Otological manifestations of Wegener's granulomatosis

Radiologic Differentiation between Granulomatosis with Polyangiitis and Its Mimics Involving the Skull Base in Humans Using High-Resolution Magnetic Resonance Imaging

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.

Two cases of refractory eosinophilic granulomatosis with polyangiitis wherein mepolizumab was effective against pulmonary and ear lesions

Recently, mepolizumab, an interleukin (IL)-5 inhibitor, has been indicated for the treatment of eosinophilic granulomatosis with polyangiitis (EGPA) refractory to standard therapies. However, no reports have compared the efficacy of mepolizumab according to symptoms and organ lesions. Herein, we report two cases in which mepolizumab was highly effective in the management of EGPA with lung lesions and otitis media refractory to treatment with multiple immunosuppressive agents. These two cases suggest that mepolizumab is effective in treating pulmonary and ear lesions in EGPA.

[Otologic Manifestations in Patients with ANCA Associated Vasculitis-Comparative Analysis among Microscopic Polyangiitis, Granulomatosis with Polyangiitis and Eosinophilic Granulomatosis with Polyangiitis]

Anti-neutrophil cytoplasmic antibody (ANCA) -associated vasculitides (AAVs) include microscopic polyangiitis (MPA), granulomatosis with polyangiitis (GPA) and eosinophilic granulomatosis with polyangiitis (EGPA), the incidences of which are reported to be increasing in Japan. We reviewed the clinical records of 20 cases with systemic AAVs (five cases with MPA, nine cases with GPA, and six cases with EGPA), who visited our otolaryngology department with otological symptoms from 2004 to 2014, and compared the otological characteristics among the diseases. Otologic symptoms appeared as an initial symptom(s) in 40% of MPA cases, 56% of GPA cases, and 83% of EGPA cases. GPA and EGPA cases showed a variety of symptoms such as otalgia, otorrhea, hearing loss, ear fullness, tinnitus and dizziness, while MPA cases showed only hearing loss and ear fullness, but otalgia or otorrhea. AAVs and otitis media associated with ANCA vasculitis (OMAAV) are usually diagnosed shortly after the appearance of otological symptoms in GPA cases, while the final diagnosis is delayed in EGPA cases. Furthermore, the diagnosis of OMAAV was made after the diagnosis of AAV in most cases of EGPA. More than half of MPA cases did not meet the diagnostic. criteria for OMAAV. It is noteworthy that in a significant number of AAV patients with ear disease, otological symptoms are supposed to appear as an initial symptom(s). Therefore, otolaryngologists have a major role to achieve early diagnosis of AAV. The patients with adult-onset inflammation of the middle ear, inner ear or both should undergo careful examinations, and they should be closely followed even if the diagnosis is uncertain.

Otologic disorders causing dizziness, including surgery for vestibular disorders

This chapter will focus on vertigo/dizziness due to inner-ear malformations, labyrinthine fistula, otosclerosis, infectious processes, and autoimmune inner-ear disorders. Inner-ear malformation due to dehiscence of the superior semicircular canal is the most recently described inner-ear malformation. Vertigo/dizziness is typically induced by sound and pressure stimuli and can be associated with auditory symptoms (conductive or mixed hearing loss). Labyrinthine fistula, except after surgery for otosclerosis, in the context of trauma or chronic otitis media with cholesteatoma, still remains a challenging disorder due to multiple uncertainties regarding diagnostic and management strategies. Otosclerosis typically manifests with auditory symptoms and conductive or mixed hearing loss on audiometry. Vertigo/dizziness is rare in nonoperated otosclerosis and should draw clinical attention to an inner-ear malformation. Computed tomography scan confirms otosclerosis in most cases and should rule out an inner-ear malformation, avoiding needless middle-ear surgical exploration. Labyrinth involvement after an infectious process is unilateral when it complicates a middle-ear infection but can be bilateral after meningitis. Labyrinth involvement due to an inflammatory disease is a challenging issue, particularly when restricted to the inner ear. The diagnosis relies on the bilateral and rapid aggravation of audiovestibular symptoms that will not respond to conventional therapy but to immunosuppressive drugs.

