Wegener's granulomatosis of the subglottis and the upper portion of the trachea

Current Therapeutic Approaches to Subglottic Stenosis in Patients With GPA: A Systematic Review

BACKGROUND

The management of subglottic stenosis (SGS) in granulomatosis patients with polyangiitis (GPA) has no clear guidelines. This systematic review aimed to identify different surgical techniques and evaluate the outcomes of applied procedures.

METHODS

An electronic search was performed using 3 major databases, CINAHL, PubMed, and Clinical key, to include relevant studies published from the databases from inception through January 2017. All primary studies reporting treatment of SGS in cases with GPA were included. Articles were excluded if not relevant to the research topic or if they were duplicates, review articles, editorials, short comments, unpublished data, conference abstracts, case reports, animal studies, or non-English studies.

RESULTS

Thirteen papers were included in our systematic review with a total of 267 cases for the qualitative review Endoscopic approaches showed favorable outcomes with the need to use multiple procedures to achieve remission. The open transcervical approach showed excellent results mainly after failure of other endoscopic techniques. Tracheostomy was necessary for severe respiratory obstruction symptoms. Medical treatment was essential for stabilizing the active disease and therefore may enhance the success rate postoperatively.

CONCLUSION

Subglottic stenosis in patients with GPA requires a multidisciplinary approach to provide optimal management regarding disease activity, grade of stenosis, and severity of symptoms.

"Exercise induced asthma" is not always asthma

A 25 year old woman was referred to our center for further evaluation of an exercise-induced dyspnea. Moreover, the patient suffered from hoarseness and recurrent sinusitis and otitis. After initially finding nothing suspicious, a spiro-ergometry was performed. Interestingly, we saw a relevant limitation of the inspiratory flow-volume curve under maximal exercise load. Further evaluation (in particular the bronchoscopy and the resulting biopsies) led us to the final diagnosis of a granulomatosis with polyangiitis. After 4 weeks of an established therapy regime with prednisone and rituximab the prior detected subglottic stenosis and the inspiratory flow-volume curve limitation could no longer detected. We describe a rare differential diagnosis of an exercise-induced asthma and we underline the importance of a multimodal therapy concept. We highlight the critical nature of the flow-volume curve in spiro-ergometry under maximal exercise load. We recommend frequent follow-up control visits to monitor the subglottic stenosis.

The presentation and management of granulomatosis with polyangiitis (Wegener's Granulomatosis) in the pediatric airway

OBJECTIVE

Granulomatosis with polyangiitis (GPA) is a necrotizing inflammatory disease that can affect the airway. The purpose of this study was to present a case of pediatric laryngotracheal GPA and provide management recommendations based on a thorough review of the literature.

DATA SOURCES

Retrospective chart and literature review REVIEW METHODS: A pediatric patient with laryngotracheal and pulmonary manifestations of GPA who underwent chemotherapy and intralesional corticosteroid injection is described. An extensive literature review of pediatric GPA affecting the larynx/trachea was also performed.

RESULTS

A pediatric patient presented with acute respiratory distress. Flexible laryngoscopy revealed a laryngeal mass. Magnetic resonance imaging showed circumferential subglottic stenosis, and chest computed tomography demonstrated multiple pulmonary nodules. Laryngeal and tracheal biopsy revealed granulation tissue and primary vasculitis. Labs demonstrated positive cytoplasmic antineutrophil cytoplasmic antibody, consistent with GPA. Methylprednisone, rituximab, cyclophosphamide, and intralesional steroid injection resulted in remission after 12 weeks. Review of the literature revealed two pediatric cases series and 10 case reports of GPA affecting the larynx or trachea.

CONCLUSIONS

There is a higher prevalence of GPA of the airway in children when compared to adults. Biopsy of the airway lesion may not be necessary and has lower diagnostic yield compared to other GPA subsites. Medical management includes induction therapy followed by maintenance therapy once the disease is in remission. Most patients will require a surgical intervention to maintain the airway.

LEVEL OF EVIDENCE

NA Laryngoscope, 127:233-240, 2017.

