Upper respiratory tract manifestations in patients with ANCA-associated vasculitides and their association with the presence and type of ANCA

Aim of the work – to compare the frequency of upper respiratory tract (URT) involvement in patients with ANCAassociated vasculitides (AAV), to reveal its main clinical and radiological patterns and to estimate their association with the serological profile (ANCA presence and type).Material and methods. This retrospective study evaluated 369 patients with granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA) and eosinophilic granulomatosis with polyangiitis (EGPA). The enrolled patients were diagnosed with AAV according to the ACR criteria, CHCC classification (2012) and EMA algorithm. Patients with URT manifestations underwent standard ENT assessment and X-ray/CT. Serum ANCA levels were measured by ELISA.Results. URT involvement was diagnosed in 280 (75.9%) patients with AAV. It was significantly more common amongthe patients with GPA (86.4%) and EGPA (85.5%) compared with the MPA group (29.2%) (p<0.001).URT manifestations mainly appeared as sinusitis (77.2% – GPA; 33.3% – MPA; 70.8% – EGPA) and rhinitis with crusting (87.8%, 72.2% and 16.9% respectively).Proteinase 3 ANCA positive patients had a significantly higher incidence of bone destructive URT lesions, including sinuses wall destruction (p<0.001) and saddle nose deformity (p=0.016), compared with myeloperoxidase-ANCA-positive patients. Similar results were obtained in the GPA group separately.Localized disease with isolated URT involvement was observed in 41.3% cases of ANCA negative GPA (p<0.001).Conclusion. The frequency and patterns of upper respiratory tract manifestations depend both on the nosologic form of AAV and type of ANCA. Localized forms of URT involvement can be observed in patients with GPA and are closely associated with absence of ANCA, which determines the need for especially high suspicion level.

POS0249 THE EFFECT OF NASAL STAPHYLOCOCCUS AUREUS COLONIZATION ON DISEASE ACTIVITY AND THE EFFECT OF ANTIBIOTIC TREATMENT IN PATIENTS WITH ANCA ASSOCIATED VASCULITIS; A RETROSPECTIVE COHORT STUDY

Background:Antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) is a necrotizing vasculitis, predominantly affecting small or medium vessels with few or no immune deposits. Ear, nose and throat (ENT) involvement in AAV is frequently present. AAV has a relapsing-remitting disease course. A factor that has been associated with induction of relapses is nasal Staphylococcus aureus (S. aureus) colonization. This alleged association between nasal colonization and induction of relapses has resulted in the use of antibiotics. However, the effect of antibiotic treatment on disease activity remains controversial. Some studies showed a beneficial effect of antibiotic treatment whereas other studies found no effect of antibiotic treatment on disease activity.Objectives:The aim of this study was to identify the role of nasal S. aureus colonization and the effect of systemic or local antibiotic treatment on disease activity in patients with AAV.Methods:Clinical, laboratory and histological data from all AAV patients with ENT involvement, diagnosed in two medical centers between 1981 and 2020, were retrospectively collected. Nasal S. aureus colonization was defined as at least one positive nasal swab during follow-up. Data on systemic (cotrimoxazole and azithromycin) and local antibiotics (mupirocin) use was collected. Disease activity was divided into systemic and local disease activity. Systemic disease activity consisted of history of relapses, relapse number per patient years and Birmingham vasculitis activity score version 3 (BVAS3) at last visit. Local disease activity included history of ENT relapses, development of saddle nose deformity or subglottic stenosis during follow-up.Results:Two-hundred and thirteen patients were included in the analysis. Median follow-up time was 8 (IQR 3 -17) years. S. aureus colonization was tested in 100 (46.9%) cases of which 44 patients tested positive. Only one patient developed a subglottic stenosis, and 13 patients developed a saddle nose deformity during follow-up. Systemic and local disease activity at baseline and at last visit were comparable between patients with and without and S. aureus colonization. Regression analysis showed no difference in relapse number per patient year between AAV patients colonized with S. aureus versus non-colonized patients (RR 2.03; 95%CI, 0.97 – 4.26, p=0.06). This also accounted for local ENT relapses (OR 0.134; 95%CI 0.06-1.47, p=0.14) and saddle nose deformity (OR 0.61; 95%CI 0.04-10.68, p=0.74). Twenty-eight (13.1%) S. aureus positive patients received antibiotics aimed at eradication of S. aureus. Twenty-two (10.3%) received cotrimoxazole, 2 (0.9%) received azithromycin and 17 (8.0%) patients received mupirocin ointment. No significant difference was found between the treated versus non-treated group with regard to systemic and local disease activity.Conclusion:Nasal S. aureus colonization does not influence systemic or local disease activity. Antibiotic eradication treatment did not modify disease activity in this study.Table 1.Effect of AB treatment on disease activity of 40 AAV patients with ENT involvement and S. aureus colonizationDisease activityAntibiotic treatmentP-valueYes (n=28)No (n=12)Systemic symptomsHistory of one or more relapses, n (%)18 (47.4%)4 (10.5%)0.635Relapse number per patient years, median (IQR) *0.11 (0-0.18)0.17 (0.02 – 0.26)0.346BVAS3 last visit, median (IQR)1 (0-4)1 (0-4)0.932Local symptomsHistory of one or more ENT relapses, n(%) *9 (33.3%)3 (11.1%)0.438Development of saddle nose deformity during follow-up, n (%) *4 (12.1%)0 (0%)0.367Values are median (interquartile range IQR) or n (%). BVAS3: Birmingham Vasculitis Activity Score version 3; ANCA: Anti-Neutrophilic Cytoplasmic Autoantibody; AAV: ANCA associated vasculitis; ENT: ear, nose and throat. * More than 10% missings in analysis. For an overview of the number of included patients per analysis, see supplementary table B.Disclosure of Interests:None declared

