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Wasserman I, Chari DA, Gray ST, Naunheim MR, Miloslavsky EM. Ear, Nose, and Throat Manifestations of Vasculitis and Other Systemic Autoimmune Diseases: Otologic, Sinus, and Airway. Rheum Dis Clin North Am 2023; 49:633-645. [PMID: 37331737 DOI: 10.1016/j.rdc.2023.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
Auricular, nasal, and laryngeal manifestations occur frequently in rheumatic diseases. Inflammatory ear, nose, and throat (ENT) processes often result in organ damage and have profound effects on quality of life. Herein, we review the otologic, nasal, and laryngeal involvement of rheumatic diseases, focusing on their clinical presentation and diagnosis. ENT manifestations generally respond to treatment of the systemic disease, which is outside the scope of this review; however, adjunctive topical and surgical treatment approaches, as well as treatment of idiopathic inflammatory ENT manifestations will be reviewed.
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Affiliation(s)
- Isaac Wasserman
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Divya A Chari
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA; Department of Otolaryngology, University of Massachusetts Memorial Health Center, Worcester, MA, USA
| | - Stacey T Gray
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Matthew R Naunheim
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Eli M Miloslavsky
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Byszewska A, Skrzypiec I, Rymarz A, Niemczyk S, Rękas M. Ocular Involvement of Granulomatosis with Polyangiitis. J Clin Med 2023; 12:4448. [PMID: 37445483 DOI: 10.3390/jcm12134448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 06/22/2023] [Accepted: 06/27/2023] [Indexed: 07/15/2023] Open
Abstract
Granulomatosis with polyangiitis (GPA), formerly referred to as Wegener's disease, is a form of ANCA-associated vasculitis. It manifests mainly in the kidneys and the upper respiratory tract, but ocular involvement is not uncommon. In this article, four cases with ocular manifestations are presented with comprehensive photographic documentation. We describe the way to proper diagnosis, which may be long, the possible treatment, and the final outcomes. Our patients had the following ocular manifestations of GPA: retinal vasculitis, anterior necrotizing scleritis, medial orbital wall and orbital floor erosion with middle face deformation, compressive optic neuropathy due to retrobulbar inflammatory mass, and the abscess of the eyelids, inflammatory intraorbital mass causing exophthalmos and diplopia. This manuscript includes the description of severe forms of GPA, the initial signs and symptoms, relapses, and difficulties in achieving remission. The extraocular involvement is described with diagnostic modalities and laboratory findings. One of the reported cases was diagnosed by an ophthalmologist on the basis of ocular symptoms in the early stages of the disease. Our outcomes are compared with those discussed in the literature.
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Affiliation(s)
- Anna Byszewska
- Ophthalmology Department, Military Institute of Medicine-National Research Institute, Szaserów 128, 04-141 Warsaw, Poland
| | - Izabela Skrzypiec
- Ophthalmology Department, Military Institute of Medicine-National Research Institute, Szaserów 128, 04-141 Warsaw, Poland
| | - Aleksandra Rymarz
- Nephrology Department, Military Institute of Medicine-National Research Institute, Szaserów 128, 04-141 Warsaw, Poland
| | - Stanisław Niemczyk
- Nephrology Department, Military Institute of Medicine-National Research Institute, Szaserów 128, 04-141 Warsaw, Poland
| | - Marek Rękas
- Ophthalmology Department, Military Institute of Medicine-National Research Institute, Szaserów 128, 04-141 Warsaw, Poland
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van Eeden C, Mohazab N, Redmond D, Yacyshyn E, Clifford A, Russell AS, Osman MS, Cohen Tervaert JW. Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and fibromyalgia: PR3-versus MPO-ANCA-associated vasculitis, an exploratory cross-sectional study. LANCET REGIONAL HEALTH. AMERICAS 2023; 20:100460. [PMID: 36890852 PMCID: PMC9986636 DOI: 10.1016/j.lana.2023.100460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 02/10/2023] [Accepted: 02/10/2023] [Indexed: 03/03/2023]
Abstract
Background Persistent fatigue is a common complaint in ANCA-vasculitis (AAV) patients and has a profound impact on patient's quality of life. The symptoms associated with this fatigue mirror those found in patients with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and fibromyalgia. Etiologic and pathophysiologic differences exist between PR3- and MPO-ANCA disease, yet differences in their fatigue manifestations have not been well researched. We compared fatigue and its associations in healthy controls, AAV patients and fibromyalgia controls. Methods The Canadian consensus criteria were used for ME/CFS diagnosis, and American College of Rheumatology criteria for fibromyalgia diagnosis. Factors such as cognitive failure, depression, anxiety, and sleep disturbances were assessed by patient reported questionnaires. Clinical factors such as BVAS, vasculitis damage index, CRP and BMI were also collected. Findings Our AAV cohort comprised 52 patients, with a mean age of 44.7 (20-79), 57% (30/52) of the patients were female. We found 51.9% (27/52) of patients fulfilled the diagnostic criteria for ME/CFS, with 37% (10/27) of those having comorbid fibromyalgia. Rates of fatigue were higher in MPO-ANCA patients, than in PR3-ANCA patients, and their symptoms were more similar to the fibromyalgia controls. Fatigue in PR3-ANCA patients was related to inflammatory markers. These differences may be due to the varied pathophysiology of the PR3- and MPO-ANCA serotypes. Interpretation A large proportion of AAV patients suffer from debilitating fatigue consequential enough to meet the diagnostic criteria for ME/CFS. Fatigue associations were not the same between PR3- and MPO-ANCA patients, suggesting that the underlying mechanisms may be different. Future studies should consider ANCA serotype, as further research may inform different clinical treatment strategies for AAV patients suffering from ME/CFS. Funding This manuscript was funded by the Dutch Kidney Foundation (17PhD01).
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Affiliation(s)
- Charmaine van Eeden
- Division of Rheumatology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada.,University of Alberta, Rm5-68, Heritage Medical Research Center, Edmonton, T6G 2S2, Canada
| | - Naima Mohazab
- Division of Rheumatology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada.,University of Alberta, Rm5-68, Heritage Medical Research Center, Edmonton, T6G 2S2, Canada
| | - Desiree Redmond
- Division of Rheumatology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada.,University of Alberta, Rm5-68, Heritage Medical Research Center, Edmonton, T6G 2S2, Canada
| | - Elaine Yacyshyn
- Division of Rheumatology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada.,University of Alberta, 8-130 Clinical Sciences Building, Edmonton, T6G 2B7, Canada
| | - Alison Clifford
- Division of Rheumatology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada.,University of Alberta, 8-130 Clinical Sciences Building, Edmonton, T6G 2B7, Canada
| | - Anthony S Russell
- Division of Rheumatology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada.,University of Alberta, 8-130 Clinical Sciences Building, Edmonton, T6G 2B7, Canada
| | - Mohammed S Osman
- Division of Rheumatology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada.,University of Alberta, 8-130 Clinical Sciences Building, Edmonton, T6G 2B7, Canada
| | - Jan Willem Cohen Tervaert
- Division of Rheumatology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada.,University of Alberta, 8-130 Clinical Sciences Building, Edmonton, T6G 2B7, Canada
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4
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Updates of ocular involvement in granulomatosis with polyangiitis. Graefes Arch Clin Exp Ophthalmol 2022; 261:1515-1523. [DOI: 10.1007/s00417-022-05918-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 10/11/2022] [Accepted: 11/22/2022] [Indexed: 12/12/2022] Open
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Missed Otological Presentation of Wegener’s Granulomatosis: A Case. Indian J Otolaryngol Head Neck Surg 2022; 74:492-494. [PMID: 36032906 PMCID: PMC9411451 DOI: 10.1007/s12070-020-02328-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 12/14/2020] [Indexed: 10/22/2022] Open
Abstract
Wegener's granulomatosis is a rare systemic autoimmune disease of unknown etiology. Typically, it affects the upper respiratory tract, lungs, and kidneys. Sometimes localized form of the disease in head and neck region is also seen. These often go unrecognized till the patient develops systemic signs and symptoms leading to significant complications affecting the quality of life of patient. If timely diagnosed, such potentially life altering sequelae can be avoided with treatment. We present here a case report of a female who presented with breathing difficulty along with Otological symptoms but remained undiagnosed for a long time leading to permanent morbidity because of facial nerve damage and hearing loss.
