Study of oral, ear, nose and throat involvement in pemphigus vulgaris by endoscopic examination

Characteristic Laryngeal Findings in Patients with Pemphigus Vulgaris

OBJECTIVE

Pemphigus Vulgaris (PV) is a rare autoimmune disease that could cause laryngeal lesions; however, only a few studies have described the localization of the laryngeal lesions associated with this disease owing to its rarity. Therefore, this study aimed to determine the localization of laryngeal lesions in patients with PV.

METHODS

Fourteen patients with PV accompanied by laryngeal or pharyngeal lesions, who underwent flexible laryngeal endoscopy performed by laryngologists, were examined retrospectively.

RESULTS

The arytenoid area was the most frequently affected site in the larynx, followed by the epiglottis and aryepiglottic folds. Vocal folds and ventricular bands were the least affected.

CONCLUSION

Lesions in the arytenoid area were observed more frequently in this study than in previous studies. This result suggests that a more careful inspection of arytenoid lesions in patients with PV is required under laryngeal fiber observation. Moreover, we proposed a novel classification system for laryngeal findings in patients with PV and a systematic observation method. This novel classification and method would be useful not only for determining the lesions but also for careful inspection in this field.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:3719-3725, 2024.

Nasal, oral, and pharyngolaryngeal manifestations of pemphigus vulgaris: Endoscopic ororhinolaryngologic examination

Pemphigus vulgaris is an autoimmune blistering disorder that involves the skin and mucous membranes. Few reports have described nasal and oropharyngolaryngeal lesions in pemphigus vulgaris using an endoscopic ororhinolaryngologic examination. We retrospectively reviewed the clinical records of 11 patients with pemphigus vulgaris between 2001 and 2013 with respect to their symptoms, lesion sites, lesion features, and treatments received. All patients had undergone an endoscopic ororhinolaryngologic examination. Their mucosa-related symptoms were sore throat, oral pain, odynophagia, gingival bleeding, hoarseness, and epistaxis. The most frequent sites were the oral cavity (gingiva and buccal mucosa), larynx (epiglottis and vocal fold), oropharynx (soft palate), and nasal cavity (nasal septum). Lesions were typically characterized by erosion, erosion with a whitish exudate, and erythematous patches. Thus, our study findings reveal that pemphigus vulgaris involves both the nasal and oropharyngolaryngeal regions. Patients with pemphigus vulgaris should undergo an endoscopic ororhinolaryngologic examination to determine the range of their lesions.

Ocular involvement in pemphigus vulgaris - a retrospective study of a large Spanish cohort

BACKGROUND AND OBJECTIVES

Ocular/periocular involvement in pemphigus vulgaris (OPV) has rarely been reported. The objective of the present study was to investigate the pattern of OPV and define the prognostic value of its manifestation.

PATIENTS AND METHODS

From 1985 to 2014, a total of 167 patients with pemphigus vulgaris (PV) were treated at four tertiary Spanish hospitals. In this retrospective study, we included all patients with OPV. Clinical data and information on associated symptoms were obtained from patients' medical records.

RESULTS

Only 24 (14.3 %) of all PV patients had ocular lesions. In most cases, -ocular involvement was preceded by PV lesions at various other sites (mean duration: 33.7 months). Ocular PV lesions occurred during flares of mucocutaneous pemphigus, and was never the only mucosal manifestation. The most common clinical signs were conjunctival hyperemia (87.5 %), erosions on the eyelids (41.6 %) as well as of the palpebral/bulbar conjunctiva (33.3 %) and at the medial epicanthus (20.8 %). The most relevant associated symptoms included local pain/stinging (71.4 %), irritation (47.6 %), photophobia (38.1 %), and epiphora (23.9 %). Ocular PV improved with systemic and adjuvant topical therapies. Only two patients experienced sequelae.

CONCLUSIONS

In patients with PV, ocular involvement is an exception. Ocular PV is associated with greater disease activity, and usually follows a benign course. Sites affected are the conjunctiva, the eyelids, or both.

Pharyngolaryngeal ulcers associated with the improper use of alendronate

Bisphosphonates can cause mucosal irritation. Although esophageal ulceration is a well-recognized adverse effect of bisphosphonates, pharyngolaryngeal ulcers associated with the improper use of oral bisphosphonates have rarely been described. A previously healthy 78-year-old woman presented with refractory pharyngolaryngeal ulcers. Extensive evaluation, including biopsy, bacterial culture, and blood tests did not identify any findings that indicated a specific disease diagnosis. Antibiotics and oral prednisolone were ineffective. Ultimately, it was found that the patient regularly took a tablet of alendronate, a type of bisphosphonate, by dissolving it in the oral cavity. Within 2 weeks after withdrawal of the use of the medication, her symptoms were eliminated, and the lesions were completely healed. This case illustrates the importance of correct administration of bisphosphonates. Given the widespread use of bisphosphonates, physicians need to be aware that their improper use can cause pharyngolaryngeal ulcers.

