Head and neck manifestations of autoimmune disease

Hearing impairment in systemic sclerosis patients-what do we really know?

Background

Systemic sclerosis (SSc) is a disease of a very heterogeneous clinical picture and immunological profile with progression rate that varies between individuals. Although hearing deterioration is not a complaint that comes to the fore in SSc patients, as it is not life-threatening compared to many other more severe symptoms of this disease, it can significantly impair the quality of life. Medical literature concerning this problem is rather scarce.

Materials and methods

In this article we systematically reviewed the medical publications concerning hearing impairment in patients with systemic sclerosis to evaluate current understanding of this complex problem. Following PRISMA guidelines a total of 19 papers were found and analysed including 11 original studies and 8 case reports.

Results

Although it seems that hearing impairment in SSc patients is relatively more common than in the general population, based on the analysis of available literature, no firm conclusions regarding its frequency and pathomechanism can be drawn yet. Microangiopathy leading to damage to the sensory cells of the inner ear is suspected to be the main mechanism of hearing loss, although damage to the higher levels of the auditory pathway appears to be underestimated due to incomplete audiological diagnosis.

Conclusion

Undoubtedly, the reason for the difficulty in such an evaluation are the complex and still not fully elucidated pathomechanism of SSc, the individually variable dynamics of the disease and the unique heterogeneity of symptoms. Nevertheless, further studies in larger and appropriately selected groups of patients, focused more on the dynamics of microangiopathy and not solely on clinical symptoms could provide answers to many key questions in this regard.

A mechanosensitive peri-arteriolar niche for osteogenesis and lymphopoiesis

Leptin Receptor⁺ (LepR⁺) stromal cells in adult bone marrow are a critical source of growth factors, including Stem Cell Factor (SCF), for the maintenance of hematopoietic stem cells (HSCs) and early restricted progenitors^1–6. LepR⁺ cells are heterogeneous, including skeletal stem cells, osteogenic, and adipogenic progenitors^7–12, though few markers have been available to distinguish these subsets or to compare their functions. Here we show expression of an osteogenic growth factor, Osteolectin^13,14, distinguishes peri-arteriolar LepR⁺ cells poised to undergo osteogenesis from peri-sinusoidal LepR⁺ cells poised to undergo adipogenesis (but retaining osteogenic potential). Peri-arteriolar LepR⁺Osteolectin⁺ cells are rapidly dividing, short-lived, osteogenic progenitors that increase in number after fracture and are depleted during aging. Deletion of Scf from adult Osteolectin⁺ cells did not affect the maintenance of HSCs or most restricted progenitors but depleted common lymphoid progenitors (CLPs), impairing lymphopoiesis, bacterial clearance, and survival after acute bacterial infection. Peri-arteriolar Osteolectin⁺ cell maintenance required mechanical stimulation. Voluntary running increased, while hindlimb unloading decreased, the frequencies of peri-arteriolar Osteolectin⁺ cells and CLPs. Deletion of the mechanosensitive ion channel, Piezo1, from Osteolectin⁺ cells depleted Osteolectin⁺ cells and CLPs. A peri-arteriolar niche for osteogenesis and lymphopoiesis in bone marrow is maintained by mechanical stimulation and depleted during aging.

A peri-arteriolar niche in the bone marrow for osteogenesis and lymphopoiesis is maintained by mechanical stimulation and is depleted during aging.

Obesity and COVID-19: Oro-Naso-Sensory Perception

Through a recent upsurge of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic, the clinical assessment of most of the coronavirus disease 19 (COVID-19) patients clearly presents a health condition with the loss of oro-naso-sensory (ONS) perception, responsible for the detection of flavor and savor. These changes include anosmia and dysgeusia. In some cases, these clinical manifestations appear even before the general flu-like symptoms, e.g., sore throat, thoracic oppression and fever. There is no direct report available on the loss of these chemical senses in obese COVID-19 patients. Interestingly, obesity has been shown to be associated with low ONS cues. These alterations in obese subjects are due to obesity-induced altered expression of olfacto-taste receptors. Besides, obesity may further aggravate the SARS-CoV-2 infection, as this pathology is associated with a high degree of inflammation/immunosuppression and reduced protection against viral infections. Hence, obesity represents a great risk factor for SARS-CoV-2 infection, as it may hide the viral-associated altered ONS symptoms, thus leading to a high mortality rate in these subjects.

