the arytenoid cartilages is confirmed with long-term endotracheal intubation (in 68,8% of patients), short-term endotracheal intubation (in 9,4%), Wegener granulomatosis (in 9,4%) of rheumatoid arthritis (in 6,3%) of previous surgery in the larynx (in 3,1%) and caustic ingestion (in 3,1%) (Eckel, 2003).
\n\t\t\tThe 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. Joint damage in rheumatoid arthritis begins a few weeks since the begining of the disease symptoms and that’s why the early treatment reduces the disease progression rate (Emery, 2002). Pharmacotherapy generally includes several groups of medications: nonsteroidal anti-inflammatory drugs (NSAID) for pain control, oral or intra-articular glucocorticoids in low doses and start with DMARD. “Reverse pyramid” approach is required in RA treatment today, when DMARD are started immediately in order to slow down the disease progression as soon as possible (Rindfleisch, 2005). This approach is accepted on the basis of several facts: joint damages start in the early phase of the disease (Emery, 2002), DMARD have a significant use when they are used in the early phase of the disease, the uses of DMARD can be helped when the medications are used in the combination (Pincus, 1999; Lipsky, 2000; Weinblatt, 2004), a great number of medications from this group with positive evidence of useful effects are accessible. RA patients of medium stage and normal radiographic results should start the treatment with hydroxychloroquine, sulphasalazine or minocycline, although methotrexate is also a possibility. Patients with heavier stage of disease or radiographic changes should start treatment with methotrexate. If the disease symptoms aren’t controlled well by mentioned medications, leflunomid or combined therapy should be taken into consideration (methotrexate together with one medication of newer generation). For initial RA treatment for reducing pain and joint swelling together with the combination of the mentioned medications, NSAID, salicylate or ciclooxygenease-2 inhibitors should be used. These medications can’t be used independently because they don’t change clinical course of RA. Glucocorticoids, usually in the dose that is equivalent to 10 mg of prednisone a day are highly important for freeing from RA symptoms and they can slow down joint damage (Kirwan, 1995). Their dosing should be kept at minimum because of a great risk of unwanted effects, which include osteoporosis, cataract, hyperadrenocorticism and altered glycemia levels. American college for rheumatology has recommended the intake of 1500mg of calcium and 400-800 IU of vitamin D a day. The most often used medications for RA treatment are methotrexate, hydroxychloroquine, sulphasalazine, leflunomide, infliximab and etanercept. Newer DMARD are leflunomide, antagonists tumor necrosis factor (TNF) and anakinra. Pharmacotherapeutic approaches for RA are very different depending on certain studies. One of such approaches is a combination of these two medications from the DMARD group, mainly methotrexate and sulphasalazine or methotrexate and cyclosporine (Dougados, 1999; Tugwell, 1995). Combination of methotrexate, sulphasalazine and high doses of corticosteroids has brought up to prolonged effects on radiographic progression in comparison to monotherapy by sulphasalazine (Landewe, 2002). In the two-year study, 197 RA patients were chosen by coincidence to take therapeutic protocol with four medications, methotrexate, sulphasalazine, hydroxychloroquine and prednisolone (5mg/a day) or individual medication from DMARD where it has been noticed that greater number of patients in remission got combined therapy, while fewer number of patients in remission were in the group of monotherapy by some other medication from DMARD group (Korpela, 2004). In some studies, cricoarytenoid arthritis treatment in a 65-year-old male patient and 56-year-old female patient was carried out by local, intra-articular injections of triamcinolone combined with prednisolone (Jol, 1997; Simpson, 1980; Habib, 1977). Systemic application of corticosteroids brought up to significant mobility of the arytenoid cartilages in a 63-year-old patient (Jurik, 1985). Beclomethasone diproprionat in the treatment of rheumatoid changes in the larynx was useful (Sladek, 1983). Surgical approach to immobility of the vocal cords from paramedial position, in other words rheumatoid ankylosis of cricoarytenoid joints implies mobilizational and laterofixational techniques (Ejnell, 1985). Arytenoid adduction surgery was carried out successfully in a 57-year-old female patient who didn’t have dyspnea year and a half after the surgery (Kumai, 2007). Endoscopic arytenoidectomy is usually a surgery of choice (Koufman, 2003).
\n\t\t\tRheumatoid arthritis is a disease of unknown cause with several assumed etiological theories, but pathoanatomical and pathophysiological changes are mostly familiar. It is manifested on different organs and tissues and about 25% of all patients have clinical manifestations in the larynx. Patients with RA manifested on more than one joint, must be sent to and examined by a rheumatologist 6 weeks since the beginning of the disease symptoms. Joint and bones swelling points to early arthritis especially if at least two joints are involved and/or morning rigidity lasts longer than 30 minutes and/or if there is an affection of metacarpophalangeal and/or metatarsophalangeal joints (Emery, 2002). Following the disease course includes counting of painful and swollen joints, complete cooperation between the patient and the physician, determining erythrocyte sedimentation and C - reactive protein. Disease activities should be followed in the intervals from 1 to 3 months until the remission period is reached. Structural damages must be followed rardiographically every 6 to 12 months during the first several years. Family doctor must think about the structural damage of the larynx in the patients with advanced arthritis and he must send these patients to periodical otorhinolaryngological examinations every 1 to 3 months. At that time, it is necessary to carry out indirect laryngoscopy and graphic flow/volume which is enough for the initial screening. Forced inspiratory/expiratory relationship between the flow and volume provide a simple non-invasive test for revealing stenosis in upper airways. Pathological results of screening cause additional examinations by fiberoptical laryngoscopy, laryngomicroscopy with the examination of the arytenoid cartilages fixation, helped by multislice scanner larynx examination every six months to a year, computered stroboscopy and electromyography of the larynx. This is important because laryngoscopy provides better view of the mucous and functional integrity preservation, and multislice scanner larynx examination offers more precise visualisation of the structural changes. Periodical otorhinolaryngological examinations should be routine when treating patients with rheumatoid arthritis and they are always undertaken when family doctor and/or the rheumatologist of the clinic find the smallest disease progression on laryngeal and/or extralaryngeal localizations. Then, together with basic rheumatological therapy, intra-articular application of corticosteroid medications needs to be applied into every sick cricoarytenoid joint. When conservative treatment fails, after providing airways by tracheostomy, it is indicated to carry out endoscopic arytenoidectomy which presents a surgery of choice. For patients of extremely bad state to bear laryngeal surgery, or with those patients where surgical procedures failed to provide adequate airway, permanent tracheostomy is the final therapeutic possibility. In RA patients where a surgery in general endotracheal anesthesia is indicated, the otorhinolaryngologists inform the anesthesiologist after every examination about every laryngeal disorder. Anesthesiological risk is always present in the patients with rheumatoid arthritis in the larynx during endotracheal intubation and immediately after the extubation (Segebarth, 2007). In these patients, a careful search for cricoarytenoid arthritis is the basic thing, especially in those with laryngeal stridor which can be inforced after general anesthesia.