Tracheobronchial Stenoses in Granulomatosis With Polyangiitis (Wegener's): A Report on 26 Cases

Tracheobronchial stenoses (TBSs) are potentially severe manifestations of granulomatosis with polyangiitis (Wegener's) (GPA) that usually respond poorly to corticosteroids and immunosuppressive agents. We describe 26 GPA patients with ≥1 tracheal (mainly subglottic, SGS) and/or bronchial stenosis(ses) (BS(s)).Sixteen patients had solitary SGS and 10 had ≥1 BS(s). The male/female sex ratio was 9:17, and the median age at GPA diagnosis was 32 years (3:13 and 28 years, respectively, for SGS patients). Antineutrophil cytoplasm antibodies were proteinase 3-positive in 65.5% of the patients (50% of those with SGS).Despite conventional GPA therapy, 62% patients experienced ≥1 stenosis relapse(s) (81% of SGS patients, for a total of 1-8 relapses per patient). None of the several systemic or endoscopic treatments prevented future relapses. Cyclophosphamide induction therapy was effective in 4/6 patients with BS(s) and in 1 patient with SGS among the 7 treated. After many relapses, rituximab achieved remission in 3/4 SGS patients. Endoscopic treatments (dilation, laser, corticosteroid injection, etc.) had only transient efficacy. Other GPA manifestations relapsed independently of TBSs. One SGS patient died of acute respiratory distress syndrome.Our findings confirmed that TBSs are severe GPA manifestations that evolve independently of other organ involvements and do not respond to conventional systemic regimens. As previously described, our population was younger and comprised more females than usual GPA patients, especially those with SGS.The small number of patients and the wide variety of local and systemic treatments prevent us from drawing definitive conclusions about the contribution of each procedure. However, cyclophosphamide seemed to effectively treat BSs, but not SGS, and rituximab may be of interest for SGS management.

Non-malignant central airway obstruction

The most common causes of non-malignant central airway obstruction are post-intubation and post-tracheostomytracheal stenosis, followed by the presence of foreign bodies, benign endobronchial tumours and tracheobronchomalacia. Other causes, such as infectious processes or systemic diseases, are less frequent. Despite the existence of numerous classification systems, a consensus has not been reached on the use of any one of them in particular. A better understanding of the pathophysiology of this entity has allowed us to improve diagnosis and treatment. For the correct diagnosis of nonspecific clinical symptoms, pulmonary function tests, radiological studies and, more importantly, bronchoscopy must be performed. Treatment must be multidisciplinary and tailored to each patient, and will require surgery or endoscopic intervention using thermoablative and mechanical techniques.

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.

Airway reconstruction in Wegener's granulomatosis-associated laryngotracheal stenosis

OBJECTIVES/HYPOTHESIS

Open airway reconstruction is considered definitive treatment of laryngotracheal stenosis (LTS). Although most cases of LTS are not autoimmune, there are few data reported in patients with Wegener's granulomatosis. In this study, we aimed to assess outcomes of airway reconstruction in LTS patients with Wegener's compared to nonautoimmune patients.

STUDY DESIGN

Retrospective chart review of LTS cases managed with open airway reconstruction at an academic medical center.

METHODS

Patients who underwent open airway reconstruction for LTS due to Wegener's or nonautoimmune causes were identified from 1995 to 2010. Clinical, demographic, and procedural data were recorded. Fisher exact test, Mann-Whitney U test, and McNemar's test were used to test for significance.

RESULTS

A total of 53 patients were identified; eight Wegener's, 45 nonautoimmune, with median follow-up time of 8.3 and 1.8 years, respectively. Before reconstruction, there was no statistical difference between Wegener's and nonautoimmune patients with previous dilations (88% vs. 68%, P = .41) and tracheostomy dependence (50% vs. 42%, P = .72). Following reconstruction, 75% Wegener's and 36% nonautoimmune patients required further dilations (P = .05), with a decannulation rate of 75% and 58% (P = 1.0), respectively.

CONCLUSIONS

Wegener's patients have an increased need for dilations after open airway reconstruction for LTS. However, these patients can be decannulated after surgery at a rate similar to patients with nonautoimmune LTS.