Taste bud homeostasis in health, disease, and aging

The mammalian taste bud is an onion-shaped epithelial structure with 50-100 tightly packed cells, including taste receptor cells, supporting cells, and basal cells. Taste receptor cells detect nutrients and toxins in the oral cavity and transmit the sensory information to gustatory nerve endings in the buds. Supporting cells may play a role in the clearance of excess neurotransmitters after their release from taste receptor cells. Basal cells are precursor cells that differentiate into mature taste cells. Similar to other epithelial cells, taste cells turn over continuously, with an average life span of about 8-12 days. To maintain structural homeostasis in taste buds, new cells are generated to replace dying cells. Several recent studies using genetic lineage tracing methods have identified populations of progenitor/stem cells for taste buds, although contributions of these progenitor/stem cell populations to taste bud homeostasis have yet to be fully determined. Some regulatory factors of taste cell differentiation and degeneration have been identified, but our understanding of these aspects of taste bud homoeostasis remains limited. Many patients with various diseases develop taste disorders, including taste loss and taste distortion. Decline in taste function also occurs during aging. Recent studies suggest that disruption or alteration of taste bud homeostasis may contribute to taste dysfunction associated with disease and aging.

Defects in the peripheral taste structure and function in the MRL/lpr mouse model of autoimmune disease

While our understanding of the molecular and cellular aspects of taste reception and signaling continues to improve, the aberrations in these processes that lead to taste dysfunction remain largely unexplored. Abnormalities in taste can develop in a variety of diseases, including infections and autoimmune disorders. In this study, we used a mouse model of autoimmune disease to investigate the underlying mechanisms of taste disorders. MRL/MpJ-Fas(lpr)/J (MRL/lpr) mice develop a systemic autoimmunity with phenotypic similarities to human systemic lupus erythematosus and Sjögren's syndrome. Our results show that the taste tissues of MRL/lpr mice exhibit characteristics of inflammation, including infiltration of T lymphocytes and elevated levels of some inflammatory cytokines. Histological studies reveal that the taste buds of MRL/lpr mice are smaller than those of wild-type congenic control (MRL/+/+) mice. 5-Bromo-2'-deoxyuridine (BrdU) pulse-chase experiments show that fewer BrdU-labeled cells enter the taste buds of MRL/lpr mice, suggesting an inhibition of taste cell renewal. Real-time RT-PCR analyses show that mRNA levels of several type II taste cell markers are lower in MRL/lpr mice. Immunohistochemical analyses confirm a significant reduction in the number of gustducin-positive taste receptor cells in the taste buds of MRL/lpr mice. Furthermore, MRL/lpr mice exhibit reduced gustatory nerve responses to the bitter compound quinine and the sweet compound saccharin and reduced behavioral responses to bitter, sweet, and umami taste substances compared with controls. In contrast, their responses to salty and sour compounds are comparable to those of control mice in both nerve recording and behavioral experiments. Together, our results suggest that type II taste receptor cells, which are essential for bitter, sweet, and umami taste reception and signaling, are selectively affected in MRL/lpr mice, a model for autoimmune disease with chronic inflammation.

Inflammation and taste disorders: mechanisms in taste buds

Taste disorders, including taste distortion and taste loss, negatively impact general health and quality of life. To understand the underlying molecular and cellular mechanisms, we set out to identify inflammation-related molecules in taste tissue and to assess their role in the development of taste dysfunctions. We found that 10 out of 12 mammalian Toll-like receptors (TLRs), type I and II interferon (IFN) receptors, and their downstream signaling components are present in taste tissue. Some TLRs appear to be selectively or more abundantly expressed in taste buds than in nongustatory lingual epithelium. Immunohistochemistry with antibodies against TLRs 1, 2, 3, 4, 6, and 7 confirmed the presence of these receptor proteins in taste bud cells, of which TLRs 2, 3, and 4 are expressed in the gustducin-expressing type II taste bud cells. Administration of TLR ligands, lipopolysaccharide, and double-stranded RNA polyinosinic:polycytidylic acid, which mimics bacterial or viral infection, activates the IFN signaling pathways, upregulates the expression of IFN-inducible genes, and downregulates the expression of c-fos in taste buds. Finally, systemic administration of IFNs augments apoptosis of taste bud cells in mice. Taken together, these data suggest that TLR and IFN pathways function collaboratively in recognizing pathogens and mediating inflammatory responses in taste tissue. This process, however, may interfere with normal taste transduction and taste bud cell turnover and contributes to the development of taste disorders.