Presentation and initial assessment of ENT problems in patients with granulomatosis with polyangiitis (Wegener's)

BACKGROUND

Granulomatosis with polyangiitis (formerly known as Wegener's granulomatosis) is a primary systemic vasculitis that affects medium to small sized vessels throughout the body. It often presents with symptoms and signs involving the ear, nose, and head and neck area.

OBJECTIVE

To highlight salient features of ENT-related issues in granulomatosis with polyangiitis, and raise awareness of the condition.

METHODS

A case report of a patient with limited disease and an insidious onset is presented, along with a review of the current literature. In addition, basic initial management is described.

RESULTS

Eighty-six publications were used to describe salient features of ENT-related issues in granulomatosis with polyangiitis.

CONCLUSION

The time to diagnosis has not reduced significantly in the last 10 years in the UK. A high index of suspicion is required for an earlier diagnosis of granulomatosis with polyangiitis.

Early Intervention in Localized Wegener’s Granulomatosis With Sensorineural Hearing Loss Preserves Hearing

Purpose

Wegener’s granulomatosis has been renamed granulomatosis with polyangiitis (GPA). In this article, the authors refer to WG as “WG/GPA” to indicate the old and new names of this condition. WG/GPA is a systemic necrotizing granulomatous vasculitis that can affect, in particular, the lungs, sinuses, and kidneys. The authors report 2 cases with antineutrophil cytoplasmic antibodies (c-ANCA) positive WG/GPA whose initial presentations were in the form of both conductive and sensorineural hearing loss without systemic features. The authors contrast the reversal of hearing loss and prevention of disease progression with early recognition and treatment.

Method

The authors present 2 contrasting cases of WG/GPA. Changes in hearing were measured through use of a GSI 61 audiometer as well as guidelines from the British Society of Audiology. Serum ANCA were detected by indirect immunofluorescence and formalin fixed neutrophils. Proteinase 3 (PR3) and myeloperoxidase antibodies were measured through use of a fluoroenzyme immunoassay.

Results

Persistent deafness and systemic disease are more likely, and more aggressive therapy was required when the diagnosis of WG/GPA was delayed.

Conclusion

WG/GPA should be considered in acute or subacute deafness presenting over days to weeks and even in the absence of systemic symptoms. A negative or weak ANCA with absent antibodies to serine PR3 and myeloperoxidase should not exclude the possible diagnosis of WG/GPA, and a high index of suspicion should be maintained.

[Otolaryngological manifestations of Wegener's disease]

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.

Otorhinolaryngological manifestations in granulomatosis with polyangiitis (Wegener's)

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.

Otologic symptoms as initial manifestation of wegener granulomatosis: diagnostic dilemma

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.

Wegener's granulomatosis mimicking skull base osteomyelitis

Objective:

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.

Vasculitis of the upper and lower airway

The pulmonary vasculitides are a heterogeneous group of rare disorders that result from an inflammatory process damaging the vessel wall and consequent impaired blood flow, ischaemia and tissue necrosis. The clinical manifestation of these vasculitides depends on the site, size, type and severity of the inflammatory process. Vasculitis involving the airways is a common feature of the anti-neutrophil cytoplasmic antibody (ANCA)-associated systemic vasculitides (AASVs) and can predate the diagnosis by years. Secondary causes of vasculitis associated with connective tissue disorders are also capable of presenting with pulmonary features. Recognition of involvement, investigation and treatment are important to ameliorate symptoms for patients. This article concentrates on the assessment and specific management of upper and lower airway problems of AASV.

Hearing Loss in Wegenerʼs Granulomatosis

OBJECTIVE

To describe the frequency, type, and clinical course of hearing loss in Wegener's granulomatosis and assess hearing loss as an indicator of disease activity.

STUDY DESIGN, SETTING, AND PATIENTS

Retrospective cohort review of all patients with Wegener's granulomatosis seen in 1 year at an academic medical center.

MAIN OUTCOME MEASURES

Hearing loss documented by pure-tone audiogram.

