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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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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: 118] [Impact Index Per Article: 13.1] [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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Ghavidel A. Otitis media triggered by Wegener’s granulomatosis: A case report and review of the literature. JOURNAL OF ANALYTICAL RESEARCH IN CLINICAL MEDICINE 2015. [DOI: 10.15171/jarcm.2015.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Lee JH, Kim KW, Myong NH, Jung JY. Wegener's granulomatosis presenting as bilateral otalgia with facial palsy: a case report. KOREAN JOURNAL OF AUDIOLOGY 2013; 17:35-7. [PMID: 24653903 PMCID: PMC3936517 DOI: 10.7874/kja.2013.17.1.35] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Revised: 03/30/2013] [Accepted: 04/02/2013] [Indexed: 12/03/2022]
Abstract
Wegener's granulomatosis (WG) is defined as a granulomatous inflammation of the upper and lower respiratory tract due to a systemic vasculitis. Facial nerve palsy may occur during the course of any granulomatous or vasculitis disease. But very few cases have been reported in which facial nerve palsy is the presenting feature of WG. We recently experienced an interesting case of WG presenting as acute middle ear infection and subsequent bilateral facial palsy.
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Affiliation(s)
- Jeong Hyun Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Dankook University College of Medicine, Cheonan, Korea
| | - Kun Woo Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Dankook University College of Medicine, Cheonan, Korea
| | - Na Hye Myong
- Department of Pathology, Dankook University College of Medicine, Cheonan, Korea
| | - Jae Yun Jung
- Department of Otorhinolaryngology-Head and Neck Surgery, Dankook University College of Medicine, Cheonan, Korea
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Sharma A, Deshmukh S, Dabholkar J. ENT manifestations of Wegeners granulomatosis. Otolaryngol Pol 2013; 67:257-60. [PMID: 24021829 DOI: 10.1016/j.otpol.2013.02.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2012] [Accepted: 02/05/2013] [Indexed: 10/27/2022]
Abstract
Wegeners granulomatosis is a necrotizing granulomatous vasculitis with multisystemic involvement. We present two cases of Wegener's presenting with otological manifestations as the first symptom. These symptoms are subtle and diagnosis may be easily overlooked. Hence a high index of suspicion is required. Early diagnosis and treatment goes a long way in improving the outcomes and in preventing further complications.
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Affiliation(s)
- Arpit Sharma
- Department of Otorhinolaryngology & Head-Neck Services, Seth GS Medical College, KEM Hospital, Mumbai, India
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Wegener's granulomatosis mimicking skull base osteomyelitis. The Journal of Laryngology & Otology 2011; 126:203-6. [DOI: 10.1017/s0022215111002064] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractObjective:To report a case of Wegener's granulomatosis mimicking skull base osteomyelitis.Case report:A case of Wegener's granulomatosis is reported in a diabetic woman presenting with facial palsy and hearing loss. The clinical course of the disease was very similar to that of skull base osteomyelitis, especially since the patient was diabetic and the ear swab was positive for pseudomonas. The definitive diagnosis was made based on clinical presentation, imaging and serum antineutrophil cytoplasmic antibody testing. The patient was started on immunosuppressants, and her hearing loss and facial palsy recovered.Conclusion:Wegener's granulomatosis is a systemic disease with various manifestations. A high index of clinical suspicion is required to reach the correct diagnosis. The clinician should be alerted to the possibility of Wegener's granulomatosis in the presence of: systemic upset out of proportion to the apparent intensity of the local lesion; middle-ear disease failing to respond to conventional treatment; and a consistently raised erythrocyte sedimentation rate.
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Manna R, Cadoni G, Ferri E, Verrecchia E, Giovinale M, Fonnesu C, Calò L, Armato E, Paludetti G. Wegener's granulomatosis: an update on diagnosis and therapy. Expert Rev Clin Immunol 2008; 4:481-95. [PMID: 20477576 DOI: 10.1586/1744666x.4.4.481] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Wegener's granulomatosis (WG) is a unique clinicopathological disease characterized by necrotizing granulomatous vasculitis of the respiratory tract, pauci-immune necrotizing glomerulonephritis and small-vessel vasculitis. Owing to its wide range of clinical manifestations, WG has a broad spectrum of severity that includes the potential for alveolar hemorrhage or rapidly progressive glomerulonephritis, which are immediately life threatening. WG is associated with the presence of circulating antineutrophil cytoplasm antibodies (c-ANCAs). The most widely accepted pathogenetic model suggests that c-ANCA-activated cytokine-primed neutrophils induce microvascular damage and a rapid escalation of inflammation with recruitment of mononuclear cells. The diagnosis of WG is made on the basis of typical clinical and radiologic findings, by biopsy of involved organ, the presence of c-ANCA and exclusion of all other small-vessel vasculitis. Currently, a regimen consisting of daily cyclophosphamide and corticosteroids is considered standard therapy. A number of trials have evaluated the efficacy of less-toxic immunosuppressants and antibacterials for treating patients with WG, resulting in the identification of effective alternative regimens to induce or maintain remission in certain subpopulations of patients. Recent investigation has focused on other immunomodulatory agents (e.g., TNF-alpha inhibitors and anti-CD20 antibodies), intravenous immunoglobulins and antithymocyte globulins for treating patients with resistant WG.