Intralesional corticosteroid injection and dilatation provides effective management of subglottic stenosis in Wegener's granulomatosis

OBJECTIVES/HYPOTHESIS

To describe our experience with the use of intralesional corticosteroid injection and dilatation (ILCD) in the management of subglottic stenosis (SGS).

STUDY DESIGN

Retrospective chart review.

METHODS

A retrospective chart review was performed of all patients with SGS requiring ILCD, from 2003 to 2008, at the Department of Otolaryngology-Head and Neck Surgery, Mount Sinai Hospital, Toronto, Canada.

RESULTS

Twelve patients with SGS underwent 36 ILCD operations with a mean of three procedures per patient. We identified eight patients with Wegener's granulomatosis (WG) and four patients without WG. The eight WG patients received an average of 3.37 procedures, whereas non-WG patients required an average of 2.25 procedures. This maintained airway patency and symptom control for an average of 11.9 and 8.1 months, respectively. Only one complication was identified, and no long-term sequelae were found. No patients required new tracheotomies and one patient with a previous tracheotomy was successfully decannulated.

CONCLUSIONS

Our data supports the use of ILCD as a safe and effective treatment of SGS in both WG and non-WG patients.

Surgical interventions and local therapy for Wegener's granulomatosis

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.

Wegener's granulomatosis in the chest: high-resolution CT findings

OBJECTIVE

Wegener's granulomatosis is an uncommon necrotizing vasculitis having variable presentations in the chest that are best depicted on high-resolution CT. Imaging findings may include nodules, which may cavitate; ground-glass opacity secondary to pulmonary hemorrhage; and airway stenoses and ulcerations. Active Wegener's granulomatosis can mimic pneumonia, septic emboli, and metastases.

CONCLUSION

This article will illustrate the high-resolution CT findings of Wegener's granulomatosis in the chest.

Wegener's granulomatosis presenting as acute systemic vasculitis following 20 years of limited tracheobronchial disease

OBJECTIVE

We report a patient with a 20-year history of apparently idiopathic airways stenoses, who presented with an antineutrophil cytoplasmic antibody (ANCA) associated, acute, systemic vasculitis with necrotising glomerulonephritis, subsequently diagnosed as Wegener's granulomatosis.

METHODS

We present a case report and a review of the world literature on airway stenosis in Wegener's granulomatosis.

RESULTS

To our knowledge, this is the first report of Wegener's granulomatosis manifesting as local airway disease for such a prolonged period, before transforming into a systemic vasculitis.

CONCLUSIONS

This case highlights the need for physicians to be alert to the possibility of Wegener's granulomatosis as a cause of apparently idiopathic airway stenosis, and to be aware that systemic disease may occur in very long-standing, limited Wegener's granulomatosis.

Uncommon causes of tracheobronchial stenosis and wall thickening: MDCT imaging

Some uncommon diseases may involve the central airways focally or diffusely. These include Wegener's granulomatosis, relapsing polychondritis, tracheobronchopathia osteochondroplastica, amyloidosis, papillomatosis, rhinoscleroma, sarcoidosis and tuberculosis. Related computed tomography (CT) findings essentially include calcifications, luminal stenosis, wall thickening and nodules. The purpose of this paper is to help refine the differential diagnosis among these diseases through the use of multidetector CT (MDCT) imaging.

Endoscopic laser surgery for subglottic stenosis in Wegener's granulomatosis

PURPOSE

Wegener's granulomatosis (WG) is a rare multisystem inflammatory disease, which infrequently involves the subglottic area and trachea. Treatment usually involves the use of immunosuppressive agents with corticosteroids. Some patients, however, continue to have symptoms of airway obstruction after clinical remission following the standard therapeutic regimen.

OBJECTIVE

To investigate laser treatment for subglottic stenosis in five patients suffering from WG.

MATERIALS AND METHODS

We endoscopically treated 5 patients with subglottic stenosis due to WG and airway obstruction by Nd:YAG and CO2 lasers. One of the patients had preoperative tracheostomy and after treatment was decannulated and could not breathe without dyspnea. Another patient required stenting of the subglottic area.