\n\t\tI would like to give credit to my wife Tatjana, my daughter Nina and my son Luka for their support and immense patience during elaboration of this chapter, as well as for their recognition of the importance of this work in diagnosis and treatment of all rheumatoid arthritis patients.
\n\t\tThe advent of globalization promotes organizations with the persistent pursuit of competitiveness, forcing businesses moving competitive advantages. Still, organizations that are in the forefront of their sectors and considered successful are those that actually trying to develop its core competencies to offer a standard of excellence in goods and services and are concerned with its strategy and with the workforce. The market organizations have demanded a set of features that include efficiency, effectiveness, dynamism, creativity, agility, flexibility and having holistic vision, to be competitive and having defined their strategies, seeking business sustainability.
\nIn [1] are highlighted the indicators that assess the efficiency of internal activities and processes, and logistics performance indicators are suggested. They are classified into the following categories: stock management, cost, productivity, quality and customer service. However, it is necessary to develop a performance evaluation form for the supply chain, using external and internal indicators together to evaluate the performance of the entire chain, not only internal indicators of logistics, so that, working together, companies manage to achieve the best return business of supply chain.
\nIn [2], it is considered the designation of logistics as “logistics management.” Also it is cited that this concept can be included into customer service, traffic and transportation means, storage, selection of local to manufacture and store, inventory control, order processing, acquiring, transportation of materials, distribution, supply of parts, packaging, returning goods and order volume forecast and that an organization must provide products and services to customers according to their needs and requirements as efficiently as possible.
\nSometimes logistics is related to the marketing, as the strategic process to managing the acquisition, transfer, storage, parts, and finished products, together with the flow of information and its marketing channels to maximize profit with cost-cutting. There is no single definition for conceptualizing logistics, which be accepted by all researchers in the field. The important thing is that companies know that it is present in the business world and that professionals must understand their target that “is to make available products and services where they are needed, when they are desired” [3].
\nThe traditional logistics refers to activities such as packaging, transportation, loading, unloading and storage, etc. The modern logistics reaffirms the concept of integrated logistics management and its implementation. It is important to outstanding that modern logistics must be understood as the medium during the acquisition, production, and operation of the whole process to delivery to the final consumer [4].
\nIn contemporary organizational environment, logistics appears as a strategic concept, because of not only materials management and physical distribution, but also for providing values of time and place for customers, for becoming an element that stands for organizations, with agility, flexibility and integration of internal and external channels. Several authors describe that the concept of logistics can be separated into three basic items: food (suppliers), plants (internal) and distribution (customers). This represents a group that is often defined as highly empirical, resulting in negative effects that directly influence the outcome of the final performance of organizations [5, 6].
\nDespite the importance of internal logistics, it has not been fully understood, particularly in manufacturing industry [7, 8, 9]. However, it constitutes a large part of the total cost for businesses [10]; average logistics costs represent between 10% and 30% of total sales volume in a typical production company [11]. This chapter is composed by eight parts: An introduction, a Literature Review, a section of materials and methods where it is explained all the procedure developed, a section of results analysis and finally the conclusions, the acknowledgments, the conflict of interest and the references.
\nSeveral authors state that an internal logistics system well designed and correctly used increases the efficiency of an organization [12, 13].
\nTo summarize, several aspects of logistics performance are very important for a company, and among others refer to delivery, quality, robustness, information, and cost and customer service. However, it is also important to consider which is the combination of high efficiency, performance, and effectiveness [14]. For [15] the performance efficient logistics activities alone are not enough. To create competitiveness for the company, it is essential that the right kind of logistics activities to be prioritized and through the right performance variables. However, as discussed by [16], there is a lack of standardized ways of dealing with the internal logistics requirements influencing the overall logistics performance. In general, logistics managers are trying to use measurements to help design and manage more effective and efficient logistic systems for the client. Identifying the value of internal logistics and its critical performance criteria can be a way to help this development [17].
\nDesign and improve the internal logistics system involves decision making at different levels, such as strategic, tactical and operational issues. As such, it involves long-term planning (strategic) and aspects of planning and control (management) of short and medium term [18]. An internal logistics system that works well requires involvement and understanding of the system at all levels. Logistics professionals should be empowered with the necessary experience in essential and critical functions for their own company and fully understand how they affect the entire value chain [19].
\nInternal Logistics handles all the management of the internal supply process, storage, transportation and distribution of goods within the organization, that is, to meet its domestic demands as support for manufacturing [20]. According to [6], the cycle of support to manufacturing activities is directly related to internal logistics, i.e., planning and production control. Thus, the logistical support to the production aims mainly to establish and maintain an economic and orderly flow of materials and stocks in process in order to meet the schedules of the production sector. The logistics support production has the operational responsibility for the following activities: handling and storage of products, materials, components and semi-finished parts. With the changes in the business environment, logistics service concepts have evolved and various issues were added in operational logistics tasks such as packaging, outsourced inventory management, bar code, and information systems. These operational logistics tasks were considered, and called as “internal logistics,” and these activities should “interact with other functional areas” [21]. Internal logistics thus involves logistics activities within the walls of an organization, e.g. internal transport, materials handling, storage and packaging [15].
\nOther more recent studies indicate that the internal logistics has been the attempt to organize and optimize the internal activities with the cost reduction objective for organizations in different segments. However, organizational issues such as the lack of a strategic vision that become in difficulties need to be addressed. The transfer of knowledge and technology used in the manufacturing industry could be of great benefit concluded by [22].
\nAccording to [23], the end consumer determines the success or failure of supply chains. Thus, an important part of logistics performance is linked to customer service and to be able to respond to their needs and requirements. When it comes to internal logistics as a system, both the client and the service provider are the same at the organization itself. So to see the internal logistics as a system, both the service provider and the customer are the same company. As such, the customer’s needs and requirements can be translated for internal purposes. Therefore, the performance of internal logistics is under the control of the company, and can provide a more direct indication of the effects of the relationship involving structure and logistics [16].
\nGiven this approach to internal logistics, was noticed a gap both in theory and in practice referred to this issue. Many discussions in the general theoretical field of logistics has been developed. Companies need support with tools and models or methods that make it possible to identify, organize and help to define and shape to analyze them; it is evident in the daily graded citations mentioned above about the lack of studies in this area. Therefore, this chapter suggests a way to define and evaluate the internal logistics.