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Affiliation(s)
- R Manna
- Clinical Autoimmunity Unit, Department of Internal Medicine, Catholic University of the Sacred Heart, Largo A Gemelli, 8-00168 Rome, Italy.
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Yildirim N, Arslanoglu A, Aygun N. Otologic and leptomeningeal involvements as presenting features in seronegative Wegener granulomatosis. Am J Otolaryngol 2008; 29:147-9. [PMID: 18314030 DOI: 10.1016/j.amjoto.2007.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2007] [Accepted: 04/06/2007] [Indexed: 10/22/2022]
Abstract
Wegener granulomatosis is an immune-mediated, systemic vasculitis with unknown etiology that can be seen in almost any anatomical site. Positivity for antineutrophil cytoplasmic antigene, which is a serological marker, and presence of granulomatous vasculitis in histopathologic specimens from the lesions are accepted as diagnostic. A case of Wegener granulomatosis whose presenting symptoms and signs are related to otologic and meningeal involvement of the disease is reported. Apart from atypical presentation, histopathological and serological findings from this patient remained negative throughout the course of the disease, and the diagnosis was made on the basis of clinical and secondary laboratory findings. We herewith discuss this unusual case in the light of relevant literature.
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Cadoni G, Prelajade D, Campobasso E, Calŏ L, Agostino S, Manna R, Paludetti G. Wegener's granulomatosis: a challenging disease for otorhinolaryngologists. Acta Otolaryngol 2005; 125:1105-10. [PMID: 16298794 DOI: 10.1080/00016480510028500] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Diagnosis of Wegener's granulomatosis (WG) can be delayed because of its aspecific presenting symptoms. Detection of serum circulating antineutrophil cytoplasm antibodies (c-ANCAs), in combination with histology, permits one to identify WG at an early stage and to implement stage-adapted therapy. c-ANCA levels may also help to evaluate the response to medical therapy. Recently, the quality of life of WG patients has been improved by administering cotrimoxazole in order to prevent infections and recurrent diseases during the remission period.WG is of special significance to the otorhinolaryngologist because it is often initially limited to the upper respiratory tract before becoming systemic. The aim of this paper was to describe a series of WG patients and underline the difficulties involved in diagnosing and treating this challenging disease. This was a prospective study in 23 consecutive patients with head and neck manifestations of WG (17 systemic, 6 limited). Diagnosis was performed by means of both c-ANCAs detection using indirect immunofluorescence and histology in biopsy specimens. Treatment consisted of daily cyclophosphamide (CYC; 2 mg/kg/day) and glucocorticoids (prednisone; 1 mg/kg/day). If an improvement or toxic events occurred, CYC was discontinued and methotrexate was started. If, during remission of the disease, low serum c-ANCAs levels were detected, CYC was suspended and cotrimoxazole (1 g/day) was introduced. Serum c-ANCAs detection was positive for all patients. Biopsy was diagnostic from the beginning in 19/23 cases. The six patients with limited WG did not show a progression to systemic disease. Only 3 patients with a diagnosis of delayed systemic WG died, whereas 19/23 patients were alive with good control of relapses.
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Affiliation(s)
- Gabriella Cadoni
- Department of Otorhinolaryngology, Catholic University of the Sacred Heart, Rome, Italy.