RESULTS

All five patients were able to breathe without dyspnea after the treatment. Three patients were treated with an Nd:YAG laser but needed repeated laser treatment every four to six months, whenever they complained of dyspnea. The other two patients were treated with a CO2 laser; one of these patients had preoperative tracheostomy and was treated twice by CO2 laser and decannulated, with no further difficulty in breathing. The follow-up period was 1-5 years.

CONCLUSIONS

Nd:YAG and CO2 lasers are recommended in the treatment of subglottic stenosis (SS) due to WG, particularly when the stenosis is in continuity or close proximity to the vocal cords.

Pharmacological therapy for Wegener's granulomatosis

Wegener's granulomatosis (WG) is the most common pulmonary granulomatous vasculitis and was a uniformly fatal disease prior to the identification of efficacious pharmacological regimens. The pathogenesis of WG remains elusive but proteinase 3-specific anti-neutrophil cytoplasmic antibodies may be involved. Histologically, WG is defined by the triad of small vessel necrotising vasculitis, 'geographic' necrosis and granulomatous inflammation. Organ involvement characteristically includes the upper and lower respiratory tracts and kidney, but virtually any organ can be involved. The severity of the disease varies, ranging from asymptomatic disease to fulminant, fatal vasculitis. Similarly, the degree of organ involvement is highly variable; WG may be limited to a single organ (typically the lungs or upper respiratory tract), or may be systemic. Currently, a regimen consisting of daily cyclophosphamide and corticosteroids, which induces complete remission in the majority of patients, is considered standard therapy. Since approximately 50% of patients experience a relapse following discontinuation of therapy, alternative regimens designed to maintain remissions after using cyclophosphamide and corticosteroids are usually necessary. This 'induction maintenance' approach to treatment has emerged as a central premise in planning therapy for patients with WG.A number of trials have evaluated the efficacy of less toxic immunosuppressants (e.g. methotrexate, azathioprine, mycophenolate mofetil) and antibacterials (i.e. cotrimoxazole [trimethoprim/sulfamethoxazole]) for treating patients with WG, resulting in the identification of effective alternative regimens to induce or maintain remissions in certain sub-populations of patients. Given the efficacy of methotrexate (for early systemic WG) and cotrimoxazole (in WG limited solely to the upper airways) to induce remissions, and the relatively decreased associated morbidity compared with cyclophosphamide, these alternative regimens are preferred in appropriate patients. Similarly, therapeutic options to maintain disease remission that are less toxic than cyclophosphamide should be offered following induction of remission unless a specific contraindication exists. By following this premise, the development of cyclophosphamide-induced morbidities (e.g. haemorrhagic cystitis, uroepithelial cancers and prolonged myelosuppression) may be minimised. Recent investigation has focussed on other immunomodulatory agents (tumour necrosis factor-alpha inhibitors [infliximab and etanercept] and anti-CD20 antibodies [rituximab]) for treating patients with WG. However, the current data are conflicting and difficult to interpret. As a result, these newer agents cannot be recommended for routine use until vigorous clinical study confirms their efficacy.

Transbronchial Needle Injection: A Systematic Review of a New Diagnostic and Therapeutic Paradigm

BACKGROUND AND OBJECTIVE

Transbronchial needle catheters are commonly used during flexible and rigid bronchoscopy for needle aspiration. The use of these catheters can be expanded by employing the technique of transbronchial needle injection.

METHODS AND RESULTS

By injecting lesions in the airways, peribronchial structures, mediastinum, or lung parenchyma, transbronchial needle injection has been applied to the treatment of lung cancer, inflammatory disorders of the airways, recurrent respiratory papillomatosis, as well as bronchopleural fistulas. Diagnostic applications have included the localization of peripheral lung nodules as well as sentinel lymph nodes.

CONCLUSIONS

Our review defines this bronchoscopic technique and summarizes its various reported applications.

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.

Subglottic stenosis associated with Wegener's granulomatosis

OBJECTIVE

To evaluate the outcomes of subglottic stenosis in patients with Wegener's granulomatosis.