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Koritala T, Mene-Afejuku TO, Schaefer M, Dondapati L, Pleshkova Y, Yasmin F, Mushtaq HA, Khedr A, Adhikari R, Al Mutair A, Alhumaid S, Rabaan AA, Al-Tawfiq JA, Jain NK, Khan SA, Kashyap R, Surani S. Granulomatous Polyangiitis With Renal Involvement: A Case Report and Review of Literature. Cureus 2021; 13:e19814. [PMID: 34963834 PMCID: PMC8695666 DOI: 10.7759/cureus.19814] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 11/22/2021] [Indexed: 12/02/2022] Open
Abstract
Granulomatosis with polyangiitis (GPA), formerly named Wegner’s granulomatosis is an antineutrophilic cytoplasmic antibody (ANCA) associated vasculitis of the small vessels. GPA can affect several organ systems even though predominantly affects respiratory and renal systems. Pathogenesis is initiated by activation of the immune system to produce ANCA, Cytoplasmic (C-ANCA) antibody, which thereby leads to widespread necrosis and granulomatous inflammation. Multisystem involvement with varied symptomatology makes GPA diagnosis more challenging. Early diagnosis and management are vital and can alter the prognosis of the disease. We present a literature review and a clinical scenario of a 26-year-old male with a history of chronic sinusitis, testicular carcinoma in remission, recent onset of worsening cough, epistaxis, hoarseness of voice, weight loss, and dark-colored urine. Workup revealed high titers of C-ANCA, C-reactive protein, procalcitonin, CT chest evidence of mass-like consolidation, and bronchoscopy findings of friable tissue that was not amenable for biopsy. Methylprednisolone and rituximab (RTX) were administered, which resulted in marked clinical improvement. Therefore, a keen eye for details is necessary to diagnose GPA early, which can improve disease outcomes dramatically.
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Affiliation(s)
| | | | | | - Lavanya Dondapati
- Internal Medicine, Dr. N.T.R University of Health Sciences, Vijayawada, IND
| | | | - Farah Yasmin
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | | | - Anwar Khedr
- Critical Care Medicine, Mayo Clinic, Mankato, USA.,Medicine, Tanta University Faculty of Medicine, Tanta, EGY
| | - Ramesh Adhikari
- Hospital Medicine, Franciscan Health, Lafayette, USA.,Geriatrics, Brown University, Providence, USA
| | - Abbas Al Mutair
- Emergency Medicine, Almoosa Specialist Hospital, Al-Ahsa, SAU
| | - Saad Alhumaid
- Pharmaceutical Care, Al-Ahsa Health Cluster, Al-Ahsa, SAU
| | - Ali A Rabaan
- Molecular Microbiology, Johns Hopkins Aramco Healthcare, Dhahran, SAU
| | | | | | | | - Rahul Kashyap
- Anesthesiology and Critical Care, Mayo Clinic, Rochester, USA
| | - Salim Surani
- Anesthesiology, Mayo Clinic, Rochester, USA.,Medicine, Texas A&M University, College Station, USA.,Medicine, University of North Texas Dallas, Dallas, USA.,Internal Medicine, Pulmonary Associates of Corpus Christi, Corpus Christi, USA.,Clinical Medicine, University of Houston, Houston, USA
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Radiologic Differentiation between Granulomatosis with Polyangiitis and Its Mimics Involving the Skull Base in Humans Using High-Resolution Magnetic Resonance Imaging. Diagnostics (Basel) 2021; 11:diagnostics11112162. [PMID: 34829509 PMCID: PMC8618208 DOI: 10.3390/diagnostics11112162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 11/16/2021] [Accepted: 11/20/2021] [Indexed: 12/20/2022] Open
Abstract
Granulomatosis with polyangiitis (GPA) can involve the skull base or the Eustachian tubes. GPA is diagnosed on the basis of clinical manifestations and serological tests, although it is challenging to discriminate GPA from infectious processes driving skull base osteomyelitis (SBO) and malignant processes such as nasopharyngeal carcinoma (NPC). Moreover, current serological tests have a low sensitivity and cannot distinguish GPA from these other conditions. We hypothesized that certain MRI characteristics would differ significantly among conditions and aimed to evaluate whether the features could differentiate between GPA, SBO, and NPC involving the skull base. We retrospectively evaluated the MRI findings of patients with GPA, SBO, and NPC. We performed univariable logistic regression analyses to identify the predictive variables for differentiating between conditions and evaluated their diagnostic values. We showed, for the first time, that certain MRI findings significantly differed between patients with GPA and those with SBO or NPC, including the lesion morphology and extent, the apparent diffusion coefficient (ADC) values, the contrast enhancement patterns, the presence or absence of necrosis, and retropharyngeal lymphadenopathy. In conclusion, utilizing certain MRI features can improve the diagnostic performance of MRI by differentiating GPA with skull base involvement from other conditions with similar radiologic findings, including SBO and NPC, facilitating treatment plans and, thus, improving patient outcomes.
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Usefulness of the Video Head Impulse Test for the Evaluation of Vestibular Function in Patients With Otitis Media With Antineutrophil Cytoplasmic Antibody-Associated Vasculitis. Otol Neurotol 2021; 42:e483-e488. [PMID: 33306665 DOI: 10.1097/mao.0000000000002975] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To investigate usefulness of the video Head Impulse Test (vHIT) as a method for evaluating semicircular canal function in patients with otitis media with antineutrophil cytoplasmic antibody-associated vasculitis (OMAAV). STUDY DESIGN Retrospective case review. SETTING Tertiary referral center. PATIENTS Fourteen patients with OMAAV underwent vestibular examination. MAIN OUTCOME MEASURES The gain in vestibulo-ocular reflex (VOR) and the presence of catch-up saccade were examined for each semicircular canal. RESULTS Seven (50.0%) of the 14 patients felt subjective symptoms of disequilibrium. Dysfunction in at least one semicircular canal was detected in all ears of the OMAAV patients evaluated by vHIT. Dysfunction in posterior semicircular canal was detected more frequently than that in the anterior or horizontal canal. There were no significant correlations between the gain in VOR and hearing loss. CONCLUSIONS vHIT is thought to be the most suitable method for evaluating semicircular canal function in patients with OMAAV as vHIT is not influenced by middle ear pathology and was able to evaluate vertical canal function including the posterior canal.
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Granulomatosis with Polyangiitis as a Cause of Sudden-Onset Bilateral Sensorineural Hearing Loss: Case Report and Recommendations for Initial Assessment. Case Rep Otolaryngol 2021; 2021:6632344. [PMID: 33968458 PMCID: PMC8081636 DOI: 10.1155/2021/6632344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 03/04/2021] [Accepted: 04/08/2021] [Indexed: 11/18/2022] Open
Abstract
Granulomatosis with polyangiitis (GPA) is a severe systemic vasculitis that commonly affects the paranasal sinuses, upper and lower respiratory tracts, and kidneys. GPA has also been associated with sensorineural hearing loss (SNHL), through inflammation of the cochlear apparatus. Early recognition, diagnostic laboratory evaluation, and appropriate treatment are essential to improve outcomes and achieve remission for patients with GPA. Here, we present a case of bilateral sudden sensorineural hearing loss (SSNHL) and distal symmetric polyneuropathy as the first presenting signs of GPA. A specific diagnostic work-up to rule out autoimmune inner-ear disease in patients with bilateral SSNHL is not clearly stated in the clinical practice guidelines from the American Academy of Otolaryngology-Head and Neck Surgery. The aim of this paper is to delineate an appropriate diagnostic work-up for patients with bilateral SSNHL when there is concern for autoimmune disease.
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10
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Fujikawa T, Honda K, Ito T, Kishino M, Kimura N, Umezawa N, Hirano M, Aoki N, Kawashima Y, Tsutsumi T. Enhanced fallopian canal as a potential marker for temporal bone vasculitis. Laryngoscope Investig Otolaryngol 2020; 5:1168-1175. [PMID: 33364409 PMCID: PMC7752078 DOI: 10.1002/lio2.489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/23/2020] [Accepted: 10/23/2020] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES This study aimed to test the hypothesis that contrast-enhanced 3D MRI with gradient-echo sequences (CE-3D-GRE) can detect signs of vasculitis in the fallopian canal, which may cause otologic involvement, in four patients with antineutrophil cytoplasmic antibody-associated vasculitis (AAV). METHODS CE-3D-GRE acquired at 3.0 Tesla was performed on four patients diagnosed with granulomatosis with polyangiitis or eosinophilic granulomatosis with polyangiitis, at onset or relapse of the disease, and in remission. Clinical correlations between otologic symptoms and radiological findings were examined for each patient. Furthermore, signal intensity of the mastoid segment of the fallopian canal was compared between the ears with active disease (n = 3) and those in remission or without vasculitis (n = 3). RESULTS Intense enhancement in the tympanic and mastoid segments of the fallopian canal was associated with development of external otitis, otitis media, and sensorineural hearing loss, and was unrelated to the presence of facial paresis. Maximal intensity projection images visualized the close relationship between the enhanced fallopian canal and middle ear inflammation. The findings were absent in remission. Signal intensity of the mastoid segment of the fallopian canal was higher in ears with active disease than in normal ears (P < .001) and decreased to normal levels during remission (P = .597). CONCLUSION CE-3D-GRE can demonstrate vasculitis in the temporal bone, reflecting disease activity and the severity of otologic manifestations, including cochlear involvement, in AAV patients. Intense enhancement of the fallopian canal on CE-3D-GRE can be a potential marker for vasculitis of the temporal bone. LEVEL OF EVIDENCE 5.