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Abstract
OBJECTIVE Major salivary gland enlargement is a rare presenting symptom of Wegener's granulomatosis. The unrecognized occurrence of this entity can delay diagnosis, leading to increased morbidity from disease progression. This report discusses the clinical features and diagnostic testing of salivary gland enlargement secondary to Wegener's granulomatosis to differentiate it from other, more common, salivary gland diseases. STUDY DESIGN A case report of a single subject with unilateral parotid gland enlargement secondary to Wegener's granulomatosis. METHODS A review of the clinical course, diagnostic studies, and histopathology related to the presenting disease. RESULTS A 54-year-old male was evaluated for a 6-week history of progressive right parotid enlargement and pain unresponsive to antimicrobial therapy. Computed tomography scans showed diffuse, unilateral parotid swelling without enhancement and without a mass lesion or sialolith. Multiple open biopsies from the gland were necessary to demonstrate the presence of necrotizing granulomatous inflammation with vasculitis. Elevated antineutrophil cytoplasmic autoantibody, cytoplasmic pattern (c-ANCA) titers confirmed Wegener's granulomatosis. Hemoptysis and acute renal failure requiring hemodialysis developed shortly after diagnosis but eventually resolved after the initiation of corticosteroids and cyclophosphamide. CONCLUSIONS Unilateral parotid enlargement is a rare presentation of Wegener's granulomatosis. A high level of clinical suspicion should prompt biopsy and testing of c-ANCA when initial studies or empirical treatment fails to lead to a proper diagnosis. Early treatment may prevent the development of other serious systemic complications such as renal failure.
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Affiliation(s)
- Burke E Chegar
- Department of Otolaryngology and Communication Sciences, SUNY-Upstate Medical University, 750 East Adams Street, Syracuse, NY 13210, U.S.A
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Abstract
Facial palsy can occur as a result of various pathological processes, which are not always amenable to early diagnosis. This article is a case presentation of a patient with facial palsy, after an acute otitis media manifestation, as a first symptom of Wegener's granulomatosis. The clues leading to diagnosis consist of the practitioner's clinical suspicion of the disease, the use of the appropriate serological measurements (c-antineutrophil cytoplasmic autoantibody), and the histological confirmation. The early initiation of treatment leads to high rates of remission of an otherwise lethal disease.
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Affiliation(s)
- Vassilis Drinias
- Ear, Nose, and Throat Department, Ryhov Hopsital, Jönköping, Sweden.
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Ferlito A, Devaney KO, Anniko M, Arnold W, Rinaldo A. Otological Wegener's granulomatosis at the time of initial presentation: a potential diagnostic dilemma. Acta Otolaryngol 2003; 123:675-7. [PMID: 12953764 DOI: 10.1080/00016480310002447] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Nagai H, Takahashi H, Yao K, Inagi K, Nakayama M, Makoshi T, Okamoto M. Clinical review of Wegener's granulomatosis. Acta Otolaryngol 2003:50-3. [PMID: 12212594 DOI: 10.1080/000164802760057572] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The prognosis of Wegener's granulomatosis (WG) improved following the introduction of immunosuppressant agents. We, however, still experience some difficult cases that are resistant to treatment. Early diagnosis and treatment may improve the prognosis of WG. We reviewed patients with WG attending the Department of Otorhinolaryngology, Kitasato University Hospital. Of the 13 patients reviewed, 5 are still alive. A definite diagnosis was difficult to make without the presence of certain characteristic features. Recently, cytoplasmic antineutrophil cytoplasmic antibody (c-ANCA) has gained importance in the diagnosis of WG and five of our patients were positive for c-ANCA. Close long-term follow-up of WG is recommended: remission was observed in two of our patients and side-effects of the treatment were identified in four.
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Affiliation(s)
- Hiromi Nagai
- Department of Otorhinolaryngology, School of Medicine, Kitasato University, Kanagawa, Japan
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Takagi D, Nakamaru Y, Maguchi S, Furuta Y, Fukuda S. Otologic manifestations of Wegener's granulomatosis. Laryngoscope 2002; 112:1684-90. [PMID: 12352687 DOI: 10.1097/00005537-200209000-00029] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE/HYPOTHESIS To evaluate the clinical features, treatment, and outcomes of otologic manifestations in Wegener's granulomatosis (WG) treated at Hokkaido University Graduate School of Medicine, Sapporo, Japan. STUDY DESIGN We retrospectively reviewed 15 cases of WG with ear involvement. METHODS Twenty-five patients with WG were treated at Hokkaido University Graduate School of Medicine between 1992 and 2001. Fifteen of these patients had otologic symptoms. We evaluated the clinical course, method of therapy, and outcomes in all cases. Diagnosis of WG was made when the patients had clinical findings and a positive titer of cytoplasmic pattern antineutrophil cytoplasmic antibodies (c-ANCA), or when there were clear histologic findings. We also present three case reports. RESULTS In 15 cases, the most frequent finding was chronic otitis media. Sensorineural hearing loss was present in 2 patients. In 7 patients whose otologic manifestations were the primary involvement of WG, all were confirmed positive for c-ANCA and were treated with glucocorticoids and immunosuppressive drugs. Three patients who could be treated within 1 month of symptom onset showed marked improvement. CONCLUSIONS In localized cases, biopsy specimens are often small, and it is frequently difficult to make a histologic diagnosis. The prognosis for hearing was poor when appropriate treatment was not given in the early stages of the disease. Therefore, WG should be included in the differential diagnosis in cases of atypical inflammatory states of the ear. Early diagnosis and appropriate treatment are important to prevent irreversible changes in the middle ear and inner ear.