\nBased on the readings of selected articles and the development of a pattern was possible to define a more comprehensive concept of internal logistics:
\nInternal logistics is planning, execution and control of the physical flow and internal information of the company, seeking to optimize the resources, processes and services with the highest possible profit.
\nAccording to the standpoint of logistics as a picture or an approach that consists of several parts and aspects, it is often described as a system, which is the perspective used in this work to analyze the internal logistics as part of the system. According to [24], the logistics system is always open and in a state of exchange with its environment. However, the limits of the system and subsystems and components included vary depending on different perspectives.
\nThe system studied in this chapter is the internal logistics system, where the system boundaries are the physical limits of the company under study. Then internal logistics comprises logistics activities within the walls of an organization, such as internal transport, materials handling, storage and packaging [15].
\nThere are three different angles from which, logistics operations can be seen: processes, resources and organization. All these aspects can be seen as parts of the logistics system, as the flow of goods and information to be made through a series of stages called activities and processes [25]. In addition, resources refer to all means, equipment and personnel needed to run the process. Finally, the organization includes all planning and control procedures necessary to implement and manage the system.
\nSeveral authors argue that an internal logistics well designed and properly used increases the efficiency of an organization [26]. The project of internal logistics system is therefore an aspect that strongly influences the competitiveness of the system and is therefore related to the objective of this chapter.
\nProjecting and improve internal logistics system comprises decision making at different levels, such as strategic, tactical and operational levels. As such, it includes long-term planning (strategic) and aspects of planning and control (management) of short and medium term [18]. Internal logistics system that works well requires participation and understanding of the system at all levels. Logistics professionals must be equipped with the necessary expertise in critical and essential functions for their own company and fully understand how they affect the entire value chain. Supply chains are often faced with the situation where they have to accept some degree of uncertainty, however, must develop a strategy that allows them to adjust supply to demand [27]. In general, it can be affirmed that a strategy is about how to make the planning, which is very different from doing [18]. To conduct portfolio analysis were consolidated by central themes articles and one can see some evidence as to the possible parts of internal logistics. For a better demonstration of sets of items was prepared to Table 1 resulting in a preliminary view of the parts.
\nArticles key points | \nIT | \nLT | \nPCP | \nPCM | \nST | \nIM | \nSP | \nRC | \nWP | \nLA | \nHL | \nIM | \nPP | \n
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Supply networks | \nX | \nX | \n\n | \n | \n | \n | X | \n\n | \n | \n | \n | \n | \n |
Decision making | \nX | \nX | \n\n | X | \nX | \nX | \n\n | \n | \n | \n | \n | \n | X | \n
Delivery | \n\n | X | \nX | \n\n | \n | \n | \n | X | \n\n | \n | \n | \n | \n |
Health care logistics | \nX | \nX | \n\n | X | \n\n | \n | X | \n\n | \n | \n | X | \n\n | \n |
Logistics performance | \nX | \nX | \nX | \n\n | \n | X | \nX | \n\n | \n | \n | \n | X | \n\n |
Inbound logistics | \nX | \nX | \n\n | \n | X | \nX | \n\n | \n | \n | \n | X | \nX | \nX | \n
Cross-docking | \n\n | X | \n\n | \n | X | \n\n | \n | \n | \n | \n | X | \n\n | X | \n
Automated material handling systems | \nX | \n\n | X | \n\n | X | \n\n | \n | \n | \n | \n | X | \nX | \n\n |
Identifying business value using the RFID e-Valuation framework | \nX | \nX | \n\n | \n | \n | \n | \n | \n | \n | \n | \n | \n | \n |
Cost-cutting | \nX | \nX | \nX | \n\n | X | \nX | \nX | \n\n | \n | X | \nX | \n\n | X | \n
Customer and supplier logistics | \nX | \nX | \nX | \n\n | \n | \n | \n | \n | \n | \n | \n | X | \n\n |
Inventory and transportation decisions | \nX | \nX | \n\n | \n | X | \nX | \n\n | \n | \n | \n | \n | \n | \n |
Intralogistics operations | \nX | \nX | \n\n | \n | \n | \n | \n | \n | \n | X | \n\n | \n | \n |
EDI in logistics | \nX | \nX | \n\n | \n | \n | X | \n\n | X | \n\n | \n | \n | X | \n\n |
Integration between logistics and Assembly lines | \nX | \nX | \nX | \n\n | X | \nX | \n\n | \n | \n | X | \n\n | \n | X | \n
Optimization transport | \n\n | X | \nX | \n\n | \n | \n | \n | \n | \n | \n | X | \nX | \nX | \n
Routing and inventory | \nX | \nX | \nX | \n\n | X | \nX | \nX | \n\n | \n | \n | X | \nX | \nX | \n
Smart logistics | \nX | \nX | \nX | \n\n | \n | \n | X | \n\n | X | \n\n | \n | \n | \n |
Manufacturing strategy | \nX | \nX | \nX | \n\n | \n | \n | \n | \n | X | \n\n | \n | \n | \n |
Consolidation loads | \nX | \nX | \n\n | \n | \n | \n | X | \n\n | \n | \n | \n | X | \n\n |
Key points to compose the concept and components parts.
IT = information technology; LT = logistics techniques; PCP = planning and control production; PCM = planning and control manufacturing; ST = storage; IM = inventory management; SP = supply; RC = receipt; WIP = working-in-progress; LA = layout; HL = handling; IM = internal transport; PP = picking and packing.
Source: Prepared by authors (2020).
A well-formulated strategy helps to use all the resources of an organization and create value based on its internal competition and shortcomings in relation to the external environment. However, it is of great importance that the logistic function and logistics strategy are integrated and aligned with other functions and strategies of the organization, to create competitiveness [15].
\nCompanies that emphasize logistics periodically reorganize its logistics functions in their attempt to find and keep the best design in the business environment which is rapidly changing [28]. The overall response capacity could be achieved through a greater sharing of information between partner organizations and a careful selection of suppliers by the purchaser. Table 2 provides a summary of the components used in different studies applied to internal logistics.
\nInternal logistics components | \nSource | \n
---|---|
Physical flow | \n|
Receipt | \n[29, 30, 31, 32, 33] | \n
Warehouse | \n[25, 34, 35, 36, 37, 38, 39] | \n
Supply | \n[40, 41, 42]. | \n
Movement | \n[32, 34, 43, 44, 45, 46, 47] | \n
Working in process | \n[19, 48, 49, 50, 51, 52, 53] | \n
Internal transport | \n[39, 54, 55, 56, 57, 58] | \n
Picking/packing | \n[32,59, 60, 61, 62, 63, 64, 65] | \n
Information flow | \n|
Information technology | \n[40, 55, 66, 67, 68, 69, 70, 71] | \n
Planning and material control | \n[54, 68, 72, 73, 74, 75] | \n
Planning and production control | \n[74, 76, 77, 78, 79] | \n
Customer service | \n[40, 80, 81, 82, 83, 84] | \n
Order processing | \n[48, 68, 73, 85, 86, 87] | \n
Inventory management | \n[32, 34, 41, 66, 68, 88, 89, 90, 91] | \n
Theoretical background of the internal logistics components.
