Very painful acute frontal sinusitis revealing granulomatosis with polyangiitis

IntroductionGranulomatosis with polyangiitis (GPA) is a necrotizing vasculitis of small and medium-sized vessels comprising inflammation of the vessel wall and perivascular and extravascular granulomas, frequently presenting in the form of chronic sinusitis.ObservationWe report the case of a 27-year-old man who presented with very painful acute frontal sinusitis that was managed medically and surgically. The symptoms rapidly recurred despite treatment and CT scan demonstrated diffuse thickening of the sinus mucosa. Anti-proteinase 3 ANCA were positive. Biopsy of a pulmonary nodule confirmed the diagnosis of GPA. The patient was treated with corticosteroids in combination with rituximab, resulting in improvement of the clinical, laboratory and CT signs.DiscussionIn the presence of persistent, acute, localized sinusitis despite appropriate treatment, associated systemic signs and/or the presence of other signs suggestive of GPA, the ENT surgeon must request a targeted work-up. In the absence of treatment, GPA can be fatal within a few months. However, with currently available treatment, remission is obtained in 80% of cases with a 75% 10-year survival rate.     

Manifestaciones otorrinolaringológicas en pacientes con enfermedad de Behçet

Introduction and objectives: Behçet disease (BD) is a systemic immune-mediated vasculitis of unknown origin characterised by recurrent orogenital ulceration, ocular inflammation and skin lesions.The aim of our study was to identify ear, nose and throat (ENT) manifestations associated with BD.Patients and methodsRetrospective review of the medical records of all patients diagnosed with BD who attended a tertiary public hospital in Cantabria (Spain) over a period of 22 years. Clinical manifestations, in particular those concerning ENT, were retrieved from medical records. A medical literature review of ENT manifestations was conducted.ResultsThirty-three patients (age range: 17-64 years) were included in the study. Most of them presented oral ulcers (97%). Eight patients (24%) presented oropharyngeal ulcers and 5 patients (15%) experienced audiovestibular symptoms (high frequency sensorineural hearing loss, vertigo and bilateral vestibular hypofunction). One patient had symptoms compatible with vestibular neuronitis as the presentation manifestation of Neuro-Behçet. In 4 patients (12%) the presence of odynophagia secondary to the presence of oropharyngeal lesions, initially interpreted as acute or recurrent tonsillitis, was the first manifestation of the disease, alone or associated with cutaneous or ocular lesions.ConclusionsIn addition to the characteristic oral ulcers present in most patients with BD, ulcers in the oropharynx, occasionally interpreted as acute pharyngitis, are also common in these patients. Audiovestibular manifestations frequently appear during the course of the disease and may be the first symptom of central nervous system involvement.     

Clinical features of sarcoidosis patients presenting with head and neck manifestations – a two-center retrospective study and proposal of a diagnostic algorithm for the otorhinolaryngologist

Abstract

Background and Aims: We aimed to investigate the clinical characteristics of patients presenting with sarcoidosis of the head and neck as the initial manifestation and to provide recommendations for the diagnostic work-up for the practicing otorhinolaryngologist.

Material and Methods: We performed a retrospective cohort study at two university medical centers in Germany. Patients with a histopathologically confirmed diagnosis of sarcoidosis treated in the otorhinolaryngology departments were analyzed.

Results: We identified 62 patients (2003–2016). In total, 85.4% (n?=?53) of patients received the initial diagnosis of sarcoidosis during their ENT treatment. Sarcoidosis was detected in the lymph nodes in 42.3% (n?=?30) of the patients; 57.7% had extra-lymphatic manifestations. Fifteen patients (24.2%) showed pulmonary involvement. 30.6% (n?=?19) were treated with oral glucocorticoids (GC) alone, three patients with GC and methotrexate, one patient initially received a combination of GC and azathioprine, one patient rejected the recommended treatment.

Conclusions: Sarcoidosis should be considered as a differential diagnosis in patients presenting with head and neck symptoms. The most frequent presenting symptoms were cervical lymphadenopathy and affection of the paranasal sinuses. Therefore, otorhinolaryngologists should be aware of sarcoidosis and help guide referral strategies as they may be the first physicians treating these patients.     