An Unusual Case of Nasal Septal Hematoma Caused by Local Dental Anesthesia in a 15-Year-Old Girl

Introduction: Nasal septal hematoma (NSH) is a complication of nasal trauma, which its emergency treatment is drainage of hematoma. Delayed treatment may result in necrosis of the nasal cartilage and saddle nose deformity. Case Presentation: Here, we reported a 15-year-old girl presented with NSH associated with a dental local anesthetic injection, which led to nasal septum necrosis. Conclusions: Computerized tomography (CT) scanning was performed to determine the hematoma size and existence of other complications.

Method of surgical treatment of the saddle nose deformity

Saddle deformity of the external nose, which is a consequence of trauma, is usually combined with a nasal septal deviation and is quite widespread in the population. The problem of surgical treatment of this group of patients lies not only in the technical complexity, trauma of the proposed methods but also in the need to carry out significant interventions under general anesthesia, which limits the use of available techniques by a wide number of ENT surgeons, increases the duration of the operation, recovery time and temporary disability of the patient. The invention aims to improve surgical treatment of patients with saddle nasal deformity by providing stable cosmetic and functional results. Materials and methods: The proposed method of surgical treatment of saddle deformity of nasal dorsum includes several stages. Cartilage autograft taken from nasal septum during septoplasty is milled to 0,5–1,0 mm, mixed with 0,5 ml of latex tissue glue (LTG) having hemostatic and antiseptic properties due to aminocaproic acid and dioxidine content, respectively. This mixture is kept for 5 minutes and delivered to the pocket formed under the SMAS (superficial musculoaponeurotic system) layer in the soft tissues of the dorsum of the external nose, after which the final shape of the nose is simulated and fixed with a plaster splint for a week. Results: Based on the department of otolaryngology of Semashko Ryazan Regional Clinical Hospital, for the period from 2012 to 2019, 17 patients were treated with a diagnosis: saddle deformity of the external nose and nasal septum deviation. All patients underwent rhinoseptoplasty under local anesthesia using LTG as described above. No complications were observed in the postoperative period. During follow-up from 7 to 24 months, patients retain constant functional and cosmetic results. Conclusions. This method is a simple, low-traumatic one of surgical treatment of saddle deformity of the nasal dorsum, which allows reducing the operation time, performing it under local anesthesia and obtaining good cosmetic and functional results. The technical simplicity and accessibility of the method make it possible to use it in hospitals engaged in the surgical treatment of nasal diseases.

AN INTERESTING CASE OF LONG STANDING IMPACTED BUTTON BATTERY CAUSING SEPTAL PERFORATION AND DEFORMITY

Button batteries usage in electrical devices like toys, watches, calculators etc has significantly increased in recent times and due to their easy availability and small size, these batteries can be very easily inserted by small children in the nose. A nasal button battery is an otorhinolaryngological emergency as it can lead to severe damage, necrosis, and perforation of the nasal septum, intranasal synechiae , and nasal deformity [1]. Button batteries should ideally be removed in a controlled setting under general anesthesia if they cannot be removed in the outpatient department. We hereby report this case to advocate that button battery in the nasal cavity is a serious condition and can lead to grave complications like nasal synechiae, granulations , septal perforation further causing saddle nose deformity.