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Affiliation(s)
- Taro Fujikawa
- Department of OtolaryngologyTokyo Medical and Dental UniversityTokyoJapan
| | - Keiji Honda
- Department of OtolaryngologyTokyo Medical and Dental UniversityTokyoJapan
| | - Taku Ito
- Department of OtolaryngologyTokyo Medical and Dental UniversityTokyoJapan
| | - Mitsuhiro Kishino
- Department of RadiologyTokyo Medical and Dental UniversityTokyoJapan
| | - Naoki Kimura
- Department of RheumatologyTokyo Medical and Dental UniversityTokyoJapan
| | - Natsuka Umezawa
- Department of RheumatologyTokyo Medical and Dental UniversityTokyoJapan
| | - Mana Hirano
- Department of RheumatologyNational Defence Medical CollegeTokorozawaJapan
| | - Natsuki Aoki
- Department of OtolaryngologyTokyo Medical and Dental UniversityTokyoJapan
| | | | - Takeshi Tsutsumi
- Department of OtolaryngologyTokyo Medical and Dental UniversityTokyoJapan
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Nasal reconstructive surgery for vasculitis affecting the nose: our two-centre international experience. Eur Arch Otorhinolaryngol 2020; 277:3059-3066. [PMID: 32623509 DOI: 10.1007/s00405-020-06180-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 06/28/2020] [Indexed: 01/28/2023]
Abstract
PURPOSE To recommend an international multidisciplinary medical and surgical algorithm of treatment in nasal vasculitis, which will create a more streamlined approach. METHODS A two-centre, international retrospective analysis of granulomatosis with polyangiitis (GPA) and levamisole-associated vasculitis (LAV) cases presenting between 2005 and 2019 was carried out. Demographic data, and surgical and medical treatment were recorded. Patients' signs and symptoms were analysed, and recommended treatment strategies outlined with key surgical procedures described. RESULTS Forty-one GPA patients and 11 LAV patients were included in the study with a mean age of 38.6 and 38.8 years, respectively. A stepwise surgical management approach with reconstructive options is described and includes: (1) examination under general anaesthesia, biopsy, and insertion of silastic nasal splints; (2) septal perforation repair (with caution); (3) mild-to-moderate saddle nose reconstruction with costal cartilage; (4) severe saddle nose reconstruction with osseocartilaginous rib grafts; (5) soft-tissue reconstruction techniques. CONCLUSIONS The management of nasal vasculitis is a particular challenge in facial plastic surgery. It requires a close collaborative approach with a physician skilled in the medical management of vasculitis. Surgery must be planned judiciously, with realistic patient expectations and only after a sustained period of remission. For more severe saddle deformities, the modified osseocartilaginous Andrews technique gives excellent long-term results.
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12
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Pendolino AL, Unadkat S, Zhang H, Pendolino M, Bianchi G, Randhawa PS, Andrews PJ. The role of surgery in antineutrophil cytoplasmic antibody-associated vasculitides affecting the nose and sinuses: A systematic review. SAGE Open Med 2020; 8:2050312120936731. [PMID: 32676189 PMCID: PMC7340348 DOI: 10.1177/2050312120936731] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 05/29/2020] [Indexed: 01/28/2023] Open
Abstract
Background: The ear, nose and throat region has been reported to be one of the commonest sites involved in antineutrophil cytoplasmic antibody (ANCA)–associated vasculitis diseases and often precedes the diagnosis of ANCA–associated vasculitis by many months. Although treatment for ANCA–associated vasculitis primarily requires systemic immunosuppressive therapy, there are specific indications for sinonasal surgery during the course of the disease process. The three major roles for surgery in sinonasal vasculitis are to aid diagnosis through biopsy, enable symptom relief and nasal reconstructive surgery consideration when in remission. Purpose: The aim of this systematic review is to provide an overview of the surgical procedures which can be performed in patients with ANCA–associated vasculitis presenting with sinonasal involvement. Materials and methods: A systematic literature search was performed for scientific articles on MEDLINE (PubMed Advanced MEDLINE Search) and EMBASE. The search included all articles up to April 2020. Conclusion: Surgical intervention during the active phase of ANCA–associated vasculitis disease can improve the patient’s symptoms and enable histological diagnosis. The surgical decision to manage the nose requires a multidisciplinary approach involving the vasculitis specialist and the ear, nose and throat surgeon. Nasal reconstruction can be performed to restore form and function but only when the disease is in remission so as to maximise success and minimise complications.
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Affiliation(s)
- Alfonso Luca Pendolino
- Department of ENT, Royal National ENT & Eastman Dental Hospitals, London, UK.,Ear Institute, University College London (UCL), London, UK
| | - Samit Unadkat
- Department of ENT, Royal National ENT & Eastman Dental Hospitals, London, UK
| | - Henry Zhang
- Department of ENT, Royal National ENT & Eastman Dental Hospitals, London, UK
| | - Monica Pendolino
- Division of Rheumatology, Department of Locomotor System, ASL 3, Genoa, Italy
| | - Gerolamo Bianchi
- Division of Rheumatology, Department of Locomotor System, ASL 3, Genoa, Italy
| | - Premjit S Randhawa
- Department of ENT, Royal National ENT & Eastman Dental Hospitals, London, UK
| | - Peter J Andrews
- Department of ENT, Royal National ENT & Eastman Dental Hospitals, London, UK.,Ear Institute, University College London (UCL), London, UK
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Coates ML, Martinez Del Pero M. Updates in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis for the ENT surgeon. Clin Otolaryngol 2020; 45:316-326. [PMID: 32145151 DOI: 10.1111/coa.13524] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 02/13/2020] [Accepted: 02/29/2020] [Indexed: 12/31/2022]
Abstract
ENT involvement is common in ANCA-associated vasculitis (AAV), particularly in GPA and EGPA. Early recognition and treatment is important for good outcomes, yet evidence suggests that UK ENT surgeons may not consistently recognise the early features of AAV, despite a similar incidence to vestibular schwannoma. AAV is a rapidly advancing field, with significant developments in the understanding of its pathogenesis, classification and treatment over the past decade. Relevant vasculitis mimics are also discussed with a particular focus on the increasing prevalence of vasculitis mimics driven by an increase in recreational cocaine use, as well as the emergence and reclassification of several other vasculitis mimics in the head and neck. This article reviews key recent updates in the vasculitis literature, with a particular focus on those relevant to recognition and diagnosis of AAV for the ENT surgeon. Strengths and limitations of relevant diagnostic testing are discussed, and a method of evaluation of patients with features of AAV presenting to ENT services is outlined.
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14
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Miłkowska-Dymanowska J, Laskowska P, Rzuczkowski M, Białas AJ, Piotrowski WJ, Górski P. Untypical Manifestations of Granulomatosis with Polyangiitis—A Review of the Literature. ACTA ACUST UNITED AC 2019. [DOI: 10.1007/s42399-019-00083-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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15
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Carnevale C, Arancibia-Tagle D, Sarría-Echegaray P, Til-Pérez G, Tomás-Barberán M. Head and Neck Manifestations of Granulomatosis with Polyangiitis: A Retrospective analysis of 19 Patients and Review of the Literature. Int Arch Otorhinolaryngol 2019; 23:165-171. [PMID: 30956700 PMCID: PMC6449134 DOI: 10.1055/s-0038-1675759] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 09/10/2018] [Indexed: 10/29/2022] Open
Abstract
Introduction Granulomatosis with Polyangiitis (GPA) is a small vessel vasculitis characterized by a necrositing granulomatous inflammation of the upper and lower respiratory tracts and focal/proliferative glomerulonephritis. In more than 70% of the cases, the presenting symptoms are head and neck manifestations that are often misdiagnosed as infectious or allergic in etiology. Objective The present study provides an analysis of head and neck manifestations in a series of patients diagnosed with GPA. It also evaluates their medical and surgical treatment and provides a review of the relevant literature. Methods A retrospective analysis of 19 patients diagnosed with GPA at a public tertiary care hospital between 2006 and 2017 was performed. Results A total of 19 patients were included in the present study, and 16 of them presented head and neck manifestations. Sinonasal symptoms were the most common, affecting 56% of the patients, followed by laryngotracheal (31.25%) and ear (25%) symptoms. In 7 patients, sinonasal symptoms were the first manifestation of the disease (43.75%). Four patients underwent surgery at some stage of the disease. Conclusions Head and neck involvement is common in GPA and may stand for the first or the only manifestation of the disease. The otolaryngologists play a central role in the diagnosis and long-term treatment of these patients, and they have to keep this pathology in mind when treating patients with ENT symptoms that do not respond as expected to the treatment.