Structured clinical assessment of the ear, nose and throat in patients with granulomatosis with polyangiitis (Wegener’s)

The objective of this prospective cross-sectional study is to describe the clinical otorhinolaryngological manifestations of granulomatosis with polyangiitis (Wegener’s) (GPA) in a prospective cohort. All patients suffering from GPA seen in a tertiary centre between March 2007 and November 2008 had a detailed clinical assessment by an ENT surgeon of their ear, nose and head and neck complaints. An evaluation of whether there was disease activity and/or infection in each ENT area was made using the European Vasculitis Study Group guidelines. The number of patients assessed was 144. The proportion of female patients was 47 % (n = 69) and the median age was 57.7 years (IQ range 42.5–68.5). The prevalence of ENT involvement was 87 % (125/144). Hearing loss and abnormal tympanic membrane appearance were more common in patients with active disease and no infection (7/8 and 6/8, respectively, in active disease cf. 59/131 and 52/131, respectively, in remission). Nasal crusting was the most common nasal complaint recorded (52/144, 36 %) and bloody rhinorrhoea was the most common symptom in patients with disease activity. Rhinoscopy was highly sensitive in diagnosing disease activity (100 %). Subglottic stenosis was the most common head and neck manifestation (27/121, 22 %) and 74 % were symptomatic. In conclusion, the pattern and frequency of clinical ENT manifestations in GPA have been described in a large patient cohort. The use of tools readily available in the ENT clinic was essential to assess these patients accurately. This dataset will form the basis of an objective scoring system to measure disease activity in the ENT system.     

ENT manifestation in COVID-19 patients

Objectiveto detect, analyze and discuss the different ear nose throat (ENT) manifestations those were reported in COVID19 positive patients in the reviewed and published literatures.MethodsWe performed a search in the PubMed databases, Web of Science, LILACS, MEDLINE, SciELO, and Cochrane Library using the keywords; COVID-19, Novel coronavirus, corona, 2019-nCoV, SARS-CoV-2, ENT, ear, nose, throat, otorhinolaryngology, ORL, pharynx, ORL, smell, larynx, different ENT related symptoms. We reviewed published and peer reviewed studies that reported the ENT manifestations in COVID-19 laboratory-confirmed positive patients.Resultswithin the included 1773 COVID-19 laboratory-confirmed positive patients, the most common ENT manifestations of COVID-19 were sore throat (11.3%) and headache (10.7%). While the other reported ENT manifestations were pharyngeal erythema (5.3%), nasal congestion (4.1%), runny nose or rhinorrhea (2.1%), upper respiratory tract infection (URTI) (1.9%), and tonsil enlargement (1.3%).ConclusionENT manifestations for COVID-19 are not common as fever and cough. But, a universal questionnaire using well-defined COVID-19 manifestations is needed to make the COVID-19 data precisely defined, complete and homogenous.     

ENT manifestations of Wegeners granulomatosis

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.     

Updates in antineutrophil cytoplasmic antibody (ANCA)‐associated vasculitis for the ENT surgeon

ENT involvement is common in ANCA‐associated vasculitis (AAV), particularly in GPA and EGPA. Early recognition and treatment is important for good outcomes, yet evidence suggests that UK ENT surgeons may not consistently recognise the early features of AAV, despite a similar incidence to vestibular schwannoma. AAV is a rapidly advancing field, with significant developments in the understanding of its pathogenesis, classification and treatment over the past decade. Relevant vasculitis mimics are also discussed with a particular focus on the increasing prevalence of vasculitis mimics driven by an increase in recreational cocaine use, as well as the emergence and reclassification of several other vasculitis mimics in the head and neck. This article reviews key recent updates in the vasculitis literature, with a particular focus on those relevant to recognition and diagnosis of AAV for the ENT surgeon. Strengths and limitations of relevant diagnostic testing are discussed, and a method of evaluation of patients with features of AAV presenting to ENT services is outlined.     

Otolaryngologic manifestations of systemic vasculitis

Systemic vasculitis is a heterogeneous group of diseases of various aetiologies and manifestations. In general, the clinical results derive from ischemia caused by vascular inflammation, which depends on the organ affected. Such vasculitis cases are classified according to the classification of the Chapel Hill conference. They can present with relative frequency as ENT manifestations in both their debut and throughout their evolution. Consequently, the ENT specialist should include them in the differential diagnosis in patients with ENT manifestations that are difficult to control or of atypical presentation. Our objective was to review the most common ENT clinical signs and symptoms in each of these diseases.     