RESULTS

Thirty-six patients were included in the analysis: 20 men and 16 women, with a mean age of 55.5 years (range, 22-87 yr); 30 (83%) were antineutrophil cytoplasmic autoantibodies-positive, and the mean disease duration was 47 months (range, 2-196 mo). Twenty patients (56%) had documented hearing loss: there were 17 (47%) cases of sensorineural hearing loss and 12 (33%) cases of conductive hearing loss. Seven of 12 cases of conductive hearing loss improved with immunosuppressive treatment of Wegener's granulomatosis, 2 worsened, and 3 remained stable. Of 17 cases of sensorineural hearing loss, 3 improved, 4 worsened, and 10 remained stable. Seven patients had hearing loss requiring amplification. Five of 35 (14%) patients had established hearing loss months to years before diagnosis of Wegener's granulomatosis. Hearing loss occurred both on initial presentation and with disease relapse. The rates of conductive hearing loss (38%) and sensorineural hearing loss (31%) were also high in the subset of patients 65 years of age or younger and without history of noise exposure.

CONCLUSIONS

Both sensorineural hearing loss and conductive hearing loss are common in Wegener's granulomatosis, may result in significant morbidity, and may precede the diagnosis of Wegener's granulomatosis by years. Both types of hearing loss in patients with Wegener's granulomatosis may be used as an indicator of disease. These data suggest that it may be appropriate to obtain screening audiograms in all patients with newly diagnosed or relapsing Wegener's granulomatosis.

Autoimmune sensorineural hearing loss

Autoimmune sensorineural hearing loss has been increasingly recognized as a clinical entity since its description by McCabe in 1979. Recognition and proper management of this condition is important, as it is one of the very few forms of sensorineural hearing loss that can be successfully treated by medical therapy. Recent studies have provided experimental evidence to suggest that immune processes can cause sensorineural hearing loss in animals and humans. However, antigenic targets within the inner ear are diverse and as a result conclusive evidence for specific autoimmune damage to the inner ear has been elusive. This review focuses on the recent progress in understanding of the aetio-pathogenesis of autoimmune hearing loss along with a description of the various clinical conditions in which they occur. Recent advances in the laboratory diagnosis and management of this interesting condition are also described.

Head and neck manifestations of Wegener's granulomatosis

Wegener's granulomatosis is an idiopathic, granulomatous disease with the potential for multiple head and neck manifestations. The otolarygologist is an essential part of the multidisciplinary team involved in establishing the diagnosis and providing ongoing care for patients with Wegener's granulomatosis. Diagnostic difficulties abound in Wegener's granulomatosis, making repeat biopsies and the use of ANCA imperative. Medical therapy consisting of corticosteroids and immunosuppressive agents is the mainstay of treatment in Wegener's granulomatosis, whereas surgery is reserved for selected head and neck manifestations. With appropriate medical and surgical treatment, many patients living with Wegener's granulomatosis can enjoy a good quality of life.

Temporal bone pathology in Wegener's granulomatosis

This study aimed to demonstrate the temporal bone histopathology of two cases of Wegener's granulomatosis in which the initial symptoms were profound hearing loss and facial nerve palsy respectively. The first case, a woman of 44, suffered profound hearing loss which was remarkably improved by steroid and cyclophosphamide treatment for a time, and which seemed to be caused by invasion from granulation tissue filled in the tympanic cavity. The second case was a 61-year-old woman presenting with the facial nerve palsy. The bony canal of the horizontal portion of the facial nerve was destroyed due to granulation tissue which filled in the tympanic cavity, and granulomatous involvement was observed in the facial nerve. Wegener's granulomatosis can involve the middle ear and/or inner ear, causing hearing loss of conductive, mixed or sensorineural type. Pathogenesis of facial nerve palsy seems to be related to Wegener's granulomatous involvement of facial nerve, because the facial nerve palsy also resolved by using steroid and cyclophosphamide.

Wegener's granulomatosis presenting as mastoiditis

Wegener's granulomatosis is an uncommon autoimmune disease. It has a peak incidence in the fifth decade of life, with a slight male predominance. Nasal problems are the predominant presentation, with rare otological manifestations. We report 2 cases of Wegener's granulomatosis presenting as mastoiditis in 2 young female patients. We conclude that young patients presenting with mastoiditis unresponsive to conventional medical and surgical therapy should be investigated for Wegener's granulomatosis.