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Affiliation(s)
- Claudio Carnevale
- Department of Otorhinolaryngology, Hospital Universitari Son Espases, Palma de Mallorca, Illes Balears, Spain
| | - Diego Arancibia-Tagle
- Department of Otorhinolaryngology and Head and Neck Surgery, Hospital Universitari Son Espases, Palma de Mallorca, Illes Balears, Spain
| | - Pedro Sarría-Echegaray
- Department of Otorhinolaryngology, Hospital Universitari Son Espases, Palma de Mallorca, Illes Balears, Spain
| | - Guillermo Til-Pérez
- Department of Otorhinolaryngology, Hospital Universitari Son Espases, Palma de Mallorca, Illes Balears, Spain
| | - Manuel Tomás-Barberán
- Department of Otorhinolaryngology and Head and Neck Surgery, Hospital Universitari Son Espases, Palma de Mallorca, Illes Balears, Spain
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16
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Nogaki T, Keskin N, Azuma T, Paparella MM, Nadol JB, Cureoglu S. Quantitative assessment of vestibular otopathology in granulomatosis with polyangitis: A temporal bone study. Laryngoscope Investig Otolaryngol 2018; 3:473-477. [PMID: 30599032 PMCID: PMC6302790 DOI: 10.1002/lio2.182] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2018] [Indexed: 11/10/2022] Open
Abstract
Objective To investigate the temporal bone histopathology of vasculitis, especially in the vestibular organs, in granulomatosis with polyangitis (GPA). Methods Using light and differential interference contrast microscopy, we examined 12 human temporal bones from six deceased GPA patients and 12 histopathologically normal human temporal bones from six deceased age‐matched patients. Results In the GPA group, three patients had undergone tympanostomy tube placement. Two of them had suffered mixed hearing loss; one, sensorineural hearing loss; and one, conductive hearing loss. Of the 12 specimens in the GPA group, the granulation tissue invaded the round window niche in seven; cochlear hair cells were not preserved in five. Hemosiderin was deposited in the stria vascularis in eight specimens, in the ampulla or semicircular duct in 10, and in the vestibule in three. The spiral ligament showed severe loss of cellularity in two specimens. In the GPA group, type I vestibular hair cell density was significantly decreased; however, type II vestibular hair cell density did not significantly differ between the GPA group and the control group. Conclusion Our histopathologic findings in human temporal bone specimens of GPA patients delineated changes in the tympanic membrane, middle ear cavity, round window membrane, organ of Corti, stria vascularis, spiral ligament, ampulla, semicircular duct, and vestibule. Type I vestibular hair cell density significantly decreased in the GPA group, as compared with the control group. Level of Evidence N/A
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Affiliation(s)
- Taketoshi Nogaki
- Department of Otolaryngology-Head and Neck Surgery University of Minnesota Minneapolis Minnesota USA.,Department of Otolaryngology Showa University School of Medicine Tokyo Japan.,Department of Otology and Laryngology Harvard Medical School Boston Massachusetts USA
| | - Nevra Keskin
- Department of Otolaryngology-Head and Neck Surgery University of Minnesota Minneapolis Minnesota USA.,Department of Internal Medicine, Faculty of Veterinary Medicine University of Ankara Ankara Turkey.,Department of Otolaryngology, Massachusetts Eye and Ear Infirmary Boston Massachusetts USA.,Department of Otology and Laryngology Harvard Medical School Boston Massachusetts USA
| | - Takahiro Azuma
- Department of Otolaryngology-Head and Neck Surgery University of Minnesota Minneapolis Minnesota USA.,Department of Otolaryngology University of Tokushima School of Medicine Tokushima Japan
| | - Michael M Paparella
- Department of Otolaryngology-Head and Neck Surgery University of Minnesota Minneapolis Minnesota USA.,Paparella Ear Head and Neck Institute Minneapolis Minnesota USA
| | - Joseph B Nadol
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary Boston Massachusetts USA.,Department of Otology and Laryngology Harvard Medical School Boston Massachusetts USA
| | - Sebahattin Cureoglu
- Department of Otolaryngology-Head and Neck Surgery University of Minnesota Minneapolis Minnesota USA
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17
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Abstract
Tracheal resections are major surgical procedures with a complication rate as high as 44%. Early detection of complications followed by a structured and expedited course of action is critical for achieving a successful outcome. The prevention of complications after tracheal resection starts with a correct indication for resection. A thorough preoperative evaluation, meticulous surgical technique, and good postoperative care in a center that performs airway surgery routinely are important factors for achieving good results.
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18
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Eosinophilic granulomatosis with polyangiitis and laryngeal involvement: review of the literature and a cross-sectional prospective experience. The Journal of Laryngology & Otology 2018; 132:619-623. [PMID: 29888684 DOI: 10.1017/s0022215118000737] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Eosinophilic granulomatosis with polyangiitis and granulomatosis with polyangiitis show variable otorhinolaryngological involvement. Up to 14 per cent of granulomatosis with polyangiitis patients have subglottis involvement; little is known about the laryngeal involvement in eosinophilic granulomatosis with polyangiitis. METHOD A literature review was conducted, together with a prospective cross-sectional analysis of 43 eosinophilic granulomatosis with polyangiitis patients. All patients underwent fibre-optic laryngoscopy with narrow-band imaging, and completed health-related questionnaires. RESULTS The literature review showed only two cases of laryngeal involvement in eosinophilic granulomatosis with polyangiitis; in our cohort, no cases of subglottis stenosis were found, but local signs of laryngeal inflammation were present in 72 per cent of cases. Of the patients, 16.2 per cent had a pathological Reflux Finding Score (of 7 or higher). CONCLUSION Laryngeal inflammation in eosinophilic granulomatosis with polyangiitis is frequent. It is possibly due more to local factors than to eosinophilic granulomatosis with polyangiitis itself. However, ENT evaluation is needed to rule out possible subglottis inflammation. These findings are in line with current literature and worthy of confirmation in larger cohorts.
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19
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Beltrán Rodríguez-Cabo O, Reyes E, Rojas-Serrano J, Flores-Suárez LF. Increased histopathological yield for granulomatosis with polyangiitis based on nasal endoscopy of suspected active lesions. Eur Arch Otorhinolaryngol 2017; 275:425-429. [DOI: 10.1007/s00405-017-4841-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Accepted: 12/04/2017] [Indexed: 10/18/2022]
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20
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Coordes A, Loose S, Hofmann V, Hamilton G, Riedel F, Menger D, Albers A. Saddle nose deformity and septal perforation in granulomatosis with polyangiitis. Clin Otolaryngol 2017; 43:291-299. [DOI: 10.1111/coa.12977] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2017] [Indexed: 12/12/2022]
Affiliation(s)
- A. Coordes
- Department of Otorhinolaryngology; Head and Neck Surgery; Berlin Institute of Health; Charité - Universitätsmedizin Berlin; corporate member of Freie Universität Berlin; Humboldt-Universität zu Berlin; Campus Benjamin Franklin; Berlin Germany
| | - S.M. Loose
- Department of Otorhinolaryngology; Head and Neck Surgery; Berlin Institute of Health; Charité - Universitätsmedizin Berlin; corporate member of Freie Universität Berlin; Humboldt-Universität zu Berlin; Campus Benjamin Franklin; Berlin Germany
| | - V.M. Hofmann
- Department of Otorhinolaryngology; Head and Neck Surgery; Berlin Institute of Health; Charité - Universitätsmedizin Berlin; corporate member of Freie Universität Berlin; Humboldt-Universität zu Berlin; Campus Benjamin Franklin; Berlin Germany
| | - G.S. Hamilton
- Department of Otorhinolaryngology; Mayo Clinic; Rochester MN USA
| | - F. Riedel
- Center of Otorhinolaryngology Rhein-Neckar; Mannheim Germany
| | - D.J. Menger
- Department of ENT-FPS; University Medical Center Utrecht; Utrecht The Netherlands
| | - A.E. Albers
- Department of Otorhinolaryngology; Head and Neck Surgery; Berlin Institute of Health; Charité - Universitätsmedizin Berlin; corporate member of Freie Universität Berlin; Humboldt-Universität zu Berlin; Campus Benjamin Franklin; Berlin Germany
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21
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Bernat AL, Lefevre E, Sène D, Herman P, Biassette HA, Froelich S. Management Scheme for Cerebral Wegener Granulomatosis: An Unusual Pseudotumoral Skull Base Pathology. World Neurosurg 2016; 96:608.e13-608.e16. [PMID: 27671887 DOI: 10.1016/j.wneu.2016.09.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 09/12/2016] [Accepted: 09/14/2016] [Indexed: 11/24/2022]
Abstract
Granulomatosis with polyangiitis (Wegener disease) is a rare antineutrophil cytoplasmic antibody (ANCA)-positive vasculitis that seldom involves brain and meninges. We present a case of a 35-year-old woman with granulomatosis with polyangiitis involving the brain and the meninges. The histologic diagnosis required a complete resection of the lesion. Despite the possibility of postoperative wound infection, surgery was mandatory to ascertain the diagnostic and to treat locally.