Otolaryngologic manifestations of small vessel vasculitis

Objective: The aim of the present study is to review the clinical manifestations associated with small vessel vasculitis (SVV) as they pertain to the head and neck region. Methods: A retrospective analysis was performed, including 34 individuals that filled the American College of Rheumatology criteria for the diagnosis of necrotizing vasculitis. Seven patients were classified as suffering from Wegener's granulomatosis (WG), 18 from microscopic polyangitis (MPA), and the remaining 19 were unclassified (unclassified small vessel vasculitis, USVV). Results: The percentage of ENT manifestations in the early clinical picture of WG patients was 86%, dropping to 44.5 and 22% for MPA and USVV patients, respectively. The overall percentage of ENT manifestations for SVV patients in their initial clinical profile was 47%. Conclusion: The results of our investigation highlight the importance of an ENT clinical examination as a guide for diagnosis of an important percentage of SVV patients.     

Ear nose throat-related symptoms with a focus on loss of smell and/or taste in COVID-19 patients

PurposeTo determine the frequency and severity of general and ear nose throat (ENT)- related symptoms, especially smell and/or loss of sense of taste (STL) in COVID-19 disease, as well as to investigate the recovery process of STL.Materials and methodsPatients with a positive COVID-19 diagnosis were given a questionnaire consisting of general questions (age, sex, date of symptoms, smoking history, concomitant diseases), questions about the most obvious symptom at presentation (one option only), the severity and frequency of symptoms (general and ENT), and STL (recovery time and degree of recovery).ResultsThe study population consisted of 172 patients, 18–65 years old (mean age, 37.8 ± 12.5 years; 51.2% female; 76.2% nonsmokers). Cough (n = 30, 17.4%) and loss of sense of smell (n = 18, 10.4%) were the most obvious general and ENT symptoms, respectively. Eighty-eight patients (51.2%) reported loss of sense of smell, and 81 patients (47.1%) reported loss of sense of taste. The mean recovery times for loss of sense of smell and loss of sense of taste were 8.02 ± 6.41 and 8.20 ± 7.07 days, respectively. The loss of sense of smell and loss of sense of taste were the unique symptoms in four (4.54%) and one (1.23%) patients, respectively.ConclusionSTL is a common symptom in COVID-19 and may be the first and/or only symptom of this disease. In patients presenting with STL complaints, surveillance for possible COVID-19 disease and screening tests will facilitate the struggle against the disease.     

Added value of Joint ENT-Rheumatology clinic in the management of ANCA-associated vasculitis: One year's experience

PurposeANCA-associated vasculitides (AAV) represent a group of diagnoses, including granulomatosis with polyangiitis (GPA), eosinophilic granulomatosis with polyangiitis (EGPA) and microscopic polyangiitis (MPA). Most commonly, they present initially with ENT-associated symptomatology, and therefore they often pose a diagnostic challenge. We aim to present our one-year experience in the joint management of AAV in a multi-disciplinary setting.MethodsWe performed a retrospective analysis based on the records of 39 patients who were seen in the joint clinic, during a period of one year.ResultsAfter clinical assessment, 13 patients had changes made to their ENT treatment, 2 had some changes in their immunosuppression, while 11 had changes in both ENT and Rheumatology treatment. Six patients did not require any alterations to their therapeutic scheme. On average three separate appointments were reduced to a single appointment in the joint clinic where definitive treatment decisions were made. This led to significant cost reductions.ConclusionsCost-effectiveness, patient satisfaction, rapid multi-disciplinary evaluation, avoidance of unnecessary immunosuppression, patient education and medical training are only a few of the many advantages of this proposed joint service.     

Otorhinolaryngo logical manifestations in patients with Down syndrome

ObjectiveThe objetive of our study was to assess the most frequent otorhinolaryngological manifestations in patients with Down syndrome, and to propose diagnostic and management guidelines to improve their quality of life.MethodsPatients with Down’s syndrome referred to the ENT Department of two spanish Hospitals during a 4-year period were retrospectively reviewed. Data of the following variables were collected: main symptoms, diagnosis, comorbidities, surgical procedures, and complications.ResultsThirty patients with Down’s syndrome were included in our study. The most frequent reasons for referral were hearing loss and newborns from the Hearing Impairment Screening Program. Otitis media with effusion, adenoid hypertrophy and obstructive sleep apnea were the most common diagnosis. Five patients underwent head and neck surgical procedures without complications.ConclusionsHearing loss secondary to chronic otitis media with effusion and upper airway obstruction are frequent pathologies in patients with Down syndrome.     