Sjogren's syndrome masquerading as nasopharyngeal carcinoma

OBJECTIVE

The aim of the study was to describe a case of nasopharyngeal involvement by Sjogren's syndrome masquerading as nasopharyngeal carcinoma.

METHODS

A description of clinical and radiologic features of facial pain, nasopharyngeal bulge, middle ear effusion, restriction of palatal movement, and infiltrating nasopharyngeal mass on imaging was given. Histologic evaluation, response to treatment with steroids and hydrochloroquine, and long-term follow-up, however, subsequently indicated the mass to be secondary to Sjogren's syndrome.

CONCLUSION

A previously undescribed manifestation of Sjogren's syndrome is described.

[Bamboo nodes as the cause of dysphonias in autoimmune diseases]

BACKGROUND

In rare cases, dysphonia can be caused by vocal fold deposits called "bamboo nodes." They often feature a transverse yellowish appearance of the middle third of the vocal cord, resembling a bamboo node. Typical histologic signs are similar to rheumatoid nodules.

CASE REPORT

We report on a 43-year-old woman with known Sharp syndrome and dysphonia. Laryngoscopy showed transverse deposits on both vocal folds. The diagnosis of bamboo nodes was made and treatment initiated.

DISCUSSION/CONCLUSION

Laryngeal deposits should be suspected and a thorough laryngostroboscopic examination carried out whenever a patient with an autoimmune disease presents with a rough and unstable voice. Because the patients may have hoarseness as their primary symptom, it is important for otolaryngologists to be familiar with this disorder. Further autoimmune investigation should be established. A combination of local laryngeal therapy with steroids and subsequent surgery seems to be a useful treatment approach for bamboo nodes. To our knowledge this is the first description of a patient with Sharp syndrome and bamboo nodes.

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.

Vocal fold deposits in autoimmune disease--an unusual cause of hoarseness

The objective of this study was to evaluate the symptoms and clinical characteristics in patients with autoimmune vocal fold deposits. Fourteen patients underwent videolaryngostroboscopic examination and voice recording. Eleven of the 14 patients underwent rheumatological examination. In all cases, endoscopic examination showed transverse white-yellow band lesions in the middle of the membranous portion of the vocal folds. In most cases, the lesions were bilateral but not exactly opposing each other. The most common voice characteristics were instability and intermittent aphonia. Inflammatory disease was present in 10 patients; five of these had rheumatoid arthritis (RA). No immunological signs common for all patients could be found. The histological examination was consistent with rheumatoid nodules. Vocal fold deposits, occurring most often in patients with RA, is an uncommon cause of hoarseness. Because the patients may have hoarseness as their primary symptom, it is important for otolaryngologists to be familiar with this disorder.

Sjögren's disease

In summary, Sjögren's syndrome is a chronic autoimmune disorder characterized by lymphocytic infiltration of the exocrine glands, particularly the salivary and lacrimal glands. The sicca complex of xerophthalmia and xerostomia are the hallmark features of Sjögren's symptomatology. In addition to these hallmark symptoms of oral and ocular dryness, one third of patients with Sjögren's syndrome present with extraglandular manifestations. Many osf these extraglandular manifestations, as well as the sicca symptoms, have otolaryngologic relevance. Because patients with Sjögren's syndrome may present with vague or nonspecific head and neck complaints, ranging from oral dryness to hoarseness to hearing loss, an otolaryngologist's high index of suspicion for this disorder may prevent delay in diagnosis, allow appropriate diagnostic evaluation, and optimize therapeutic intervention.

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.

Pathophysiological mechanisms in immune inner ear disease

Immune inner ear disease is a somewhat controversial entity which describes cochleovestibular dysfunction that is related to immune-mediated mechanisms. The diagnosis of this disease is based on clinical presentation and response to various treatment protocols. Unfortunately, the presentation is variable and the treatment empirical, and this has caused much confusion in the diagnosis and management of the condition. To elucidate the variable nature of the disease, it is important to understand that more than one mechanism of immune injury may be involved. This paper attempts to classify clinical and experimental cases of immune inner ear disease with regard to the Gell and Coombs classification scheme of immune-mediated injury. By understanding the different pathophysiological mechanisms involved, the clinician should be better able to diagnose and manage this difficult problem in a directed fashion. The ramifications of the proposed classification system on the diagnosis, treatment and future research of immune inner ear disease are discussed.