STUDY DESIGN

Retrospective chart review.

METHODS

A retrospective chart review was undertaken to review all patients evaluated in an otolaryngology-head and neck surgery department between 1993 and 2001 for active symptoms attributed to subglottic stenosis who had undergone cytoplasmic staining antineutrophil cytoplasm antibody and perninuclear staining antineutrophil cytoplasm antibody testing and who had a clinical diagnosis of Wegener's granulomatosis.

RESULTS

Twenty-seven patients were identified with Wegener's granulomatosis and subglottic stenosis. Among these, 11 of 27 (40.7%) underwent tracheotomy; 13 of 27 (48.1%) required multiple surgical procedures. A history of open laryngotracheal repair was present in 7 of 27 patients (25.9%). CO(2) laser resection and dilation was used in 12 of 27 patients (44.4%). Three of 27 patients (11.1%) had a tracheotomy at last follow-up. Patients were followed for an average duration of 76.8 months (6.4 y) from the onset of symptoms attributed to subglottic stenosis. All patients who underwent open laryngotracheal reconstruction had successful decannulation.

CONCLUSIONS

Wegener's granulomatosis is a necrotizing vasculitis that can involve the subglottis. Our approach to airway management in these patients involves a tracheotomy if obstruction occurs during acute inflammatory activity. We recommend minimizing airway manipulation during episodes of systemic disease activity. Once control of the disease process is obtained, consideration is given to either an endoscopic or an open approach based on the extent of stenosis. Either laryngotracheal reconstruction or CO(2) laser resection and dilation may be undertaken with safety and should result in favorable outcomes.

Role of thoracic surgery and interventional bronchoscopy in Wegener's granulomatosis

BACKGROUND

Wegener's granulomatosis (WG) is defined as granulomatous vasculitis affecting small and medium-sized arteries and veins. Histologically, inflammatory changes with infiltration of the endothelium, fibrinoid necrosis, and formation of necrotizing granulomas are found. Pulmonary involvement is one of the cardinal features of WG and occurs in 85% of patients during the course of disease. Surgery is often required for both diagnosis and therapy.

METHODS

Fifteen consecutive patients are presented to illustrate the spectrum of surgical interventions in WG.

RESULTS

In 8 patients open lung biopsy, wedge resection, or segmental resection for hitherto undiagnosed infiltrate revealed WG. Eight patients presented with tracheal stenosis and all 8 underwent repetitive tracheoscopic dilation. Five patients presented with subglottic stenosis without any signs of pulmonary manifestation. All patients underwent tracheoscopic dilation, 3 in conjunction with glucocorticoid injection therapy. After multiple dilations, 1 patient still had destructing ulcerative tracheitis in which total stenting maintained airway patency. One patient received subglottic tracheal resection prior to multiple dilations; another patient, because of expiratory tracheal collapse, underwent stabilization of the membranous part of the trachea and the large bronchi with a polytetrafluoroethylene implant.

CONCLUSIONS

Surgical lung biopsy in numerous patients established the final diagnosis. Thoracic surgery including bronchologic measures such as bouginage and stenting, however, also has a place in the long-term management of WG.

Airway problems in patients with rheumatologic disorders

The intensivist should be aware of the upper airway manifestations of the common rheumatologic disorders which may lead to ICU admission or which may potentially pose a problem during airway management. Information should be obtained from the patient, the patient's family, and the patient's primary physician, if possible. One should be fully prepared with various options in case a problem arises with an airway. Equipment for managing a difficult airway should be available. Alternate methods of managing the airway (e.g., the laryngeal mask airway, fiberoptic scopes, and the WU Scope) (Achi Corporation, Fremont, CA) are of great help in dealing with airway problems. The potential for cervical spine instability exists in patients with rheumatologic disorders. Intubating with care and avoiding spinal movement both seem to be more important than any particular mode of intubation in preserving neurologic function. One should make a concentrated and serious effort to be as gentle as possible and to avoid even minimal trauma to the mucosa in these patients, because they are at risk for mucosal edema and subsequent postextubation stridor. In cases of stridor, helium-oxygen mixtures may be of help and may eliminate the need for reintubation. When difficulty in establishing an airway is anticipated, it is prudent to attempt airway control in the operating room with surgical assistance standing by should cervical tracheotomy is required.