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Affiliation(s)
- Dai Takagi
- Department of Otolaryngology--Head and Neck Surgery, Hokkaido University Graduate Shool of Medicine, Sapporo, Japan.
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Affiliation(s)
- G Magliulo
- 2nd Ear, Nose, and Throat Clinic, Università Degli Studidi Roma, La Sapienza, Rome, Italy
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Abstract
Wegener's granulomatosis, characterized by necrotizing granulomas and vasculitis of the respiratory tract and kidney, frequently first presents with otologic symptoms. We report a case of primary otologic Wegener's granulomatosis in a patient who presented with symptoms of acute otomastoiditis and associated facial nerve palsy. The patient subsequently developed neuropathies of various cranial nerves. The patient underwent urgent mastoidectomy with facial nerve decompression. Nonspecific inflammatory disease of the mastoid mucosa delayed the correct diagnosis of Wegener's granulomatosis, which was confirmed by an elevated level of cytoplasmic-pattern antineutrophil cytoplasmic antibody (cANCA). We contrast the specificity of middle ear mucosal disease and cANCA serum levels in the diagnosis of Wegener's granulomatosis.
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Affiliation(s)
- P Dagum
- Division of Otolaryngology-Head and Neck Surgery, Stanford University Medical Center, California, USA
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O'Devaney K, Ferlito A, Hunter BC, Devaney SL, Rinaldo A. Wegener's granulomatosis of the head and neck. Ann Otol Rhinol Laryngol 1998; 107:439-45. [PMID: 9596226 DOI: 10.1177/000348949810700515] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Among the more puzzling non-neoplastic necrotizing lesions of the head and neck area is Wegener's granulomatosis. This is a condition of unknown cause that may present (in the head and neck area) with ulceration of the nasal septum, sinus mucosa, oral mucosa, or external ear canal, or even destruction of the vocal cord. Diagnosis depends on the pathologic finding of a characteristic inflammatory reaction pattern (which, in its best-developed form, includes necrosis, granulomatous inflammation, and vasculitis) and the serum finding of an elevated antinuclear cytoplasmic antigen. Treatment is principally medical, with the use of powerful immunosuppressive agents. Distinction from other conditions that may mimic Wegener's granulomatosis (such as malignant lymphoma and infections) is of critical importance in constructing an appropriate treatment strategy.
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Affiliation(s)
- K O'Devaney
- Department of Pathology, University of Michigan, Ann Arbor, USA
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Hartl DM, Aïdan P, Brugière O, Sterkers O. Wegener's granulomatosis presenting as a recurrence of chronic otitis media. Am J Otolaryngol 1998; 19:54-60. [PMID: 9470953 DOI: 10.1016/s0196-0709(98)90067-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- D M Hartl
- Department of Otorhinolaryngology, Faculté Xavier Bichat, Université Paris VII, Hôpital Beaujon, Clichy, France
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19
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Almadori G, Trivelli M, Scarano E, Cadoni G. Misleading clinical features in Wegener's granulomatosis. A case report. J Laryngol Otol 1997; 111:746-8. [PMID: 9327013 DOI: 10.1017/s0022215100138502] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Wegener's granulomatosis is a systemic vasculitis that may present with a variety of findings and be difficult to diagnose. We report a case of a patient who presented with serous otitis media and subsequently developed a suspected primary lung tumour. Thoracotomy and pulmonary mass excision were required to establish the diagnosis. Otological manifestations of Wegener's granulomatosis, differential diagnosis, pathological findings and c-ANCA test role are discussed.
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Affiliation(s)
- G Almadori
- Institute of Otolaryngology, Catholic University of the Sacred Heart, Rome
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Hern JD, Hollis LJ, Mochloulis G, Montgomery PQ, Tolley NS. Early diagnosis of Wegener's granulomatosis presenting with facial nerve palsy. J Laryngol Otol 1996; 110:459-61. [PMID: 8762317 DOI: 10.1017/s0022215100133973] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Wegener's granulomatosis is a multi-system disease characterized by granuloma formation and a necrotizing vasculitis. It classically presents with involvement of the upper and lower respiratory and renal systems. However locoregional disease is common and may include otological manifestations. Facial nerve palsy has been reported during the course of the disease process but it is extremely rare for it to be the presenting feature. Previously reported cases have involved a protracted diagnostic process including exploratory tympanotomy, mastoidectomy and facial nerve decompression. We report a case of Wegener's granulomatosis which presented with a facial nerve palsy. An early diagnosis was achieved by measurement of the erythrocyte sedimentation rate (ESR), followed by serological assay of cytoplasmic anti-neutrophil cytoplasmic antibody (cANCA). Histological examination of nasal mucosal biopsies confirmed granuloma formation consistent with a diagnosis of Wegener's granulomatosis. This allowed early treatment with immunosuppressive therapy and avoided unnecessary and potentially hazardous middle ear surgery.