Otologic Wegener's granulomatosis with facial nerve palsy

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.

Cochlear implantation in a case of Wegener's granulomatosis

Cochlear implantation is now a routine clinical procedure for deaf patients in many countries (Gibson, 1987). It replaces the function of damaged cochlear hair cells and therefore, detects sound and by electrical stimulation produces an appropriate signal in the remaining cochlear nerve fibres (House and Berliner, 1991). Wegener's granulomatosis is an uncommon auto-immune disease. It has a peak incidence at the fifth decade with slight male predominance. Nasal problems are the predominant presentation with otological manifestations presenting rarely. We report a case of Wegener's granulomatosis presenting with total hearing loss and after right cochlear implantation a free field threshold of 40 dB and 20 per cent Bamford-Kowal-Bench (BKB) speech test. We conclude that Wegener's granulomatosis is not an absolute contraindication for cochlear implantation.

Early diagnosis of otologic Wegener's granulomatosis using the serologic marker C-ANCA

Wegener's granulomatosis is a systemic vasculitis that may involve any organ system. Otologic manifestations are common, and can be the presenting complaint. In the past, diagnosis often necessitated the development of characteristic pulmonary or renal disease. The identification of a new serologic marker, cytoplasmic pattern antineutrophil cytoplasmic autoantibody (C-ANCA), allows for the early diagnosis of Wegener's granulomatosis and gives the patient the best chance for remission with cytotoxic therapy. We report two patients with Wegener's granulomatosis who presented with refractory otitis media, one of whom subsequently developed facial nerve paralysis, in which an early diagnosis was facilitated by the use of the C-ANCA test. Otologic manifestations of Wegener's granulomatosis and the basis of the C-ANCA test are discussed.

Referred otalgia

Referred otalgia is a challenging symptom, with the burden on the physician to identify the source. Only by careful patient history and physical examination can all causes in this extensive differential diagnosis be excluded. In the absence of primary otologic pathology, referred pain from a head and neck carcinoma must be considered foremost and ruled out.

The hearing loss in Wegener's granulomatosis: relationship between hearing loss and serum ANCA

We observed the change of hearing for 1 year in a patient with Wegener's granulomatosis. We also studied anti-human neutrophil cytoplasm antibody (ANCA), which is believed to be specific for this disease and to be associated with disease activity. From these progresses, changes in hearing were considered to be generally related with the general condition and with the ANCA titer level. Because hearing loss in our case was improved by steroids and immunosuppressants, and because ANCA is the autoantibody observed in angiitis syndrome, hearing loss in this case of Wegener's granulomatosis was suspected of being caused by angiitis of the middle and inner ear induced by autoimmune reaction.

Clinical records: a case report of Wegener's granulomatosis limited to the ear

A 12-year-old girl had a 1-week history of left otalgia with hearing loss in May, 1989. Audiometry showed a conductive hearing loss of 60 dB. The conventional medical treatment for acute otitis media was initiated, but the symptoms and signs failed to respond this treatment. Four weeks after initial presentation, a diagnostic mastoidectomy was performed. The histological findings of the granulomatous tissue in the mastoid cavity showed nonspecific granulomatous inflammation, infiltrated with multinucleated giant cells. Initial laboratory studies revealed elevated ESR, positive CRP and RA, inverted A/G ratio, and increased Ig level. She had no other sites of involvement, such as the nose, paranasal sinus, pharynx, and larynx, and also no pulmonary or renal involvement was indicated. The diagnosis of a limited form of Wegener's granulomatosis was made on the above clinical and histological findings and laboratory examinations. The patient was then treated with cyclophosphamide, 80 mg/day (2 mg/kg) and prednisolone, 60 mg/day. After 1 week her symptoms and general condition were dramatically improved. Out-patient follow-up 1 year later showed her hearing level was improved to 28 dB, and she continues to do well without evidence of recurrence of the disease.