Background Granulomatosis with polyangiitis (GPA), is a small vessel vasculitis and associated with anti-neutrophil cytoplasmic antibodies. Usually the first site involved in GPA is paranasal sinuses and nose and over the 90% of the patients the upper respiratory tract is involved in the course of the disease 1. In addition in about 5% of GPA patients the disease is solely confined to the nose and paranasal sinuses2. Awareness of clinical manifestations of the disease in head and neck is mandatory to avoid prolonged delay in the diagnosis and severe disease consequences. Therefore nasal examination is critical is diagnosis and the clinician must be alerted by some nasal signs and accompanying symptoms
Objectives To determine the predictive value of history and nasal endoscopic examination findings to suspect GPA
Methods One hundred and fourteen adult subjects (18 GPA, 29 patients with rheumatologic disease other than GPA and 77 healthy volunteers) included in this study. Healthy volunteers recruited from consecutive patients admitted to otolaryngology department with no sinonasal complaints, active upper airway infection, history of sinonasal surgery, history of allergy. Each patient was examined with flexible nasal endoscope and nasal endoscopic images are recorded with a camera for documentation. These images were evaluated by a physician blinded to the patients diagnosis.
Results Univariate analysis with χ 2 test showed that the following history items significantly associated with GPA; rhinorhea (p=0,001), postnasal drip (p=0,007), epistaxis (p=0,001) and saddle nose (p=0,014). The binary logistic regression analysis demonstrates that epistaxis (p=0,026, OR: 5,2) and rhinorrhea (p=0,03, OR: 4,1) have a predictive role in selecting patients with GPA. On the other hand saddle nose, postnasal drip did not reveal such a predictive role. Univariate analysis demonstrates that the following examination items demonstrates statistically significant difference; nasal secretion (p=0,017), nasal septal perforation (p<0,001), nasal crusting (p<0,001), nasal adhesion (p<0,001), nasal granuloma (p=0,014), hemorhagic fragile nasal mucosa (p<0,001). A binary logistic regression analysis demonstrates that only hemorrhagic fragile nasal mucosa (p<0,001, odds ratio (OR)=83) has a statistically significant predictive role in selecting patients with GPA. However nasal septal perforation (p=0,9), nasal crusting (p=0,3), nasal adhesions (p=0,9), nasal granulom (p=0,78) and nasal secretion (p=0,6) did not reveal such statistically significant predictive role.
Conclusions Our results indicate that patient's with hemorrhagic fragile nasal mucosa and a history of rhinorhea and epistaxis should alert the physicians about the possibility of GPA. Although predictive role of nasal septal perforation and nasal adhesion are not shown to be statistically significant, they are encountered only in GPA patients, their presence should also alert the physician about the possibility of GPA.
Garske U.Haack A, Beltran O, et al. Intra- and inter-rater abilityof endonasal activity estimation in granulomatosis with polyangiitis (Wegener's). Clin Exp Rheumotol.2012;30:22-28.
Holle Ju,Gross WL, Holl-Ulrich K, et al. Prospective long term follow-up of patients with localized Wegener' granulomatosis: does it occur as persistent disease stage? Ann Rheum Dis 2010; 69:1934-43.
Disclosure of Interest None declared
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