Absceso retrofaríngeo. Revisión clínica de veinticinco años

IntroductionRetropharyngeal abscess is a serious condition. Its rare occurrence, thus sharing symptoms with other processes, make it a diagnostic challenge for the clinician. Therefore, it is critical to make an early diagnosis to prevent delaying treatment and avoid complications.ObjectivesTo gain knowledge of the epidemiology, pathogenesis, clinical manifestations, the most commonly implicated microorganisms, the type of treatment used, morbidity and mortality of retropharyngeal abscesses at a tertiary institution over the last 25 years.MethodsA retrospective study was conducted by reviewing medical records of all patients diagnosed with retropharyngeal abscess in a single centre between 1 January 1990 and 31 February 2016. Thirty-three patients were included in our study. Data such as personal history, present illness, diagnoses and treatment procedures were collected from the medical records.ResultsThe incidence during the years of study was 0.2 cases/100 000 inhabitants/year. Personal medical histories most often associated were alcoholism, smoking, diabetes and obesity. The most common aetiology found was impaction of a foreign body (especially fishbone). The most common presenting symptoms were odynophagia and neck pain accompanied by fever. Preventive tracheotomy was performed in the initial management of the patient in 9 cases (27%). The most frequent complication was descending necrotizing mediastinitis. Surgical drainage of the abscess was required in 27 patients (82%), especially with external approaches (17 cases). Two patients had sequelae: paralysis of unilateral vocal cord and Horner's syndrome. No mortality was observed in the patients of the study.ConclusionRetropharyngeal abscesses must be considered medical-surgical emergencies as they are likely to produce serious complications. We must pay attention to the warning symptoms such as odynophagia and cervical pain, associated or otherwise with dyspnoea, stridor, trismus, and neck stiffness. Advances in diagnostic and therapeutic procedures together with advances in critical care have been a key factor in improving the prognosis and mortality of these patients.     

Head and neck giant cell arteritis: an autoimmune disease with many faces

Conclusion: A high rate of infrequent presentations of giant cell arteritis were seen in the ENT department and should be anticipated as a differential diagnosis in every older patient with odynophagia with high CRP values without cause in thorough ENT examination.

Objective: To describe the clinical manifestation of head and neck giant cell arteritis and to derive a diagnostic pathway covering atypical cases.

Method: Single-center, retrospective analysis of cases with GCA in the head and neck region (HN-GCA) (2002–2012) to describe the clinical presentation and to derive a diagnostic pathway covering manifestations presenting to an ENT department.

Results: Sixty-five patients were newly diagnosed with HN-GCA in the department of otolaryngology, ophthalmology and neurology. The most frequent symptoms were loss of vision (83%) and new onset headache (63%). Eight patients (12%) presented with infrequent manifestations, predominantly in the department of otorhinolaryngology. The most common atypical presentation (50%) was odynophagia in conjunction with high CRP values misleading to an infectious cause and delaying diagnosis. A diagnostic pathway for GCA was derived based on the ACR classification criteria and the clinical findings.     

Ear,nose and throat manifestations of Churg-Strauss syndrome

Conclusion. Ear, nose and throat (ENT) involvement is common in Churg-Strauss syndrome (CSS), usually manifesting as allergic rhinitis and chronic rhinosinusitis with or without polyps. Otolaryngologists may play a pivotal role in making an early diagnosis of this disease. Objectives. CSS is a systemic vasculitic disorder that affects small to medium-sized blood vessels. Although the cause of CSS remains unknown, tissue damage seems more likely to be mediated by activated eosinophils. Patients affected by CSS frequently have ENT manifestations, which are often present at the time of disease onset and may represent relevant clues for the diagnosis. Thus, our objective was to present the ENT manifestations at the onset, at the diagnosis and at some point during the course of the disease in a series of patients with CSS collected at a single center. Materials and methods. Twenty-eight patients with CSS, as defined according to the 1990 American College of Rheumatology classification criteria, were identified. Twenty-one (75%) of these patients had ENT involvement. We evaluated the clinical course, laboratory data, histologic findings, treatment and outcomes. Results. Of the 21 patients, 13 (61.9%) had ENT involvement at asthma onset and 8 (38%) at diagnosis or during follow-up. The most common ENT manifestations were allergic rhinitis in 9 (42.8%) patients and nasal polyposis in 16 (76.1%). Three (14.2%) patients developed chronic rhinosinusitis without polyps, three (14.2%) had nasal crusting, one (4.7%) serous otitis media, one (4.7%) purulent otitis media, two (9.5%) progressive sensorineural hearing loss, and one (4.7%) unilateral facial palsy. Corticosteroid therapy associated with immunosuppressive drugs usually yielded improvement or stabilization.     