Source: Prepared by authors (2020).
The novelty of this chapter is related to a new definition of internal logistics which implies a description of its component parts according to this new definition, and the procedure for evaluating its level in anyone company or factory.
\nThere were identified a few systematic attempts, proposals and techniques that improve the manufacturing system and the internal logistics and their related performance. They have to be able to assess the dynamics of production and the corresponding improvement and taking into account environmental issues. For developing the objective of the chapter there were carried out the following steps:
To identify the composition of the industrial pole of Manaus according to the different industries that compound it.
To identify in literature, the component parts and definitions of internal logistics.
To develop a new definition of internal logistics and its component parts.
To confront and discuss the new definition and its component parts with industry professionals through surveys and interviews.
When there were defined the component parts, it was elaborated a survey of then questions for assessing each one of the component part using a Likert scale of five points. This survey and questionnaire was also discussed with engineers and researchers that deal with internal logistics and supply chain.
The survey was applied to the different industries of the industrial pole of Manaus.
With all these information, then there were analyzed and decided which tools would be used for assessing the internal logistics according to its new definition and according to its components parts.
It was stablished an Internal Logistics Index for evaluating its level in any company or factory
For this porpoise there were used an Excel tab, the fuzzy logic, and the neural networks.
All this procedure is explained in detail below.
\nThe Industrial Pole of Manaus has more than 565 companies of small, medium and large size, involving seven subsectors of different branches of activities, which can be seen in Figure 1. The emphasis of the companies to be researched will focus in the two-wheel sector that is the 16.77% of the PIM billing. The research will be developed in companies of medium, large and small size.
\nShare of activities of sub-sectors in sales of the industrial pole of Manaus in the period from January to February 2015 (calculated based on sells in dollars). Source: Suframa – Industrial indicators (2015).
To assess the internal logistics, a survey was conducted to different companies of the Industrial Pole of Manaus. For data had statistical significance, it was analyzed what size the sample should have.
\nThe “right” sample magnitude for a specific application depends on many factors, such as costs, administrative aspects, level of precision, level of reliability, variability within the population or subpopulation of interest and specimen method.
\nThese factors interact in multifaceted ways. Although a consideration of all the variations is beyond the scope of this chapter, the remainder of this epigraph covers a situation that commonly occurs with simple random samples: How to find the minimum sample magnitude that offers the desired precision.
\nFor demonstrating that a process has been improved, it is necessary to measure the process competence before and after improvements are implemented. This permits to measure the process improvement (e.g., defect reduction or productivity growth) and translate the effects into a projected financial result – something that corporate leaders can understand and appreciate. Determining sample dimension is a vital topic because samples that are too large may waste time, resources and money, while samples that are too small may lead to inaccurate results.
\nIn the case of the industrial pole of Manaus, it is composed for 565 companies, and using the formulation expressed in [92], the number of companies to be considered for a good statistical representation has to be more than 60 companies.
\nAnalyzing the sectors of the Industrial Pole of Manaus, it was possible to identify the components to assess the internal logistics. They were redesigned through interactions with business professionals from different companies in order to obtain the greatest possible standardization of component parts of internal logistics. Figure 2 shows these parts. From this picture can be observed that there are component parts that have to do with the physical flow and other with the information flow.
\nComponent parts of the internal logistics. Source: Authors (2020).
Each component part of the figure above was evaluated by 10 properties or pertinent questions reflecting the respective training component behavior for performance, supported by Likert scale of 1 to 5, with 1 indicating little or no adhesion and 5 full adhesions between the question versus practice where each part can reach a maximum of 50 points is that the resulting properties of 10 x 5 points, and a total of 130 questions as a result of the 13 component parts of 10 questions each.
\nThe questionnaire applied in enterprises, medium and large, the following segments: electronics, appliances, components and two wheels. In March 2015, 539 invitations were sent to participate in the study. A total of 327 responses received, being considered only 140 (25.97%) fit and consistent for research. The sample characteristics are shown in Table 3.
\nIndustrial sector | \n% | \nSize dcounter | \n
---|---|---|
Domestic appliances | \n15 | \n100–250 | \n
Electronics | \n35 | \n100–250 | \n
Components | \n40 | \n250–500 | \n
Towels | \n9 | \n500–1000 | \n
Others | \n1 | \n100–250 | \n
Firms demographics: Industry and size.
Source: Authors based on survey (2016).
To evaluate the weight of each component part of the Internal Logistics were sent a survey to 93 companies to analyze them and to attribute a weight of importance in a Likert scale of 1–5 where 1 was minor and five very important according to the particularity and priority that represents the component parts for the aforementioned companies. In Table 4 there are offered the results of three of the companies investigated.
\n\n | \nComponent part | \nAssigned weight by each company | \n||||
---|---|---|---|---|---|---|
Company 1 | \nCompany 2 | \nCompany 3 | \nArithmetic mean | \nCompany 3 | \n||
Weight | \n||||||
Component parts of the Internal Logistics | \n||||||
Receipt | \n3 | \n5 | \n4 | \n4.00 | \n6.8% | \n|
Handling and movement | \n2 | \n4 | \n3 | \n3.00 | \n5.1% | \n|
Picking/packing | \n4 | \n4 | \n4 | \n4.00 | \n6.8% | \n|
Storage | \n1 | \n5 | \n5 | \n3.67 | \n8.5% | \n|
Stocks management | \n2 | \n5 | \n5 | \n4.00 | \n8.5% | \n|
Supplying | \n5 | \n5 | \n5 | \n5.00 | \n8.5% | \n|
PMC- planning and material control | \n2 | \n5 | \n5 | \n4.00 | \n8.5% | \n|
PPC - planning and production control | \n2 | \n5 | \n5 | \n4.00 | \n8.5% | \n|
WIP- working in process | \n1 | \n5 | \n5 | \n3.67 | \n8.5% | \n|
Order processing | \n4 | \n4 | \n5 | \n4.33 | \n8.5% | \n|
Internal transports | \n1 | \n4 | \n4 | \n3.00 | \n6.8% | \n|
Customer support | \n5 | \n5 | \n5 | \n5.00 | \n8.5% | \n|
I. T. information technology | \n3 | \n5 | \n4 | \n4.00 | \n6.8% | \n|
Internal Logistic Index | \n35 | \n61 | \n59 | \n51.67 | \n100% | \n
Answers from the companies on the degree of importance of the elements of internal logistics.