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Affiliation(s)
- Anne Laure Bernat
- Department of Neurosurgery, Lariboisière Hospital, Paris, France; Paris-Diderot, Paris-Cité-Sorbone University, Paris, France.
| | - Etienne Lefevre
- Department of Neurosurgery, Lariboisière Hospital, Paris, France; Paris-Diderot, Paris-Cité-Sorbone University, Paris, France
| | - Damien Sène
- Paris-Diderot, Paris-Cité-Sorbone University, Paris, France; Department of Internal Medicine, Lariboisière Hospital, Paris, France
| | - Philippe Herman
- Paris-Diderot, Paris-Cité-Sorbone University, Paris, France; Department of ENT, Lariboisière Hospital, Paris, France
| | - Homa Adle Biassette
- Paris-Diderot, Paris-Cité-Sorbone University, Paris, France; Department of Pathology, Lariboisière Hospital, Paris, France
| | - Sébastien Froelich
- Department of Neurosurgery, Lariboisière Hospital, Paris, France; Paris-Diderot, Paris-Cité-Sorbone University, Paris, France
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22
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Wojciechowska J, Krajewski W, Krajewski P, Kręcicki T. Granulomatosis With Polyangiitis in Otolaryngologist Practice: A Review of Current Knowledge. Clin Exp Otorhinolaryngol 2016; 9:8-13. [PMID: 26976020 PMCID: PMC4792240 DOI: 10.21053/ceo.2016.9.1.8] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 02/16/2015] [Accepted: 02/23/2015] [Indexed: 12/27/2022] Open
Abstract
Granulomatosis with polyangiitis (GPA) is an idiopathic vasculitis of medium and small arteries, characterized by necrotizing granulomatous inflammation. GPA typically affects upper and lower respiratory tract with coexisting glomerulonephritis. This disease is generally characterized by antineutrophil cytoplasm antibodies (ANCA), nevertheless, there are rare cases with negative ANCA. GPA affects people at any age, with predominance of the sixth and seventh decade of life. In 80%-95% of the patients the first symptoms of GPA are otorhinolaryngological manifestations of head and neck including nose/sinuses, ears, eyes, larynx/trachea, oral cavity, and salivary glands. Diagnosis of GPA is based on Criteria of the American College of Rheumatology. In clinical practice diagnosis, the presence of distinctive ANCA antibodies and biopsy of affected organ are crucial. GPA must be differentiated from neoplastic, infectious or inflammatory ulcerative lesions of the head and neck. The standard treatment procedure is divided into two essential phases, induction and maintenance. The induction phase is based on combination of systemic corticosteroid and immunosuppressant therapy, whereas the maintenance phase comprises corticosteroids and azathioprine/methotrexate supplementation. Surgical treatment ought to be considered for patients who are not responding to pharmacotherapy.
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Affiliation(s)
| | | | - Piotr Krajewski
- Department of Urology, Wrocław Medical University, Wrocław, Poland
| | - Tomasz Kręcicki
- Department and Clinic of Otolaryngology-Head and Neck Surgery, Wrocław, Poland
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23
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Iannella G, Greco A, Granata G, Manno A, Pasquariello B, Angeletti D, Didona D, Magliulo G. Granulomatosis with polyangiitis and facial palsy: Literature review and insight in the autoimmune pathogenesis. Autoimmun Rev 2016; 15:621-31. [PMID: 26851550 DOI: 10.1016/j.autrev.2016.02.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 02/01/2016] [Indexed: 01/28/2023]
Abstract
Granulomatosis with polyangiitis (GPA) is an autoimmune systemic necrotizing small-vessel vasculitis associated with the presence of anti-neutrophil cytoplasmic antibodies (ANCA). Oto-neurological manifestations of ANCA-associated vasculitis according to PR3-ANCA positivity and MPO-ANCA positivity are usually reported. Facial nerve palsy is usually reported during the clinical course of the disease but it might appear as the presenting sign of GPA. Necrotizing vasculitis of the facial nerve 'vasa nervorum' is nowadays the most widely accepted etiopathogenetic theory to explain facial damage in GPA patients. A central role for PR3-ANCA in the pathophysiology of vasculitis in GPA patients with oto-neurological manifestation is reported. GPA requires prompt, effective management of the acute and chronic manifestations. Once the diagnosis of GPA has been established, clinicians should devise an appropriate treatment strategy for each individual patient, based on current clinical evidence, treatment guidelines and recommendations.
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Affiliation(s)
- Giannicola Iannella
- Organi di Senso Department University, Sapienza University of Rome, Viale del Policlinico,151-00161, Rome, Italy.
| | - Antonio Greco
- Organi di Senso Department University, Sapienza University of Rome, Viale del Policlinico,151-00161, Rome, Italy.
| | - Guido Granata
- Department of Clinical Immunology, Sapienza University of Rome, Viale dell'Università, 37-00161 Rome, Italy.
| | - Alessandra Manno
- Organi di Senso Department University, Sapienza University of Rome, Viale del Policlinico,151-00161, Rome, Italy.
| | - Benedetta Pasquariello
- Organi di Senso Department University, Sapienza University of Rome, Viale del Policlinico,151-00161, Rome, Italy.
| | - Diletta Angeletti
- Organi di Senso Department University, Sapienza University of Rome, Viale del Policlinico,151-00161, Rome, Italy.
| | - Dario Didona
- First Dermatology Division, Institute Dermopatico dell'Immacolata-IRCCS, Via Monti di Creta, 104-00167 Rome, Italy.
| | - Giuseppe Magliulo
- Organi di Senso Department University, Sapienza University of Rome, Viale del Policlinico,151-00161, Rome, Italy.
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24
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Greco A, Marinelli C, Fusconi M, Macri GF, Gallo A, De Virgilio A, Zambetti G, de Vincentiis M. Clinic manifestations in granulomatosis with polyangiitis. Int J Immunopathol Pharmacol 2015; 29:151-9. [PMID: 26684637 DOI: 10.1177/0394632015617063] [Citation(s) in RCA: 107] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 10/13/2015] [Indexed: 01/19/2023] Open
Abstract
Granulomatosis with polyangiitis (GPA), formerly Wegener's granulomatosis (WG), is an uncommon immunologically mediated systemic small-vessel vasculitis that is pathologically characterised by an inflammatory reaction pattern (necrosis, granulomatous inflammation and vasculitis) that occurs in the upper and lower respiratory tracts and kidneys. Although the aetiology of GPA remains largely unknown, it is believed to be autoimmune in origin and triggered by environmental events on a background of genetic susceptibility.In Europe, the prevalence of GPA is five cases per 100,000 population, with greater incidence in Northern Europe. GPA can occur in all racial groups but predominantly affects Caucasians. Both sexes are affected equally. GPA affects a wide age range (age range, 8-99 years).Granulomatosis with polyangiitis is characterised by necrotising granulomatous lesions of the respiratory tract, vasculitis and glomerulonephritis. Classically, the acronym ELK is used to describe the clinical involvement of the ear, nose and throat (ENT); lungs; and kidneys. Because the upper respiratory tract is involved in 70-100% of cases of GPA, classic otorhinolaryngologic symptoms may be the first clinical manifestation of disease. The nasal cavity and the paranasal sinuses are the most common sites of involvement in the head and neck area (85-100%), whereas otological disease is found in approximately 35% (range, 19-61%) of cases.Diagnosis of GPA is achieved through clinical assessment, serological tests for anti-neutrophil cytoplasmic antibodies (ANCA) and histological analysis. The 10-year survival rate is estimated to be 40% when the kidneys are involved and 60-70% when there is no kidney involvement.The standard therapy for GPA is a combination of glucocorticoids and cyclophosphamide. In young patients, cyclophosphamide should be switched to azathioprine in the maintenance phase.A multidisciplinary approach, involving otorhinolaryngologists, oral and maxillofacial surgeons, oral physicians, rheumatologists, renal and respiratory physicians, and ophthalmologists, is necessary for the diagnosis and therapeutic treatment of GPA. ENT physicians have a determining role in recognising the early onset of the disease and starting an appropriate therapy.
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Affiliation(s)
- A Greco
- Policlinico "Umberto I" - Rome, Department of Organs of Sense - ENT Section, University of Rome "La Sapienza", Italy
| | - C Marinelli
- Hospital "Maggiore" - Parma, Department of Otolaryngology and Otoneurosurgery, Rome, Italy
| | - M Fusconi
- Policlinico "Umberto I" - Rome, Department of Organs of Sense - ENT Section, University of Rome "La Sapienza", Italy
| | - G F Macri
- Hospital "Maggiore" - Parma, Department of Otolaryngology and Otoneurosurgery, Rome, Italy
| | - A Gallo
- Policlinico "Umberto I" - Rome, Department of Organs of Sense - ENT Section, University of Rome "La Sapienza", Italy
| | - A De Virgilio
- Policlinico "Umberto I" - Rome, Department of Organs of Sense - ENT Section, University of Rome "La Sapienza", Italy
| | - G Zambetti
- Policlinico "Umberto I" - Rome, Department of Organs of Sense - ENT Section, University of Rome "La Sapienza", Italy
| | - M de Vincentiis
- Policlinico "Umberto I" - Rome, Department of Organs of Sense - ENT Section, University of Rome "La Sapienza", Italy
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25
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Narvid J, Talbott JF, Glastonbury CM. The caverno-apical triangle: anatomic-pathological considerations and pictorial review. Clin Imaging 2015; 40:23-32. [PMID: 26481233 DOI: 10.1016/j.clinimag.2015.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 08/04/2015] [Accepted: 08/12/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND The caverno-apical triangle (CAT) is defined from the components that define its contours: the cavernous sinus and the orbital apex. A wide range of pathologies arise from the space between the cavernous sinus and the orbital apex. OBJECT To better define radiologically this critical anatomic landmark and establish an organized approach for image analysis to help generate focused differential diagnoses and accurately characterize lesions found on imaging. CONCLUSION We have identified common imaging characteristics of frequently encountered lesions and divided them into specific categories to facilitate creation of logical and focused differential diagnoses.