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Affiliation(s)
- J D Hern
- Department of Otolaryngology, St Mary's Hospital, London, UK
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Foster WP, Greene JS, Millman B. Wegener's Granulomatosis Presenting as Ophthalmoplegia and Optic Neuropathy. Otolaryngol Head Neck Surg 1995; 112:758-62. [PMID: 7777366 DOI: 10.1016/s0194-59989570190-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Affiliation(s)
- W P Foster
- Department of Otolaryngology/Head and Neck Surgery, Geisinger Medical Center, Danville, PA 17822-1333, USA
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Gross WL, Csernok E, Helmchen U. Antineutrophil cytoplasmic autoantibodies, autoantigens, and systemic vasculitis. APMIS 1995; 103:81-97. [PMID: 7748541 DOI: 10.1111/j.1699-0463.1995.tb01083.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Antineutrophil cytoplasmic antibodies (ANCA) encompass a heterogeneous group of autoantibodies targeting antigens in neutrophils (PMN), monocytes, and endothelial cells. ANCA are routinely detected by the indirect immunofluorescence technique (IFT) and at least three different patterns of fluorescence can be distinguished which have been assigned the acronyms cANCA, pANCA and aANCA. cANCA is mostly induced by proteinase 3 (PR3) antibodies (PR3-ANCA), and pANCA by myeloperoxidase (MPO) antibodies (MPO-ANCA), while aANCA has unidentified subspecificity. Over the past decade, ANCA have been the subject of extensive investigation. They have proved to be of significant value both as diagnostic tools and for follow-up in several forms of systemic vasculitis (e.g. Wegener's granulomatosis, WG; microscopic polyarteritis, MPA; Churg-Strauss syndrome, CSS) which are now termed 'ANCA-associated vasculitides'. Furthermore, it is suspected that the presence of ANCA is an important factor in the pathogenesis of these disease groups. Data regarding the detection of ANCA and their diagnostic value and role in the pathogenesis of vasculitic disorders will be discussed in this review. Growing evidence points to a pathophysiological and diagnostic relevance of the distribution of the ANCA target antigens PR3 and MPO (presence in the circulation, on cell membranes, and in tissue extracellularly). An autoimmune process has been implicated in the pathogenesis of ANCA-associated vasculitis, but it is uncertain which mechanism underlies the induction of the ANCA-related immunoresponse. In this paper mechanisms such as antigenic cross-reactivity between human PMN proteins and extrinsic antigens by molecular mimicry, idiotypic immunoglobulin regulation, and T-cell reactivity to PR3 and MPO will be discussed.
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Affiliation(s)
- W L Gross
- Department of Rheumatology, University of Lübeck, Germany
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Abstract
Wegener's granulomatosis is a systemic vasculitis characterized by necrotizing granulomata and without treatment is associated with a poor prognosis. Antineutrophil cytoplasmic antibodies (ANCA) have proved to be a useful serological marker allowing for early diagnosis and treatment of this condition. We report two cases of patients who were ANCA-negative on presentation despite clinical suspicion of Wegener's granulomatosis. In both cases the patients developed a positive ANCA titre as the disease progressed.
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Affiliation(s)
- S Carrie
- Department of Otolaryngology, Doncaster Royal Infirmary
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Batsakis JG, el-Naggar AK. Wegener's granulomatosis and antineutrophil cytoplasmic autoantibodies. Ann Otol Rhinol Laryngol 1993; 102:906-8. [PMID: 8239356 DOI: 10.1177/000348949310201117] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Serologic tests for antineutrophil cytoplasmic autoantibodies can serve as markers for a number of necrotizing vasculitides and other inflammatory disorders. In the case of Wegener's granulomatosis, an immunofluorescent cytoplasmic pattern and immunoassay for proteinase 3 are quite specific for the disease and are capable of serving as additional criteria for diagnosis. As with any laboratory test, however, results are to be interpreted in the whole clinical and pathologic framework of the disease.
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Affiliation(s)
- J G Batsakis
- Department of Pathology, University of Texas M.D. Anderson Cancer Center, Houston 77030
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