Source: Authors.
It was found that depending on the company and its respective sector, the priorities and the degree of importance may be subject to change and therefore affect the performance of internal logistics index.
\nThe maximum score that each company can get is 65 points, which is the result of the multiplication of the 13 items by the maximum value of each item according to the Likert scale. It is noted for example that the company 1 attributed a very low note for the items: Storage, WIP and internal transport, while companies 2 and 3 attributed notes 5, 5 and 4 respectively for these same items, therefore, it follows which depending on the sector and type of production, whether continuous or discrete, the degree of importance may change. An arithmetic mean of the 3 companies was also developed in this tabulation and it was appreciated that from the maximum possible score of 65 points, company 1 scored 35 points, followed by 61 points by the company 2 and finally the company 3 with 59 points, and the arithmetic mean was 51.67 points.
\nBased on the literature investigated was developed the structure of diagnostic model of the component parts of the internal logistics, its filling, testing and subsequent validation. They were developed 10 questions to assess each property and was conducted a survey in different companies. These questions were developed based on the literature review, the survey results according to the criteria of specialists of logistics management, and consulting and business managers. It was developed an Excel tab to evaluate the performance of each of the component parts of the internal logistics as well as the Internal Logistics Index of a company.
\nThe Excel Tab developed to calculate the Internal Logistic Index was based on the following equations:
\nwhere \n
where \n
Assessing the Internal Logistic Index of a Company is a very complex task due in some case to the lack of information and in other cases to the excess of information for decision-making. This leads to difficulty in defining, measuring and monitoring of objectives and targets to set rates compliance associated with measuring the performance of the Internal Logistics [93]. In response to these challenges of business management there have been emerged theories, approaches and methodologies (flexibility, resilience, etc.) using tools such as fuzzy logic for reliable solutions that adapt easily to changing parameters of imprecision [94].
\nIn addition to the treatment of imprecise environments, another emerging challenge is to achieve that the measurement of organizational performance transcends the traditional financial approach and to be conducted throughout with suitable means to new generations of applications in the management of internal logistics.
\nA fuzzy inference method allows deriving conclusions (a fuzzy value) from a set of if-then rules and a set of input values to the system, by applying composition ratios. The two inference methods commonly used are the Mamdani introduced by Mamdani and Assilian [95] and the TSK (Takagi-Sugeno-Kang) proposed by Takagi and Sugeno [96].
\nThe main difference between these methods is the consequent type of the fuzzy rule. The systems Mamdani type use fuzzy sets as consistent rule and TSK used linear functions of the input variables with discrete data outputs. In this research the type Mamdani inference system (Figure 3) with outputs continuous values is used.
\nFuzzy system for asses the internal logistics. Source: Authors (2020).
To facilitate the modeling of the problem in fuzzy logic, it was used the Fuzzy Logic Toolbox ™ of MATLAB software. The steps for formulating the model of fuzzy inference of Mamdani type were [97, 98]:
\nPerformance measurement of the internal logistics can be based on the selection and definition of indicators used to evaluate the efficiency and effectiveness of its operations. Indicators should have a holistic approach and facilitate the implementation of initiatives for improvement. Indicators selected for the proposed fuzzy model to measure the performance of the Internal Logistics of the company studied are described in Table 5. The components were grouped into larger groups as shown therein. A letter from A to B. defines each group.
\nA | \nB | \nC | \nD | \n
---|---|---|---|
Receipt | \nWIP- working in process | \nPPC - planning and production control | \nPicking/packing | \n
Storage | \nHandling and movement | \nPMC- planning and material control | \n\n |
Stocks management | \nSupplying | \nCustomer support | \n\n |
I. T. information technology | \nInternal transports | \nOrder processing | \n\n |
Component parts of internal logistics.
Source: Authors.
Each component part of the previous group is evaluated using 10 pertinent questions that reflect the behavior of the respective part.
\nThe model has 24 rules, which were created from the experience of official logistics industry specialists and numerical data from surveys and they are offered in Table 6.
\nComponent parts/groups | \nA | \nB | \nC | \nD | \nLI | \n
---|---|---|---|---|---|
1 | \nM | \nB | \nM | \nB | \nB | \n
2 | \nM | \nG | \nG | \nB | \nM | \n
3 | \nG | \nB | \nM | \nB | \nB | \n
4 | \nG | \nG | \nG | \nB | \nM | \n
5 | \nB | \nG | \nG | \nB | \nB | \n
6 | \nG | \nB | \nG | \nG | \nM | \n
7 | \nB | \nG | \nB | \nM | \nB | \n
8 | \nM | \nG | \nB | \nM | \nM | \n
9 | \nB | \nM | \nM | \nM | \nM | \n
10 | \nM | \nB | \nM | \nM | \nM | \n
11 | \nG | \nM | \nM | \nM | \nM | \n
12 | \nM | \nB | \nG | \nB | \nM | \n
13 | \nG | \nG | \nM | \nG | \nG | \n
14 | \nM | \nB | \nG | \nG | \nM | \n
15 | \nG | \nM | \nB | \nM | \nM | \n
16 | \nB | \nB | \nM | \nB | \nB | \n
17 | \nM | \nM | \nG | \nG | \nG | \n
18 | \nG | \nM | \nB | \nM | \nM | \n
19 | \nB | \nB | \nM | \nG | \nM | \n
20 | \nM | \nG | \nB | \nG | \nM | \n
21 | \nG | \nM | \nB | \nG | \nM | \n
22 | \nB | \nM | \nB | \nG | \nM | \n
23 | \nB | \nG | \nB | \nM | \nB | \n
24 | \nB | \nM | \nG | \nR | \nM | \n
Fuzzy rules.
Source: Authors (2020).
M = medium, G = good, B = bad.
The model has four inputs that are the four groups described in Table 5 and an output that is the Internal Logistics Index. The parameters of pertinence functions associated with each variable were also specified. There were adjusted all inference functions and the defuzzification method used. The rules of an inference engine of a fuzzy system has to be made by experts, or learned by the system, in this case using neural networks to strengthen future decision-making. For making the rules in this problem were used criteria of 20 specialists in the field of Internal logistics.
\nOne problem with the method applied in the previous section is that the user of Excel tab has to assign a weight to each component part of the internal logistics based on in his own experience, which naturally influences the overall index of internal logistics of a company. Attempting to avoid subjectivity in determining this rate, it was looked to the technique of artificial neural networks. To analyze the Internal Logistics of an industrial company was used the Internal Logistics Index (ILI), evaluated between 0 and 100%. This index is calculated based on the values assigned to each of the internal logistics properties between 0 and 50 according to the 10 parameters of evaluation of each property in the Likert scale of 1 to 5.
