Laryngeal involvement in pemphigus vulgaris: a proposed classification

Characteristic Laryngeal Findings in Patients with Pemphigus Vulgaris

OBJECTIVE

Pemphigus Vulgaris (PV) is a rare autoimmune disease that could cause laryngeal lesions; however, only a few studies have described the localization of the laryngeal lesions associated with this disease owing to its rarity. Therefore, this study aimed to determine the localization of laryngeal lesions in patients with PV.

METHODS

Fourteen patients with PV accompanied by laryngeal or pharyngeal lesions, who underwent flexible laryngeal endoscopy performed by laryngologists, were examined retrospectively.

RESULTS

The arytenoid area was the most frequently affected site in the larynx, followed by the epiglottis and aryepiglottic folds. Vocal folds and ventricular bands were the least affected.

CONCLUSION

Lesions in the arytenoid area were observed more frequently in this study than in previous studies. This result suggests that a more careful inspection of arytenoid lesions in patients with PV is required under laryngeal fiber observation. Moreover, we proposed a novel classification system for laryngeal findings in patients with PV and a systematic observation method. This novel classification and method would be useful not only for determining the lesions but also for careful inspection in this field.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:3719-3725, 2024.

Pemphigus Vulgaris and Bullous Pemphigoid of the Upper Aerodigestive Tract: A Review Article and Novel Approaches to Management

BACKGROUND

Autoimmune bullous diseases are rare conditions characterized by blistering of the skin and mucous membranes. The 2 commonest forms are pemphigus vulgaris and bullous pemphigoid. The oral cavity or oropharynx may be the initial site of presentation or often the only site involved.

SUMMARY

These conditions are often misdiagnosed or overlooked leading to poorer patient outcomes. Due to the chronic nature of these conditions and the systemic effects of treatment, there is a significant associated morbidity and mortality. As such, an understanding of the fundamentals of autoimmune bullous diseases is vital to those working in otolaryngology. The mainstay of management in both conditions is topical and systemic corticosteroids. There is also a role for immunomodulating and non-steroidal anti-inflammatory drugs as adjunct or alternative therapies. Surgical intervention may be required to protect the airway. Often multimodality treatment is required involving multidisciplinary input from otolaryngologists, oral surgeons, dermatologists, and rheumatologists. This review article will highlight the aetiology, pathology, clinical features, investigations, and management of both pemphigus vulgaris and bullous pemphigoid including recent advances in management.

Pemphigus

Pemphigus consists of a group of rare and severe autoimmune blistering diseases mediated by pathogenic autoantibodies mainly directed against two desmosomal adhesion proteins, desmoglein (Dsg)1 and Dsg3 (also known as DG1 and DG3), which are present in the skin and surface-close mucosae. The binding of autoantibodies to Dsg proteins induces a separation of neighbouring keratinocytes, in a process known as acantholysis. The two main pemphigus variants are pemphigus vulgaris, which often originates with painful oral erosions, and pemphigus foliaceus, which is characterised by exclusive skin lesions. Pemphigus is diagnosed on the basis of either IgG or complement component 3 deposits (or both) at the keratinocyte cell membrane, detected by direct immunofluorescence microscopy of a perilesional biopsy, with serum anti-Dsg1 or anti-Dsg3 antibodies (or both) detected by ELISA. Corticosteroids are the therapeutic mainstay, which have recently been complemented by the anti-CD20 antibody rituximab in moderate and severe disease. Rituximab induces complete remission off therapy in 90% of patients, despite rapid tapering of corticosteroids, thus allowing for a major corticosteroid-sparing effect and a halved number of adverse events related to corticosteroids.

Nasal, oral, and pharyngolaryngeal manifestations of pemphigus vulgaris: Endoscopic ororhinolaryngologic examination

Pemphigus vulgaris is an autoimmune blistering disorder that involves the skin and mucous membranes. Few reports have described nasal and oropharyngolaryngeal lesions in pemphigus vulgaris using an endoscopic ororhinolaryngologic examination. We retrospectively reviewed the clinical records of 11 patients with pemphigus vulgaris between 2001 and 2013 with respect to their symptoms, lesion sites, lesion features, and treatments received. All patients had undergone an endoscopic ororhinolaryngologic examination. Their mucosa-related symptoms were sore throat, oral pain, odynophagia, gingival bleeding, hoarseness, and epistaxis. The most frequent sites were the oral cavity (gingiva and buccal mucosa), larynx (epiglottis and vocal fold), oropharynx (soft palate), and nasal cavity (nasal septum). Lesions were typically characterized by erosion, erosion with a whitish exudate, and erythematous patches. Thus, our study findings reveal that pemphigus vulgaris involves both the nasal and oropharyngolaryngeal regions. Patients with pemphigus vulgaris should undergo an endoscopic ororhinolaryngologic examination to determine the range of their lesions.

Exploring beyond the oral mucosa in patients affected with autoimmune blistering diseases: the importance of endoscopic procedures

Autoimmune blistering diseases (AIBD) comprise several entities characterized by the presence of autoantibodies targeted against structural proteins either in desmosomes or in the dermoepidermal junction of polystratified squamous epithelium. Patients develop blisters, erosions in cutaneous surfaces or mucosas. Diagnosis is based on the characteristic mucocutaneous lesions, the typical findings on histological studies and direct immunofluorescence assays, and the presence of specific autoantibodies against the epidermal antigens. It may not be possible for dermatologists to appropriately explore the nose and throat (NT). Thus, a clinical exploration by endoscopic procedures of NT may be a useful tool during the conventional dermatological exam. The aims of this review are to draw attention to the most frequent NT manifestations in AIBD patients, and underline the utility of endoscopic procedures to achieve a more successful and rationale management of patients. Additionally, we will provide brief information related to the anatomical structures and type of epithelium in NT areas which may explain the extent and type of NT involvement in AIBD. Endoscopic exploration in AIBD patients is important for several reasons. Firstly, it will allow the real NT mucosal involvement in each patient to be determined, thus making a differential diagnosis during the endoscopic exam possible, based on the localization of mucosal lesions. Secondary mucosal morbidity can also be ruled out. Secondly, the clinical response to treatment may be established, especially in NT mucosa, as these are anatomical areas subjected to important local traumas, and physiological functions such as breathing, swallowing, speech production and phonation may be damaged. Therefore, a multidisciplinary management in AIBD is mandatory by both dermatologists and otorhinolaryngologists, adding the clinical exploration by endoscopic procedures of NT to the conventional dermatological exam in all AIBD patients, irrespective of whether they exhibit associated symptoms.