CT virtual bronchoscopy of the central airways in patients with Wegener's granulomatosis

OBJECTIVES

To compare CT virtual bronchoscopy (VB) to CT alone and to conventional bronchoscopy for evaluation of central airway stenoses in patients with Wegener's granulomatosis.

DESIGN

Prospective observer study, in which 18 thin-section helical CT scans of the trachea and bronchi of 11 patients with Wegener's granulomatosis were obtained. VB was performed using surface rendering and was evaluated by one bronchoscopist and one radiologist in a blinded fashion. Bronchoscopic correlation within an average of 1.8 days of CT was available.

MEASUREMENTS AND RESULTS

VB displayed 188 of 198 bronchi (95%). Thirty-two of 40 stenoses (80%) were detected by VB by at least one of two physicians (double reading), and 22 of 40 stenoses (55%) were detected by a third physician reading only the CT.

CONCLUSIONS

VB depicts bronchi to the segmental level and detects the majority of central airway stenoses in patients with Wegener's granulomatosis. A team approach is useful to attain optimal clinical benefit from VB for these patients.

Management of the ear, nose, and throat manifestations of Wegener granulomatosis: an otorhinolaryngologist's perspective

A diagnosis of Wegener granulomatosis requires granulomatous manifestations in the respiratory tract. With the increasing use of antineutrophil cytoplasmic autoantibodies as a diagnostic tool, Wegener granulomatosis is diagnosed earlier than in the past, and not infrequently when only ear, nose and throat manifestations are present, placing the otorhinolaryngologist in a central role in diagnosis and management. Diagnostic biopsies should be obtained from active lesions in the nose and paranasal sinuses and concomitant infection should be identified. Because of the apparent relation between infection and activation of disease, the management of infections-especially those due to Staphylococcus aureus-requires special attention. The increasing numbers of early cases identified warrants further investigations of whether less toxic treatment regimens will be of advantage in such cases. Medical and surgical treatment of the acute and chronic manifestations presents specific problems because of altered immune competence, prevalent superinfection, and tissue destruction, and is therefore best taken care of by specially dedicated otorhinolaryngologists.

Tracheal involvement in Wegener's granulomatosis: evaluation using spiral CT

OBJECTIVE

To describe the computed tomography (CT) appearances of tracheal stenosis in Wegener's granulomatosis (WG) and to assess the additional value of reformatted images.

PATIENTS AND METHODS

Ten patients with tracheal involvement by WG were assessed with spiral CT and both coronal and three-dimensional surface shaded images were generated. Fibreoptic bronchoscopy was also performed in all patients.

RESULTS

Ninety per cent of lesions were situated in the subglottic region. In all cases there was circumferential mucosal thickening, in nine cases extending over a relatively short distance (mean 2.4 cm). The degree of narrowing of the axial luminal diameter ranged from 23% to 100%. In three patients there was contiguous involvement of the vocal cords evident on CT, two further cases with mild vocal cord inflammation were identified bronchoscopically. Other CT findings included mucosal irregularity and ulceration (50%), and involvement of the tracheal cartilages (20%).

CONCLUSION

Wegener's granulomatosis may involve the trachea with resultant stenosis. Spiral CT is an easily performed, non-invasive technique which provides accurate assessment of tracheal lesions and is complementary to bronchoscopy. The main additional advantage of coronal reformatted images was our added confidence in defining the upper and lower limits of lesions and in the evaluation of vocal cord involvement.

Wegener's granulomatosis of the head and neck

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.

Upper airway obstruction in the rheumatic diseases

Upper airway obstruction is a potentially life-threatening event that can be managed effectively when promptly recognized and treated. For this reason, all patients who are suspected of having disease affecting the larynx or trachea should be regarded as having a potentially compromised airway until proven otherwise. Although clinically significant upper airway diseases occur infrequently in rheumatic disorders, these manifestations should be considered in such patients who present with upper airway symptomatology.