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Affiliation(s)
- Jared Narvid
- Division of Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA.
| | - Jason F Talbott
- Division of Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Christine M Glastonbury
- Division of Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
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26
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Janisiewicz AM, Klau MH, Keschner DB, Lehmer RR, Venkat KV, Medhekar SS, Chang PK, Badran K, Leary R, Garg R, Nguyen AA, Lee JT. Higher Antineutrophil Cytoplasmic Antibody (C-ANCA) Titers are Associated with Increased Overall Healthcare Use in Patients with Sinonasal Manifestations of Granulomatosis with Polyangiitis (GPA). Am J Rhinol Allergy 2015; 29:202-6. [DOI: 10.2500/ajra.2015.29.4147] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Granulomatosis with polyangiitis (GPA) is an autoimmune disease characterized by necrotizing granulomatous airway inflammation and vasculitis. Sinonasal involvement occurs in more than 80% cases, with antineutrophil cytoplasmic antibody (C-ANCA) titers used as a marker of disease severity. The purpose of this study was to determine whether C-ANCA levels impact radiographic findings and healthcare use in patients with sinonasal GPA. Methods A retrospective review was performed on GPA patients evaluated in a multidisciplinary rheumatologic/otolaryngologic clinic from 2008 to 2013. Data were collected with respect to age, gender, clinical presentation, C-ANCA titers, Lund-Mackay (LM) scores, surgical interventions, and healthcare use, the latter of which were determined by assessing the number of rheumatology/otolaryngology clinic visits, computed tomography (CT) scans, and email/telephone encounters. Results A total of 44 patients were identified, 11 male and 33 female. Sinonasal manifestations were evident in 70.4%, with chronic rhinosinusitis (CRS) (41.9%), septal perforation (38.7%), and crusting (32.2%) the most common findings. No significant differences in number of CT scans (p = 0.10) or mean LM scores (p = 0.47) were found between patients with more than or equal to 1:80 and less than 1:80 C-ANCA titers, respectively. However, overall healthcare use was increased in the more than or equal to 1:80 C-ANCA group (n = 28) compared with less than 1:80 (n = 16), with a significantly greater number of rheumatologic/otolaryngologic encounters (mean 121 versus 69.2, p = 0.03) noted. When otolaryngologic healthcare use was specifically examined, the average number of encounters was also higher in more than or equal to 1:80 C-ANCA patients (31.9 versus 22.9), but this difference was not statistically significant (p = 0.16). Conclusion Sinonasal GPA patients with presenting C-ANCA titers more than or equal to 1:80 demonstrated significantly greater overall healthcare use than their lower C-ANCA level counterparts (less than 1:80). However, no significant differences in otolaryngology resource use or LM scores were evident between the two titer groups.
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Affiliation(s)
| | - Marc H. Klau
- Orange County Sinus Institute, Southern California Permanente Medical Group, Irvine, California
| | - David B. Keschner
- Orange County Sinus Institute, Southern California Permanente Medical Group, Irvine, California
| | - Randy R. Lehmer
- Department of Rheumatology, Irvine Medical Center, Southern California Permanente Medical Group, Irvine, California
| | - Kumar V. Venkat
- Department of Rheumatology, Irvine Medical Center, Southern California Permanente Medical Group, Irvine, California
| | - Swati S. Medhekar
- Department of Rheumatology, Irvine Medical Center, Southern California Permanente Medical Group, Irvine, California
| | - Parke K. Chang
- Department of Rheumatology, Irvine Medical Center, Southern California Permanente Medical Group, Irvine, California
| | - Karam Badran
- University of California, Irvine School of Medicine, Irvine, California
| | - Ryan Leary
- University of California, Irvine School of Medicine, Irvine, California
| | - Rohit Garg
- Orange County Sinus Institute, Southern California Permanente Medical Group, Irvine, California
| | - Andrew A. Nguyen
- Department of Rheumatology, Irvine Medical Center, Southern California Permanente Medical Group, Irvine, California
| | - Jivianne T. Lee
- Orange County Sinus Institute, Southern California Permanente Medical Group, Irvine, California
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
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Matsuba Y, Strassen U, Hofauer B, Bas M, Knopf A. Orbital complications:diagnosis of different rhinological causes. Eur Arch Otorhinolaryngol 2014; 272:2319-26. [PMID: 25323154 DOI: 10.1007/s00405-014-3338-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 10/11/2014] [Indexed: 11/28/2022]
Abstract
To evaluate the clinical course of orbital complication using a standardised diagnostic pathway. Seventy-three patients with orbital complications underwent a multimodal diagnostic pathway comprising ENT examination, leucocytes/CRP, CT-/MRI-scanning and disease-related data. Twenty-nine patients suffered from rhinosinusitis, 28 from mucoceles, 13 patients from neoplasms and three patients from rheumatic disorders. Clinical examination diagnosed 60 patients with eyelid swelling, 55 patients with ocular pain, 14 patients with diplopia, 4 patients with exophthalmus, 29 patients with visual field defect and 4 patients with visual loss. The diagnostic pathway identified acute rhinosinusitis with a sensitivity/specificity of 90 %/90 %, mucoceles with 79 %/100 %, neoplasms with 100 %/96 % and granulomatosis with polyangiitis with 100 %/100 %, respectively. All patients left the hospital in good general condition and with regular ocular motility; two patients suffered persistent visual loss. The standardised application of a widely accepted diagnostic pathway reliably distinguishes different causes of orbital complication.
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Affiliation(s)
- Yumiko Matsuba
- Hals-, Nasen-, Ohrenklinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675, Munich, Germany
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28
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Knopf A, Chaker A, Stark T, Hofauer B, Lahmer T, Thürmel K, Bas M. Clinical aspects of granulomatosis with polyangiitis affecting the head and neck. Eur Arch Otorhinolaryngol 2014; 272:185-93. [PMID: 24609734 DOI: 10.1007/s00405-014-2973-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 02/20/2014] [Indexed: 10/25/2022]
Abstract
There are many controversies in head and neck granulomatosis with polyangiitis (HN-GPA). Diagnostic/therapeutic regimens vary due to limited knowledge about the special properties of HN-GPA. 28 patients were diagnosed with GPA accordingly. Anti-neutrophil-cytoplasmatic-antibody (ANCA), anti-peroxidase-antibody (anti-PR3) and biopsies were performed for all patients and set into clinical context. 14 patients had sinonasal symptoms. Otological (n = 8) and laryngeal (n = 2) symptoms were usually associated with complex disease activity. Pulmonary and/or renal impairment was present in 14 patients at the time of diagnosis and developed in a further nine patients within 1 year. 21 patients with systemic disease displayed elevated ANCA/anti-PR3. In contrast, those with persistent isolated HN manifestations (n = 6) lacked auto-antibodies. These patients underwent multiple biopsies to diagnose GPA. Interestingly, five patients without clinical HN manifestations but elevated auto-antibodies were identified by nasal "blind" biopsy. Clinical examination, auto-antibody testing, and histology are effective diagnostic tools in HN-GPA. Histological diagnosis remains the gold standard in patients with persistent isolated head and neck manifestations but missing auto-antibodies. Based on our findings, we suggest early and sufficient systemic therapy for all HN-GPA. Nasal mucosal "blind" biopsy should be performed in patients with elevated auto-antibodies but lacking clinical head and neck manifestations.
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Affiliation(s)
- Andreas Knopf
- Department of Otorhinolaryngology Head and Neck Surgery, Hals-Nasen-Ohrenklinik und Poliklinik, Technische Universität München, Ismaningerstrasse 22, 81675, Munich, Germany,
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29
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Szewczyk-Bieda MJ, White RD, Budak MJ, Ananthakrishnan G, Brunton JN, Sudarshan TA. A whiff of trouble: tumours of the nasal cavity and their mimics. Clin Radiol 2014; 69:519-28. [PMID: 24525221 DOI: 10.1016/j.crad.2013.12.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Revised: 12/06/2013] [Accepted: 12/10/2013] [Indexed: 12/28/2022]
Abstract
A range of disease entities can affect the nasal cavity, often presenting with variable and non-specific symptoms. There is considerable overlap between the clinical and radiological features of neoplastic and non-neoplastic entities. The nasal cavity is often included in routine imaging of the brain, middle ear, skull base, and paranasal sinuses and should be included as a critical review area. The definitive diagnosis is in most cases confirmed by histopathological analysis. However, this review highlights the role of imaging in identifying nasal cavity disease, eliciting features of aggressive or indolent behaviour, and helping to narrow the differential diagnosis, thus facilitating a systematic approach when reviewing the nasal cavity.