Bilateral condylar resorption in dermatomyositis: a case report

Polymyositis is an inflammatory disease commonly affecting the striated muscle. When it is accompanied by characteristic skin lesions, the condition is called dermatomyositis. Bilateral condylar resorption has been reported with autoimmune conditions and chronic systemic steroids. We report the first documented case of bilateral condylar resorption in a patient with dermatomyositis. Possible etiologic factors and treatment outcomes are discussed.

Immunopathology of the inner ear: an update

We have reviewed the events of an inner-ear immune response. The perilymph contains antibody, presumably derived from the systemic circulation and CSF, which would allow for neutralization and help with opsonization and complement fixation. The endolymphatic sac contains immunocompetent cells capable of processing and presenting viral or bacterial antigen, potentiating the immune response, attacking the invaders directly or attacking infected cells, and developing immunoglobulin responses in situ. The early release of mediators such as IL-2 likely emanate from the endolymphatic sac and result in potentiation and regulation of the response and may assist in changes in the SMV, including expression of ICAM-1, which aid in the egress of immune cells from the systemic circulation. PMNs arrive first, followed by T cells and B cells, with secretion of specific antibody a relatively late event. Concomitant with the increase in cellular constituents is the formation of a dense extracellular matrix. The inner ear appears to have remarkable difficulty in clearing this matrix, ultimately resulting in ossification. The immune response is unfortunately deleterious to the inner ear, resulting in degeneration of the organ of Corti, stria vascularis, and spiral ganglion. Hearing loss is consistently seen following sterile and virally induced labyrinthitis. The inner ear also appears to be a target for autoimmune disease. While inner-ear damage has been described as part of non-organ-specific autoimmune disease, specific disease against the hearing apparatus is also likely. Experimental paradigms have allowed alterations of both the afferent and efferent limbs of this response; ultimately, with the hope that we can alter the course of the response and the subsequent damage in patients.

Fundamental Immune Mechanisms of the Brain and Inner Ear

Because of the blood-brain and blood-labyrinthine barriers, the brain and inner ear were once thought to be immunoprivileged sites. Although these barriers provide protection from inflammatory damage to the delicate structures of the organs, both sites have since been shown to be capable of active immune responses when appropriately stimulated. In the inner ear, perisacular tissue around the endolymphatic sac hosts resident lymphocytes and serves as a site of immunosurveillance. Lymphocytes also enter the inner ear from the circulation, and in the cochlea this occurs via the spiral modiolar vein. Immune responses can protect the labyrinth from infection, but they can also cause bystander injury. Moreover, the cochlea can itself become the target of immune responses that damage hearing. Such autoimmune sensorineural hearing loss can be site specific, with the primary manifestation of the disorder being hearing loss and dysequilibrium. Some of these cases can be diagnosed by antibody or lymphocyte responses to inner ear antigens. Alternately, systemic autoimmune disorders can result in inner ear dysfunction as part of a broader spectrum of disease. Both forms of immune-mediated inner ear dysfunction may respond to immunosuppressive therapies, including steroids, cytotoxic agents, and plasmapheresis.

Temporal arteritis presenting as a submandibular swelling

Temporal arteritis (giant cell arteritis) is a disease of protean manifestation. A case which presented as a submandibular swelling is reported.

Xerostomia: evaluation of a symptom with increasing significance

Xerostomia is the subjective sensation of oral dryness. Although it is most commonly associated with salivary gland dysfunction, it may also occur with normal gland activity. Xerostomia may be an early symptom of several morbid systemic conditions with important implications for the medical and dental management of patients. Oral dryness also has negative effects on an individual's emotional well-being and quality of life. The complaint of xerostomia necessitates a complete evaluation of a patient's general health, salivary gland function, and oral motor and sensory abilities. The salivary gland assessment includes symptom review, analysis of glandular secretions, scintiscanning, and minor labial gland biopsy. No single component is sufficient to adequately diagnose the presence, extent, or cause of salivary dysfunction. Treatment of a dry mouth, to date, is mainly palliative in nature, with the intent of preserving oral structures and functions. Better therapies are essential in the management of xerostomia, whatever the cause. The importance of xerostomia as a symptom is increasingly recognized in medicine and dentistry. The dentist is commonly the first health professional to hear this complaint and may be critical in directing a full and appropriate evaluation.