Validez de un programa de diagnóstico rápido del cáncer de cabeza y cuello

Introduction and objectivesGiven the epidemiological knowledge of squamous cell carcinomas of the head and neck, the prognosis in survival according to the staging at diagnosis and the absence of screening programmes that have proven cost-effective, we undertook a rapid diagnosis programme. The objective of this study was to analyse whether a rapid diagnostic programme (RDP) to be used by General Practitioners (GP) would achieve a change in the proportion of diagnoses in early versus late stages in these tumours.MethodsA prospective observational study of patients diagnosed with a tumour of ENT location in our centre, was carried out for 24 consecutive months. A “suspicion algorithm” was designed and we established a rapid remission route for these patients. The data obtained (age, sex, toxic substance consumption, initial manifestations, tumour location and extension) were compared with the data of the patients in our ENT Service database diagnosed in the 4 years prior to the start of the study.Results199 patients were included, and 82 ENT tumours diagnosed. The GPs sent to the Hospital via the RDP a total of 136 patients and 35 (26.1%) had a tumour. However, most of the tumours diagnosed in this period by our ENT Department (47 patients, 57.3% of all tumours diagnosed), were not suspected by the GP and were not sent via the RDP.Of the patients, 27% were diagnosed in stages i and ii, and 73% in stages iii and iv, there were no significant differences with the control group. The most frequent initial signs and symptoms were dysphonia, cervical mass and dysphagia, the relationship between initial symptom and stage at the moment of diagnosis was analysed, and in neither case did we obtain any significant variation.ConclusionsThe implementation of a rapid diagnosis pathway for patients who, according to the algorithm created, had a suspected head and neck cancer, has not led to an increase in the diagnosis of these tumours in early stages or a decrease in diagnoses in advanced stages.     

Otolaryngologic manifestations in HIV disease - clinical aspects and treatment

HIV is a pandemic infection with cases notified in almost all countries. The reported prevalence of symptoms in the head and neck is about 80%; otolaryngologists may be the first physician to see such patients. Oral manifestations are the most common, followed by neck and sinus manifestations. Otolaryngologic symptoms may be important signs of antiretroviral therapy failure. Symptoms are present in acute infections and advanced cases.ObjectiveTo describe new approaches in the past five years for the treatment of the most frequent otolaryngologic manifestations in HIV patients.MethodsSystematic reviews and case series published in English and Portuguese from January 2002 to October 2007 including the most common otolaryngology manifestations were selected.ConclusionOtolaryngologic manifestations are common and ENT specialists must be prepared to identify such cases.     

Unusual otolaryngological manifestations of certain systemic bacterial and fungal infections in children

ObjectiveSystemic bacterial and fungal infections may sometimes present local manifestations within otolaryngological district whose early detection may be useful in establishing a correct diagnosis and more appropriate treatment. This paper reviews certain systemic bacterial and fungal diseases presenting ENT manifestations in the pediatric population from an otolaryngological perspective.MethodsA medline searching for specific issues was performed in order to achieve more information as possible with regards to ENT manifestation of systemic bacterial and fungal infections. Limits for pediatric age were used. Two separate sections for bacterial and fungal disease are included. The section on systemic bacterial infections considers cat-scratch disease, Lyme borreliosis, actinomycosis, Lemierre's syndrome and congenital syphilis, and the section on systemic fungal infections includes candidiasis, aspergillosis and histoplasmosis.ConclusionsPediatricians and ear, nose and throat (ENT) specialists, approaching head and neck disorders in children, should therefore consider them among the possible differential diagnoses. This means that physicians need to recognize the first head and neck manifestations of systemic infections promptly in order to be able to treat them efficaciously and avoid the dangerous systemic spreading of the infective process.