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Affiliation(s)
- M J Szewczyk-Bieda
- Clinical Radiology Department, Ninewells Hospital and Medical School, Dundee, UK.
| | - R D White
- Clinical Radiology Department, Ninewells Hospital and Medical School, Dundee, UK; Department of Clinical Radiology, University Hospital of Wales, Cardiff, UK
| | - M J Budak
- Clinical Radiology Department, Ninewells Hospital and Medical School, Dundee, UK
| | - G Ananthakrishnan
- Clinical Radiology Department, Ninewells Hospital and Medical School, Dundee, UK; Department of Clinical Radiology, Manchester Royal Infirmary Hospital, Manchester, UK
| | - J N Brunton
- Clinical Radiology Department, Ninewells Hospital and Medical School, Dundee, UK
| | - T A Sudarshan
- Clinical Radiology Department, Ninewells Hospital and Medical School, Dundee, UK
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Taylor SRJ, Salama AD, Pusey CD, Lightman S. Ocular manifestations of Wegener’s granulomatosis. EXPERT REVIEW OF OPHTHALMOLOGY 2014. [DOI: 10.1586/17469899.2.1.91] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Diagnostic consideration for sinonasal Wegener's granulomatosis clinically mistaken for carcinoma. Case Rep Otolaryngol 2013; 2013:839451. [PMID: 24106630 PMCID: PMC3782763 DOI: 10.1155/2013/839451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Accepted: 08/06/2013] [Indexed: 11/17/2022] Open
Abstract
We report a case of Wegener's granulomatosis clinically mistaken for carcinoma in a 21-year-old girl presenting with an ulcerated mass of the nasopharynx associated with enlarged laterocervical nodes. The lesion was clinically suspected as malignant on the basis of clinical and radiological findings (namely, computed tomography scan and positron emission tomography). However, multiple biopsies were not conclusive for malignancy showing histological change suggestive of Wegener's granulomatosis. A serum determination of cANCA supported the diagnosis of Wegener's granulomatosis. Clinical findings and image studies suggested an erroneous diagnosis of malignancy whereas a definitive diagnosis of Wegener's granulomatosis was achieved only after repeated biopsies thus leading to a correct therapeutic approach. The Wegener granulomatosis must be added to the list of the differential diagnoses of the masses of the nasopharynx associated with or without enlarged laterocervical nodes.
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Wilfong EM, Seo P. Vasculitis in the intensive care unit. Best Pract Res Clin Rheumatol 2013; 27:95-106. [PMID: 23507060 DOI: 10.1016/j.berh.2013.01.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2013] [Accepted: 01/02/2013] [Indexed: 10/27/2022]
Abstract
The systemic vasculitides are a diverse set of diseases linked by the presence of blood-vessel inflammation and are often associated with life-threatening or critical complications, including glomerulonephritis, diffuse alveolar haemorrhage, pulmonary arterial hypertension and airway compromise. The protean manifestations of the systemic vasculitides make them challenging to diagnose. Early recognition, however, is crucial to improving outcomes. This article serves as an introduction to these complex diseases, reviewing the manifestations of systemic vasculitis that may be encountered in an intensive care setting, and outlines an overall approach to their treatment.
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Affiliation(s)
- Erin M Wilfong
- Johns Hopkins University School of Medicine, 1830 E. Monument St., Baltimore, MD 21205, USA.
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Vega Braga FL, Machado de Carvalho G, Caixeta Guimarães A, Scaramussa L, Jordão Gusmão R. Otolaryngological Manifestations of Wegener's Disease. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2013. [DOI: 10.1016/j.otoeng.2013.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Vega Braga FL, Machado de Carvalho G, Caixeta Guimarães A, Scaramussa L, Jordão Gusmão R. [Otolaryngological manifestations of Wegener's disease]. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2012; 64:45-9. [PMID: 23063377 DOI: 10.1016/j.otorri.2012.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Revised: 07/02/2012] [Accepted: 07/17/2012] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Wegener's granulomatosis (WG) is characterised by granulomatous vasculitis of the airway and glomerulonephritis. Since its first description, important advances have occurred in diagnosis and treatment; however, the aetiology remains unknown. Involvement of the head and neck region can often occur as the first and only manifestation. The aim of this study was to determine the frequency of symptoms and signs in the region of the nose, ears and pharynx-larynx in a group of patients with WG. MATERIALS AND METHODS We evaluated 17 patients with WG defined by clinical, laboratory and pathology criteria. Detailed histories were taken and an ENT physical examination, audiometry, tympanometry and nasofibrolaryngoscopy were performed in all patients. RESULTS The average age was 41.7 years and the average disease time was 9.12 years, ranging between 1 and 40. In these patients, 9 (53.1%) reported hearing loss and had altered audiometry, and 5 (55.6%) had bilateral sensorineural hearing loss. In the nose, nasal obstruction in 11 (64.8%) and rhinorrhoea in 10 (58.8%) were the most prevalent; there was altered endoscopy in 12 (70.2%). In the pharynx-larynx, dyspnoea in 6 (35%) and hoarseness in 7 (41.2%) were the most prevalent and 7 (41%) had an altered laryngoscopy. CONCLUSION The otolaryngologist plays an essential role in diagnosis, treatment and follow-up of these patients. Knowing common symptoms makes diagnosis and treatment easier and earlier.
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Affiliation(s)
- Fabio Luis Vega Braga
- Department of Otolaryngology, Complejo Hospitalario Metropolitano Dr. Arnulfo Arias Madrid (CHDAAM), Panamá.
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Arebro J, Henriksson G, Macchiarini P, Juto JE. New treatment of subglottic stenosis due to Wegener's granulomatosis. Acta Otolaryngol 2012; 132:995-1001. [PMID: 22668235 DOI: 10.3109/00016489.2012.674213] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONCLUSIONS The presented new endoscopic surgical technique offers a safe and successful approach for treatment of subglottic stenosis due to Wegener's granulomatosis. OBJECTIVE Subglottic stenosis is a potentially limiting and complex condition among patients with Wegener's granulomatosis. It causes various symptoms and often requires interventional therapy. The purpose of this study was to evaluate a new endoscopic submucosal technique. METHODS Altogether 13 consecutive patients with subglottic stenosis due to Wegener's granulomatosis were treated with a new endoscopic technique. The procedure was carried out endoscopically, removing the stenotic part submucosally, sealing back the raised mucosal flap, and the bare areas were soaked with mitomycin-C. Follow-up telephone interviews were carried out and hospital records were reviewed. RESULTS Patients included 3 males and 10 females, with an average age of 37.5 years. A total of 37 procedures were performed, with an average of 2.8 procedures per patient. There was a statistically significant reduction in the all symptoms related to the stenoses (p < 0.05). Mean follow-up period was 3.5 years (range 1.5-6.5 years). Overall success rate was 85%. Only one patient relapsed following adequate medical and surgical treatment. No perioperative mortality was recorded.
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Affiliation(s)
- Julia Arebro
- Department of Clinical Science, Intervention and Technology, Division of Otorhinolaryngology, Karolinska Institutet, Stockholm, Sweden
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Trimarchi M, Sinico RA, Teggi R, Bussi M, Specks U, Meroni PL. Otorhinolaryngological manifestations in granulomatosis with polyangiitis (Wegener's). Autoimmun Rev 2012; 12:501-5. [PMID: 22940553 DOI: 10.1016/j.autrev.2012.08.010] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Granulomatosis with polyangiitis (Wegener's, GPA) is an uncommon disease of unknown etiology classically involves the ELK triad of the ear, nose, throat (E), lungs (L) and kidneys (K) with necrotizing granulomatous inflammation and vasculitis. Most of the initial symptoms begin in the head and neck region with a wide spectrum of involvement of any site ranging from the nasal septum, paranasal sinuses, oral mucosa, larynx and even the external, middle and internal ear. Diagnosis may be delayed because the onset is heterogeneous and sometimes limited to one organ. The pathologic findings of a characteristic inflammatory reaction pattern, and the serum findings of elevated antineutrophil cytoplasmic antibodies can help to establish the diagnosis. The differentiation from other conditions that mimic GPA such as lymphoma and infections is of critical importance to initiate appropriate treatment. Treatment of the underlying disease is medical with the use of immunosuppressive agents and will not be reviewed here. This review focuses on the otorhinolaryngologic manifestation and complication of GPA as well as their surgical management and specifies the role of the otorhinolaryngologist as an integral member of the multidisciplinary care team for patients with GPA.
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Affiliation(s)
- Matteo Trimarchi
- Department of Otorhinolaryngology, San Raffaele Scientific Institute, Milan, Italy, IRCCS.
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Li DM, Lun LD. Mucor irregularis infection and lethal midline granuloma: a case report and review of published literature. Mycopathologia 2012; 174:429-39. [PMID: 22744721 DOI: 10.1007/s11046-012-9559-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Accepted: 05/28/2012] [Indexed: 12/16/2022]
Abstract
Mucor irregularis (Rhizomucor variabilis) infection and lethal midline granuloma (LMG) are characterized by progressive swelling, ulceration, and destruction of the central face that is usually fatal. Pathological features are inflammation, necrosis, and granulation. LMG has been called by various names, and in recent years, it has been known as NK/T cell lymphoma. However, diagnosis still relies on the progressive necrosis course rather than malignancy in histology. The disease has long challenged physicians, particularly when it worsens with radiotherapy or chemotherapy but sometimes achieves total remission without anti-malignancy therapies. We describe a 35-year-old man who had typical clinical-pathological symptoms of LMG, which turned out to be primary M. irregularis infection; that was diagnosed by positive tissue culture and fungal elements in histology. The patient was successfully treated with antifungal therapy (liposomal amphotericin B, total 4,600 mg and amphotericin B total 277 mg, over a duration of 70 days). We hereby review current knowledge about the epidemiology, clinical manifestations, radiographic characteristics, and pathologic features of LMG with those of M. irregularis infection and their associations. We conclude that primary M. irregulars infection can mimic the clinico-pathological symptoms of LMG and the condition responds favorably to aggressive antifungal therapy.