Clinical features and therapeutic management of subglottic stenosis in patients with Wegener's granulomatosis

OBJECTIVE

To determine the clinical features and optimal treatment of subglottic stenosis (SGS) in patients with-Wegener's granulomatosis (WG).

METHODS

Review of 43 patients with SGS and treatment of 20 patients with intratracheal dilation-glucocorticoid injection therapy.

RESULTS

SGS developed in 43 of 189 patients with WG who were followed up at the National Institutes of Health Clinical Center. The diagnosis of SGS occurred in the absence of other features of active. WG in 21 of 43 patients (49%). In 21 patients (49%), SGS began while the patient was receiving systemic immunosuppressive therapy for disease activity involving other sites. Tracheostomy was required in 10 of 18 patients (56%) who were treated with systemic immunosuppressive therapy. In 20 patients treated with intratracheal therapy, none required tracheostomy and 6 with previous tracheostomies were decannulated.

CONCLUSION

SGS often occurs independently of other features of active WG and is frequently unresponsive to systemic immunosuppressive therapy. Intratracheal dilation-injection therapy provides a safe and effective treatment for WG-associated SGS and, in the absence of major organ disease activity, should be used without concomitant systemic immunosuppressive agents.

Subglottic stenosis complicating Wegener's granulomatosis: surgical repair as a viable treatment option

Wegener's granulomatosis frequently involves the subglottis and trachea, often leading to compromise of the upper airway. Moreover, the stenotic segments may persist or progress despite control of the disease elsewhere in the body. In this report, we describe the cases of five patients with Wegener's granulomatosis who, in addition to nasal, sinus, pulmonary and renal involvement, had symptomatic subglottic or tracheal stenosis. Biopsy specimens from involved sites in the subglottis and trachea were often not diagnostic, and the diagnosis was later confirmed by a positive antineutrophil cytoplasm antibody titer. All patients had clinical remission on standard therapeutic regimens with prednisone and cyclophosphamide but continued to have symptoms of extrathoracic airway obstruction. Three of the five patients underwent primary thyrotracheal anastomosis while their disease was in clinical remission, without postoperative compromise of anastomotic integrity or wound healing despite concurrent use of prednisone and cyclophosphamide. There has been no evidence of local disease recurrence during follow-up periods ranging from 3 months to 14 years. We conclude that surgical intervention is a viable treatment option for patients who have symptomatic stenotic segments of the subglottis and trachea as a result of Wegener's granulomatosis in clinical remission.

Wegener's granulomatosis, subglottic stenosis and antineutrophil cytoplasm antibodies

Wegener's granulomatosis is difficult to diagnose, especially when the presentation is unusual, restricted to an isolated region. We report four cases of recurrent subglottic stenosis posing difficulty in diagnosis. In each case the finding of anti-neutrophil cytoplasm antibodies (ANCA) strongly suggested an underlying vasculitic pathology, Wegener's granulomatosis. We discuss reasons for the difficulty in diagnosis in the past, the possible role of the ANCA assay in such patients, and suggest it should be more widely used in the future.

Wegener's granulomatosis: isolated involvement of the trachea and larynx

A 26 year old man with subacute hoarseness and stridor was shown to have Wegener's granulomatosis isolated to the trachea and larynx. Although isolated laryngeal Wegener's is unusual, a review of the literature suggests that early treatment with cyclophosphamide is warranted.

Chronic laryngeal stenosis

The results of treatment of 82 patients with chronic laryngeal stenosis during a 20-year period are presented. Road traffic accidents accounted for 30% of the cases and iatrogenic disease for 40%. Of the stenoses 10% were supraglottic, 20% glottic, 50% subglottic, and 15% combined. Virtually all patients with supraglottic stenosis had a good result as regards voice and airway, and we describe the use of a laryngeal widening operation for this group of patients. Over 80% of patients with glottic stenosis achieved good results. However, patients with a subglottic stenosis did badly, and only 60% were relieved of their tracheostomies. Patients with stenosis due to previous tracheostomy or to systemic disease such as Wegener's granuloma did badly.