Exploring beyond the oral mucosa in patients affected with autoimmune blistering diseases: the importance of endoscopic procedures

Autoimmune blistering diseases (AIBD) comprise several entities characterized by the presence of autoantibodies targeted against structural proteins either in desmosomes or in the dermoepidermal junction of polystratified squamous epithelium. Patients develop blisters, erosions in cutaneous surfaces or mucosas. Diagnosis is based on the characteristic mucocutaneous lesions, the typical findings on histological studies and direct immunofluorescence assays, and the presence of specific autoantibodies against the epidermal antigens. It may not be possible for dermatologists to appropriately explore the nose and throat (NT). Thus, a clinical exploration by endoscopic procedures of NT may be a useful tool during the conventional dermatological exam. The aims of this review are to draw attention to the most frequent NT manifestations in AIBD patients, and underline the utility of endoscopic procedures to achieve a more successful and rationale management of patients. Additionally, we will provide brief information related to the anatomical structures and type of epithelium in NT areas which may explain the extent and type of NT involvement in AIBD. Endoscopic exploration in AIBD patients is important for several reasons. Firstly, it will allow the real NT mucosal involvement in each patient to be determined, thus making a differential diagnosis during the endoscopic exam possible, based on the localization of mucosal lesions. Secondary mucosal morbidity can also be ruled out. Secondly, the clinical response to treatment may be established, especially in NT mucosa, as these are anatomical areas subjected to important local traumas, and physiological functions such as breathing, swallowing, speech production and phonation may be damaged. Therefore, a multidisciplinary management in AIBD is mandatory by both dermatologists and otorhinolaryngologists, adding the clinical exploration by endoscopic procedures of NT to the conventional dermatological exam in all AIBD patients, irrespective of whether they exhibit associated symptoms.

Features of coexisting granulomatosis with polyangiitis in a patient with pemphigus vulgaris: a case report

Pemphigus vulgaris (PV) and granulomatosis with polyangiitis (Wegener's or GPA) are two rare autoimmune disorders. Both can involve the upper airways, and diagnosis can be difficult in the absence of extra-airway symptoms. We report the case of a patient with well-controlled PV but persistent upper respiratory tract symptoms. Further evaluation revealed perforation of the nasal septum and elevated serologies consistent with GPA. The patient improved with rituximab treatments. This case demonstrates that alternative concomitant diagnosis should be considered in patients with symptoms suggestive of recalcitrant PV and/or GPA, since these patients may require more aggressive initial treatment.

Oral mucosal manifestations of autoimmune skin diseases

A group of autoimmune diseases is characterised by autoantibodies against epithelial adhesion structures and/or tissue-tropic lymphocytes driving inflammatory processes resulting in specific pathology at the mucosal surfaces and the skin. The most frequent site of mucosal involvement in autoimmune diseases is the oral cavity. Broadly, these diseases include conditions affecting the cell-cell adhesion causing intra-epithelial blistering and those where autoantibodies or infiltration lymphocytes cause a loss of cell-matrix adhesion or interface inflammation. Clinically, patients present with blistering, erosions and ulcers that may affect the skin as well as further mucosal surfaces of the eyes, nose and genitalia. While the autoimmune disease may be suspected based on clinical manifestations, demonstration of tissue-bound and circulating autoantibodies, or lymphocytic infiltrates, by various methods including histological examination, direct and indirect immunofluorescence microscopy, immunoblotting and quantitative immunoassay is a prerequisite for definitive diagnosis. Given the frequency of oral involvement and the fact that oral mucosa is the initially affected site in many cases, the informed practitioner should be well acquainted with diagnostic and therapeutic aspects of autoimmune dermatosis with oral involvement. This paper reviews the pathogenesis and clinical presentation of these conditions in the oral cavity with a specific emphasis on their differential diagnosis and current management approaches.

Evaluation of olfaction in patients with pemphigus vulgaris

BACKGROUND

Pemphigus vulgaris (PV) is an autoimmune disease characterized by acantholysis. PV decreases quality of life and leads to morbidity and mortality. Although the association between PV and otolaryngeal disease has been studied, its effect on olfaction has not been investigated objectively and quantitatively.

METHODS

Twenty-eight patients with PV and 28 healthy volunteers were included in the study. Lesions were identified via nasal endoscopic examination. Nasal symptoms (itching, obstruction, pain, bleeding, and crusting) were recorded. Volunteers were asked to evaluate their olfactory function via a visual analog scale. The Connecticut Chemosensory Clinical Research Center (CCCRC) olfactory test was performed (butanol threshold test and identification test), and the score was calculated as the mean ± SD.

RESULTS

The mean age of the PV group (group 1: 10 male 18 female subjects) was 48.7 ± 8.9 years. The mean age of the control group (group 2: 17 male and 11 female subjects) was 48.0 ± 1.1 years. All nasal symptoms, except itching, were more severe in the PV group (p < 0.05). Nasal lesions were more common in the PV group (p = 0.0001). Evaluation of olfactory function revealed significantly lower scores in the PV group for both the butanol threshold test and the identification testing as well as the CCCRC total score (p = 0.001). PV patients with nasal lesions had significantly more nasal symptoms (p < 0.05). A negative correlation was found between the number of lesions and the olfactory scores in group 1 for the butanol threshold test, identification testing, and the CCCRC total scores, respectively (p = 0.002, p = 0.010, and p = 0.001, respectively).

CONCLUSION

PV causes olfactory dysfunction leading to eventual hyposmia that decreases quality of life. We suggest that olfactory testing be included in PV evaluation for the diagnosis and treatment of hyposmia, when necessary.