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Affiliation(s)
- Dong Ming Li
- Department of Dermatology, Research Center for Medical Mycology, Peking University Third Hospital, 49 North Garden Rd, Haidian District, Beijing 100191, China.
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Morales-Angulo C, García-Zornoza R, Obeso-Agüera S, Calvo-Alén J, González-Gay MA. Ear, Nose and Throat Manifestations of Wegener's Granulomatosis (Granulomatosis With Polyangiitis). ACTA OTORRINOLARINGOLOGICA ESPANOLA 2012. [DOI: 10.1016/j.otoeng.2012.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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[Ear, nose and throat manifestations of Wegener's granulomatosis (granulomatosis with polyangiitis)]. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2012; 63:206-11. [PMID: 22439922 DOI: 10.1016/j.otorri.2011.12.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2011] [Revised: 11/19/2011] [Accepted: 12/02/2011] [Indexed: 11/20/2022]
Abstract
INTRODUCTION AND OBJECTIVES Granulomatosis with polyangiitis (GPA), previously called Wegener's granulomatosis, is a small vessel vasculitis often associated with clinical head and neck manifestations, which are sometimes the presenting symptoms of the disease. The aim of our study was to identify ear, nose and throat (ENT) manifestations associated with GPA and propose a work-up for the management and diagnosis for patients with suspicion or confirmed diagnosis of this ENT pathology. PATIENTS AND METHODS Retrospective review of the medical records of all patients diagnosed with GPA who were seen at the Department of Otolaryngology from a tertiary public hospital in Cantabria (Spain) over a 20-year period. Clinical and laboratory data, in particular those concerning ENT manifestations, were retrieved from the patients' medical records. RESULTS Twenty-five patients (age range: 30-81 years) were included in the study. Of these, 88% had ENT manifestations at some point in the course of the disease. In 28% of the cases, ENT features were the presenting manifestations. The most frequent ENT manifestations were sinonasal symptoms (52%), followed by otological manifestations (32%). CONCLUSIONS Patients with GPA often present with clinical ENT manifestations. Consequently, routine ENT physical examination must be performed in patients with suspected vasculitis to establish a diagnosis of GPA or to better determine the degree of organ system involvement in patients with GPA.
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Parra-García GD, Callejas-Rubio JL, Ríos-Fernández R, Sainz-Quevedo M, Ortego-Centeno N. Otolaryngologic manifestations of systemic vasculitis. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2011; 63:303-10. [PMID: 22177421 DOI: 10.1016/j.otorri.2011.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2011] [Revised: 09/29/2011] [Accepted: 09/30/2011] [Indexed: 11/25/2022]
Abstract
Systemic vasculitis is a heterogeneous group of diseases of various aetiologies and manifestations. In general, the clinical results derive from ischemia caused by vascular inflammation, which depends on the organ affected. Such vasculitis cases are classified according to the classification of the Chapel Hill conference. They can present with relative frequency as ENT manifestations in both their debut and throughout their evolution. Consequently, the ENT specialist should include them in the differential diagnosis in patients with ENT manifestations that are difficult to control or of atypical presentation. Our objective was to review the most common ENT clinical signs and symptoms in each of these diseases.
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Otologic symptoms as initial manifestation of wegener granulomatosis: diagnostic dilemma. Otol Neurotol 2011; 32:996-1000. [PMID: 21725265 DOI: 10.1097/mao.0b013e31822558fd] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To show 7 cases of Wegener granulomatosis (WG) with early aural symptoms and to discuss the problems of otologic manifestation in WG. STUDY DESIGN Retrospective case review. SETTING : Tertiary care university hospital. PATIENTS All patients were administered to the ENT University Department in Poznań in years 2002-2008 because of otitis media with effusion, facial palsy, sensorineural profound hypoacusis, hypoacusis combined with purulent discharge, and facial nerve palsy or progression of mixed type hypoacusis. INTERVENTIONS Diagnostics and treatment. MAIN OUTCOME MEASURESL: Otologic symptoms as initial manifestation of WG diagnostic dilemma. RESULTS The authors want to underline the young age of the patients, ranging from 32 to 46 years. The outcome of initially otologic cases, which developed generalized form of WG, was poor (the first patient died after 2 months, the second patient died after 7 days, the third had the pulmonary insufficiency in 2 months of observation, and the fourth had severe renal failure in 1 month), whereas the patients with localized disease have been successfully under control for 1 to 5 years. CONCLUSION As WG often presents otologic symptoms, as an initial sign in some cases, it is important to take WG into consideration in atypical inflammatory states of the ear. The otologic onset of WG is very insidious, and prompt diagnosis in early stage of disease is a challenge. Focal and localized disease in the aural region might possibly require less aggressive therapy than acute-onset multi-organ disease and is connected with better prognosis.
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Cannady SB, Batra PS. In response to Sinonasal surgery in Wegener's granulomatosis: Is it time to go on?. Laryngoscope 2011. [DOI: 10.1002/lary.22166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Poon SH, Baliog CR, Sams RN, Robinson-Bostom L, Telang GH, Reginato AM. Syndrome of Cocaine-Levamisole-Induced Cutaneous Vasculitis and Immune-Mediated Leukopenia. Semin Arthritis Rheum 2011; 41:434-44. [DOI: 10.1016/j.semarthrit.2011.05.009] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2010] [Revised: 05/24/2011] [Accepted: 05/25/2011] [Indexed: 11/13/2022]
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Solans Laque R, Lorente J, Canela M. Afección traqueobronquial en la granulomatosis de Wegener. Med Clin (Barc) 2011; 137:230-5. [DOI: 10.1016/j.medcli.2011.01.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2010] [Revised: 01/04/2011] [Accepted: 01/11/2011] [Indexed: 10/18/2022]
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Sachse F, Stoll W. Nasal surgery in patients with systemic disorders. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2011; 9:Doc02. [PMID: 22073106 PMCID: PMC3199829 DOI: 10.3205/cto000066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Multisystemic disorders represent a heterogenous group of diseases which can primarily manifest at the nose and paranasal sinuses as limited disease or secondarily as part of systemic involvement. Rhinologists therefore play an important role in the diagnostic but also therapeutic process. Although therapy of multisystemic disorders is primary systemic, additional rhinosurgery may become necessary. The spectrum of procedures consists of sinus surgery, surgery of the orbit and lacrimal duct, septorhinoplasty and closure of nasal septal perforation. Since the prevalence of most systemic diseases is very rare, recommendations are based on the analysis of single case reports and case series with a limited number of patients only. Although data is still limited, experiences published so far have shown that autologous cartilage or bone grafts can be used in nasal reconstruction of deformities caused by tuberculosis, leprosy, Wegener’s granulomatosis, sarcoidosis and relapsing polychondritis. Experiences gained from these diseases support the concept that well-established techniques of septorhinoplasty can be used in systemic diseases as well. However, a state of remission is an essential condition before considering any rhinosurgery in these patients. Even under these circumstances revision surgery has to be expected more frequently compared to the typical collective of patients undergoing septorhinoplasty. In addition, experiences gained from saddle nose reconstruction may in part be of value for the treatment of nasal septal perforations since implantation of cartilage grafts often represents an essential step in multilayer techniques of closure of nasal septal perforations. Aside from the treatment of orbital complications sinus surgery has been proven beneficial in reducing nasal symptoms and increasing quality of life in patients refractory to systemic treatment.
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Affiliation(s)
- Florian Sachse
- University of Münster, Department of Otorhinolaryngology Head and Neck Surgery, Münster, Germany
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Inflammatory Bowel Disease and Other Systemic Inflammatory Diseases. Cornea 2011. [DOI: 10.1016/b978-0-323-06387-6.00068-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Bohne S, Koscielny S, Burmeister H, Guntinas-Lichius O, Wittekindt C. Bilaterale Ertaubung und einseitige Fazialisparese als Erstmanifestation eines M. Wegener. HNO 2010; 58:480-3. [DOI: 10.1007/s00106-009-2017-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Abstract
PURPOSE OF REVIEW This review discusses the use of interventional procedures to treat manifestations of Wegener's granulomatosis caused by tissue damage and scarring. These manifestations include nasal and paranasal sinus disease, middle ear inflammation, nasolacrimal duct obstruction, orbital inflammatory masses, subglottic stenosis, tracheobronchial disease, and end-stage renal disease. RECENT FINDINGS Tissue damage caused by inflammation or a cicatricial process represents one of the major sources of morbidity for patients with Wegener's granulomatosis. Some of these manifestations require special interventions used alone or in combination with conventional medical treatment. These interventional procedures may include surgical or endoscopic repair of altered tissue, replacement of damaged organs, or the delivery of topical or injectable medications directly to the site of disease. Distinguishing symptoms caused by active disease from symptoms caused by tissue scarring is challenging and may play a critical role regarding the use of systemic immunosuppressive medications in combination with interventional therapy. SUMMARY Interventional procedures are indicated in certain manifestations of Wegener's granulomatosis. Distinguishing active Wegener's granulomatosis from inactive Wegener's granulomatosis and recognizing disease manifestations that may be amenable to local interventions can greatly improve the quality of life of patients. However, the evidence supporting the use of many of these interventions is based on small case series or individual reports.
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