\nThere were selected the same 10 companies of the Industrial Pole of Manaus for their study and analysis, all of them belonging to the productive sector.
\nIt was proposed to the ANN to determine the Internal Logistic Index of 10 companies in the industrial pole of Manaus. The values of the properties of the component parts of the 10 companies are given in Table 7.
\nProperty | \nCompany number and value of the performance of each property | \n|||||||||
---|---|---|---|---|---|---|---|---|---|---|
E1 | \nE2 | \nE3 | \nE4 | \nE5 | \nE6 | \nE7 | \nE8 | \nE9 | \nE10 | \n|
Receipt | \n30 | \n35 | \n36 | \n50 | \n42 | \n47 | \n32 | \n18 | \n50 | \n22 | \n
Handling and movement | \n20 | \n44 | \n23 | \n50 | \n35 | \n45 | \n34 | \n15 | \n39 | \n19 | \n
Picking/packing | \n50 | \n22 | \n32 | \n48 | \n26 | \n34 | \n45 | \n21 | \n40 | \n23 | \n
Storage | \n40 | \n33 | \n41 | \n43 | \n12 | \n50 | \n23 | \n32 | \n35 | \n34 | \n
Stocks management | \n30 | \n11 | \n25 | \n21 | \n18 | \n16 | \n15 | \n18 | \n18 | \n35 | \n
Supplying | \n24 | \n44 | \n18 | \n50 | \n22 | \n24 | \n18 | \n43 | \n25 | \n23 | \n
PMC- planning and material control | \n33 | \n50 | \n15 | \n39 | \n19 | \n35 | \n22 | \n32 | \n35 | \n41 | \n
PP - planning and production control | \n28 | \n33 | \n21 | \n40 | \n23 | \n32 | \n18 | \n19 | \n28 | \n19 | \n
WIP- working in process | \n16 | \n22 | \n32 | \n35 | \n34 | \n18 | \n34 | \n42 | \n47 | \n32 | \n
Order processing | \n41 | \n11 | \n18 | \n18 | \n35 | \n33 | \n45 | \n35 | \n45 | \n34 | \n
Internal transports | \n33 | \n33 | \n43 | \n25 | \n23 | \n22 | \n35 | \n26 | \n34 | \n45 | \n
Customer support | \n23 | \n45 | \n32 | \n35 | \n41 | \n43 | \n25 | \n12 | \n50 | \n23 | \n
I. T. information technology | \n33 | \n44 | \n19 | \n28 | \n19 | \n21 | \n18 | \n18 | \n16 | \n15 | \n
Different properties that compose the Internal Logistic Index of a company and their values for the 10 companies evaluated.
Source: Authors.
The desired Internal Logistics Indexes for the aforementioned companies (supervised training), in order to train the ANN are given in Table 8.
\n\n | Company number and Internal Logistic Index possible according to the performance value of each property | \n|||||||||
---|---|---|---|---|---|---|---|---|---|---|
E1 | \nE2 | \nE3 | \nE4 | \nE5 | \nE6 | \nE7 | \nE8 | \nE9 | \nE10 | \n|
ILI | \n65 | \n75 | \n70 | \n67 | \n78 | \n60 | \n70 | \n65 | \n78 | \n65 | \n
Possible internal logistics indexes (ILI) for each company (targets) for training the ANN.
Source: Authors.
In Figure 4 it is showed the Architecture of the ANN implemented in MATLAB. In order to achieve reliable results, the network was trained five times. In Figures 5 and 6 the training process is displayed.
\nArtificial neural network implemented in MATLAB. Source: Authors (from MATLAB).
Neural network training state. Source: Authors (from MATLAB).
Training and retraining of the ANN. Source: Authors (from MATLAB).
It was chosen randomly the company three to answer questionnaires regarding the 13 elements or components parts of internal logistics. This company filled the Excel tab, reaching a score in% of each property that was multiplied by the weights assigned in Table to each property. This company reached a general index of 79.17% for Internal Logistics as it is shown in Table 9.
\nIt was found that depending on the company and its respective sector, the priorities and the degree of importance may be subject to changes and therefore affect the performance index of internal logistics. The maximum score that each company can get is 65 points, which is the result of the multiplication of the 13 items by the maximum value of each item according to the Likert scale. It is noted for example that the company 1 attributed a very low note for the items: Storage, WIP and internal transport, while companies 2 and 3 attributed notes 5, 5 and 4 respectively for these same items, therefore, it follows which depending on the sector and the type of production, whether continuous or discrete, the degree of importance may change. An arithmetic mean of the values of the 3 companies was also developed in this tabulation and it was noted that from the maximum possible score of 65 points, the company 1 scored 35 points, followed by 61 points by the company 2, then the company 3 with 59 points, and the arithmetic average was 51.67 points.
\nThe toolbox of fuzzy logic implemented in MATLAB with the four groups of the diffuse model is shown in Figure 7. In Figure 8 the values of Internal Logistics Index reached according to the input variables are shown. For example, if each group (from A to D) have an average value (5 points), then the Internal Logistics Index reaches a value of 37.4 points. The MATLAB allows vary input values, and consequently modifying the value of Internal Logistics Index.
\nFuzzy model for evaluating Internal Logistic Index. Source: Authors (from MATLAB).
Internal Logistics Index according to the input variables. Source: Authors (from MATLAB).
Another way of demonstrate the results between two groups and the Internal Logistic Index can be analyzed from Figure 8, where there are represented the A and B groups with the value of 5 points for each group. The maximal value of the Internal Logistic Index in this case will be of 37.50% as it is shown in Figure 9.
\nSurface of values of the internal logistic index according to the input variables. Source: Authors (from MATLAB).
It was established a comparative analysis between results of both models: Excel Tab versus Fuzzy Logic. The obtained results of the Internal Logistic Index by using the Excel tab was of 79.17% when assessing the 13 component parts. These component parts of the same company were grouped how was cited before in four groups: A, B, C and D, supported by 24 rules developed and applied in the Fuzzy Logic toolbox from MATLAB. Each input variable can reach a value between 0 and 10. If each input variable reach the average value of 5 points, the Internal Logistic Index will be of 37.50%. Following the same procedure and way of thinking the top possible value of Internal Logistic Index will be of 75%, versus 79.17% obtained by Excel Tab method, demonstrating similarity between the both tools and a precision on the order of 95% of the results.
\nValidation errors of the neural network are shown in Figure 10.
\nValidation of the artificial neural network errors. Source: Authors (from MATLAB).
The ANN enabled in MATLAB with data values of the 13 Internal Logistic Properties from the 10 companies was processed. The values of the indexes of Internal Logistics as well as their possible are given in Table 10.
\n\n\n | \nProperty | \nPerformance | \n||
---|---|---|---|---|
Percent | \nWeight | \nPoints | \n||
Component elements of the Internal Logistics | \nReceipt | \n96.00 | \n6.8 | \n6.53 | \n
Handling and movement | \n88.00 | \n5.1 | \n4.49 | \n|
Picking/packing | \n90.00 | \n6.8 | \n6.12 | \n|
Storage | \n86.00 | \n8.5 | \n7.31 | \n|
Stocks management | \n86.00 | \n8.5 | \n7.31 | \n|
Supplying | \n46.00 | \n8.5 | \n3.91 | \n|
PMC- planning and material control | \n94.00 | \n8.5 | \n4.62 | \n|
PP - planning and production control | \n92.00 | \n8.5 | \n4.62 | \n|
WIP- working in process | \n88.00 | \n8.5 | \n7.48 | \n|
Order processing | \n88.00 | \n8.5 | \n7.48 | \n|
Internal transports | \n90.00 | \n6.8 | \n6.12 | \n|
Customer support | \n88.00 | \n8.5 | \n7.48 | \n|
I. T. information technology | \n84.00 | \n6.8 | \n5.71 | \n|
General Internal Logistic Index | \n79.17 | \n
General internal logistic index of a company.
Source: Authors.
Company | \n1 | \n2 | \n3 | \n4 | \n5 | \n6 | \n7 | \n8 | \n9 | \n10 | \n
---|---|---|---|---|---|---|---|---|---|---|
ILI | \n70.65 | \n75.00 | \n67.37 | \n72.13 | \n78.15 | \n60.03 | \n70.05 | \n65.0 | \n78.0 | \n64.04 | \n
Error in % | \n2.65 | \n0.006 | \n2.62 | \n3.13 | \n0.15 | \n0.03 | \n0.059 | \n0.004 | \n0.009 | \n0.95 | \n
Obtained values of the internal logistics indexes and errors of these values in the 10 companies studied.
Source: Authors (from MATLAB).
In this chapter three approaches and their expressions to assess the internal logistics of a company are established. The first method was based on dividing the internal logistics in 13 properties, having each property 10 indicators that were evaluated between 1 and 5 points. This leads to the maximum value of Internal Logistics Index (ILI) for each company can reach up to 100 points according to the weight stablished for each indicator.
\nThe second approach was based on the fuzzy logic and the third one was based on neural networks.
\nWhen assessing the Internal Logistics Index using the Excel tab developed or by the method of Artificial Neural Networks, very similar values consistent with the reality of the companies studied were obtained, demonstrating the validity of both methods.
\nThe methodological approach developed for the definition of the three models contains all the steps and procedures, allowing replication of the research, which is as important as the application of the developed models at the companies.
\nWhen assessing this parameter, using the Excel tab or developed by the method of fuzzy logic, similar values were obtained in line with the reality of the company analyzed, indicating the rationality of both methods.
\nThe approach through the Fuzzy logic allows assess the rate of internal logistics for any position of the input variables, which can obtain a value between 0 and 10, depending on the appreciation of the user of this procedure. In the case of the company studied, specialists gave more emphasis to groups A and C.
\nTo the “Instituto de Tecnologia Galileo da Amazônia (ITEGAM),” to the “Universidade Federal de Santa Catarina(UFSC),” and the National Council for Scientific and Technological Development (Conselho Nacional de Desenvolvimento Científico e Tecnológico, CNPq-BRAZIL) Productivity of Research Funds Processes 301811/2019-9 for their support to the development of this research.
\nThe authors declare no conflict of interest.
On a scale of 5 (high) to 1 (low), how important are the following issues in your firm’s logistics efforts?
\n\n
Is the team geared to provide quality and always prioritize customer?
Is there any ERP system that allows integration and exchange of information between companies?
Is there an analysis of customer satisfaction?
Is there guidance for team procedures?
Is there guidance on the importance of customer response speed?
Are there a scheduled visit and contacts with current customers and potential and no formal or research and survey on competitors and new niches?
Is there a metric to analyze the value perceived by the customer as the supply of goods and services?
Are there procedures that allow flexibility for customer service?
Is there a division of the teams and the calls of customers by importance – ABC and analysis or particular strategy?
All valuable contacts with customers are recorded in minutes or similar?
\n
The PCM is responsible for planning and control of all production inputs of the company?
Is there a defined routine priority of PCM activities?
Is there an ERP information system that supports the planning materials, e.g. MRP and no analysis of the messages: Action, Exception and Correction?
Is there a schedule to run MRP, e.g. weekly, monthly or every 15 days, and metrics to analyze the effectiveness?
Is there a time horizon that the PCM plans to purchase inputs; e.g. monthly or every three months or 20 weeks of purchase orders range?
Is there a working definition for supply based on MTO - make to order or MTS - make to stock; or customer sales plan?
Is there a performance evaluation of the inputs delivery compliments the company (supplier evaluation)?
Is there analysis of purchasing volumes for technical ABC analysis or other?
Is there a systematic review on the BOM list of theory versus practice?
There are policy setting for Horizon Planning, Redesign, expediting and follow-up?
\n
Are there management decisions as: quality (what to produce - design and control characteristics); Process (how to produce - facilities, equipment); Capacity (when produce - planning and programming); Inventories (with what to produce and when - requirements of materials and market); Workforce (who produce - qualification, performance, motivation)?
Is there a definition as Frequency: Order one or more of an order demand and the demand is constant. Variable demand. Independent demand or demand dependent?
The Lead time or supply time are: Lead Team Lead time constant variable and how to support management systems use: Continuous review periodic. Revision or MRP?
The PCP is considered along with manufacturing as strategic for the company; and working with: Production Plan. Plan Master Production Scheduling and production?
The PCP adopts some criteria sequencing or prioritization techniques in planning the company’s production?
The PCP has a flow of information and interacts with areas: Production, Capacity, technology, Human Resources, Quality, Engineering, marketing, Maintenance, Logistics and Development?
The PCP works with forecasting techniques?
The PCP - controls the analysis of the standard cost of open orders and there are closures routines of orders in the month of opening and has OEE indicator?
The CFP has the practice of daily or weekly schedule issue and if there is time production monitoring schedule time?
The CFP has operations in three hierarchical levels: Strategic, Tactical, and Operational?
\n
Is there a practice of picking?
Is there the practice of Packing?
Is there the practice of obliterating the specifications of inputs to be released to production?
The packaging used obey some amount of standardization, weight, color, or other?
The separation or preparation of the application or request follows a priority basis the production and or PCP?
Is there any guidance on the practice of picking by: zone, batch or discrete?
Is there any validity packaging control?
The practice of packaging or Packing takes place in the industrial area or shipping?
Are there specific areas for these packaging practices?
Are there teams trained in these practices? And if there is time control for each operation?
\n
Are there set procedures on specific date in the month of receipt of order or forecast customer?
Is there a lot of tolerance and or quantity for order fulfillment?
The customer demands, both firm orders and forecast are processed by the customer service area and PCP or?
Upon receipt of applications and or forecast undergo an analysis sieve critical about the information contained in it?
Is there any responsibility of processing the request on the internal expediting to delivery to the customer?
Is there any reports on request of the situation and this feedback is sent to the client?
Is there the definition of a physical flow and information on the application?
The order processing system influences the PCP or logistics performance as a whole?
The company uses some technology strategies: Edi- Electronic Data Interchange Barcode RFID- Radio Frequency Identification QR- Quick Response ECR- Efficient Consumer Response CPFR- Collaborative Planning, Forecasting and Replenishment;
Is there a setting to work taking into account the order cycle?
\n
Are there procedure defining criteria for receiving the aspects: qualitative, quantitative, fiscal and administrative, e.g. variation of tolerance of quantity, quality criteria and time of receipt?
All supplies and materials are received only by formal authorization or by order?
Is there separation of powers between the fiscal and physical receipt?
Is there separation of powers of the incoming teams and warehouse?
Is there some defined criteria for quality assurance of production inputs?
Is there an area for segregation of inputs nonconforming when detected in receiving?
Are there different negotiations for tax problems cases: interstate, local and regional?
The flow of receiving inputs and or materials are balanced according to the available warehouse area?
Are there appropriate or docks and ramp leveler for the reception of the materials?
Are there standard definition pallets and loads unitized arrive?
\n
The supply of the manufacturing area is performed by the logistics team?.
Usually follows a daily schedule: OP, OM or OS?
The team that performs the supply meets the inputs?
The team practices management view?
Is there oriented practice of Housekeeping/5 s?
Usually communicate to existing higher losses in the process?
The team that performs the supply periodically receives training?
Is there control over the supply time to avoid any line stops and or machines?
Is there work instructions for each type of supply?
Is there a metric to determine the contents of delays and incorrect or supplies?
\n
Is there a procedure that meets the ISO 9000 or 14,000 or similar standards?
All warehouse operations are computerized with ERP system?
Is there any software that facilitates addressing allocation of material type: WMS or equivalent?
Is there a process to expedite the receipt of materials e.g. bar code or RFID?
The layout takes into account the minimization of the distance between the area of the warehouse and efficient supply and provides flexibility?
The warehouse is suitable for safety standards? And it takes into account at the time of storage: the density, selectivity, frequency output/consumption and costs?
The warehouse is structured with metal structures or equivalent within the technical standards and provides earning capacity allowing vertical storage?
There flexibility both the fixed storage as random to allow optimizing the use of available facilities?
Professionals working in the warehouse are trained, qualified and trained to operate equipment such as forklifts, monorails, and other equipment?
The warehouse professionals are aware about the importance of: store, locate, protect and preserve the materials purchased or developed?
\n
Is there inventory policy defined?
Is there harmony between: man versus machines versus materials and includes the integration of the materials and information flows?
It is known to capacity position and if there is flow control between inputs versus outputs of materials?
Studies aimed at harmony between the receipt flow and manufacturing supply?
The factory supplies: exit of warehouse supplies takes into account: the criteria: FIFO, LIFO, SHELF LIFE or other?
The low of the stock of inputs occur through: PICKING, GOOD, back flushing, or other?
Is there an ERP system that enables obtaining daily movement of input and output information?
Are there analyzes of: Giro, Coverage, Break, obsolescence, accuracy or automatic inventory replenishment?
Is it defined an inventory policy: Rotary, Cyclical, or Monthly and annual.
Is there specific team of executors?
\n
Is there specific training for staff working with handling and movement of inputs?
Is there a checklist or guide to guide staff as to the appropriate local drive; attention to inputs and or equipment?
The movement of staff is the same answer: the receipt, allocation and industrial supply?
In case of handling trucks, the team has CNH or course forklift operator?
The staff is trained to obey some as NR or orientation CIPA?
Are there training program/periodic retraining the team?
All movements of stocks are properly recorded?
The movement of staff is responsible for the low inputs of stocks?
Is there any training on the observation of the symbols of packaging as stacking, storage and handling?
Is there a control or measurement standard time for handling between warehouse receipt versus plant?
\n
The Company uses a corporate ERP?
The company has systematically to collect, check and update information for decision making and performance?
The company’s information system is aligned with the Strategic Planning?
The information system is available for the entire company and all activities are developed in the ERP environment, avoiding work in parallel spreadsheets?
Are there indicators available and understood by employees involved?
There ERP system integration with their customers through: EDI, CRM, VMI and or SAP?
The MRP and MRP II module is available for business?
The factory operating costs are closed monthly and compared with the initially foreseen (e.g. production order closure: standard estimated cost vs. actual cost occurred)?
Is there concern in updating and security of ERP (examples: Backup and version upgrades)?
Does the ERP provide: integration, speed, availability of information for decision making and the company has access management with logins and responsibilities levels?
\n
Is there a specific area to take care of this activity or if it is subject to internal logistics activities?
Are there monitoring the preventive maintenance of equipment?
In the case of trucks, repairs and repairs are carried out by specialized companies?
Is there an equipment replacement plan when they are with their completed depreciation?
The amount of internal transport equipment are adequate demand?
People who handle or operate and are trained and qualified?
The company has in its internal operations: manual operation of equipment and motorized equipment such as: strollers, manual and motorized lifts, forklifts, and others?
The company works with: monorail, monorails, overhead crane, conveyor belts, cranes, roller conveyors, tractors, dynamic roller conveyors?
Is there dangerous or flammable cargo transport, if so, follow some NR?
The people of this area have some equipment types: EPI and the company provides guidance on its use, compliance and aspects ergonomics?
\n
Is there a policy that defines the inventory level in the process: be semi-finished or finished products or raw materials?
There’s definition to return the inputs to the warehouse when a production order and or service is interrupted before its completion in month?
Is there concern at the closure of production orders and or services within the pre-set period?
There criterion set when spare or missing inputs for conclusion of production or service order?
Are there practical for use of certain order input to meet other unspecified; (In the case of common items)?
Are there practices of use of inputs in the process, other than those specified in document production? And if so, are changed in the engineering structure?
Are there different control when the packages are not within specifications?
Is there control and segregation in the plant for not conforming items?
Is there concern in accountability with senior management and or sector responsible for the required inputs versus consumed/met?
Is there control and analyze the evolution of inputs processes in monetary values to each inventory?
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