Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 31-1986. A 39-year-old woman with stenosis of the subglottic area and pulmonary artery

Tarsal-conjunctival disease associated with Wegener's granulomatosis

OBJECTIVE

To describe the clinical characteristics of tarsal-conjunctival disease in a cohort of patients with Wegener's granulomatosis (WG).

DESIGN

Retrospective, case-controlled study.

PARTICIPANTS

The medical records of 82 consecutive WG patients who underwent an eye examination between January 1996 and June 2002 at the National Institutes of Health were reviewed.

METHODS

Details of the ophthalmic examination, results of medical therapy, and histopathologic analysis results were recorded. Tarsal-conjunctival disease was defined by (1). conjunctival hyperemia and granuloma formation, areas of necrosis, or active fibrovascular changes in the tarsus or conjunctiva, or (2). evidence of inactive fibrovascular scar. The association of tarsal-conjunctival disease with major organ system involvement was assessed using Bayesian methods.

MAIN OUTCOME MEASURES

The occurrence and clinical characteristics of tarsal-conjunctival disease in a cohort of patients with WG and associations with major organ system involvement.

RESULTS

Tarsal-conjunctival disease occurred in 13 of 82 patients (16%) with WG examined over a 6.5-year period. The palpebral surface of the upper lid was involved most commonly, showing conjunctival hyperemia in seven patients, granulomatous lesions in three patients, tarsal-conjunctival necrosis in four patients, active fibrovascular proliferation in six patients, and inactive fibrous scar tissue in seven patients. Histopathologic analysis of eyelid biopsy specimens showed granulomatous inflammation, focal necrosis, and areas of occlusive vasculitis in the tarsus and conjunctiva. In reviewing the patterns of organ involvement in patients with and without tarsal-conjunctival disease, the association of subglottic stenosis and nasolacrimal duct obstruction with tarsal-conjunctival disease showed a high probability of clinical significance.

CONCLUSIONS

Tarsal-conjunctival disease, a previously uncommon finding in patients with WG, was characterized by inflammation of the palpebral conjunctiva and tarsus followed by a fibrovascular proliferation and scar formation. Because of the important association of tarsal-conjunctival disease with subglottic stenosis, which can progress and lead to laryngeal obstruction and respiratory failure, patients with tarsal-conjunctival disease should be referred to an otolaryngologist for evaluation.

Wegener's granulomatosis, acute laryngotracheal airway obstruction and death in a 17-year-old female: case report and review of the literature

OBJECTIVE

To alert practitioners to the risk of sudden airway obstruction and death in patients with Wegener's granulomatosis.

DESIGN

Case report and literature review.

SETTINGS

University and Community hospitals.

PATIENT

A 17-year-old white female.

INTERVENTION

(1) evaluation and treatment for mental status changes over 2 months. (2) Evaluation and surgical biopsy of nasal septal perforation under general anesthesia at a university children's hospital. (3) Evaluation and observation at a community hospital 2 days later. (4) autopsy.

RESULTS

Serology performed 3 days ante-mortem revealed (at 2 days post-mortem) cytoplasmic anti-neutrophil cytoplasmic antibody positive at 1:128. Autopsy was significant for microscopic fibrosis and granulomas in the kidneys and essentially total obstruction of the subglottis and upper trachea by a 3.5 x 1 x 1 cm mass of fibrosis and granulomas overlying circumferentially necrotic mucosa. This mass was centered on the crico-tracheal junction.

CONCLUSIONS

Wegener's granulomatosis can lead to proliferative tissue growth with acute airway obstruction in the larynx and trachea, and death. Any patient with WG under age 20, as well as patients with WG and laryngotracheal symptoms (e.g. strider, hoarseness, wheezing) would benefit from evaluation of the airway.

Sarcoidosis of the larynx: preserving and restoring airway and professional voice

Professional voice users may present with disastrous dysponia and life-threatening upper airway disturbances due to a rare condition. Two teachers demonstrated extrathoracic obstructive laryngeal lesions by videolaryngoscopy and pulmonary function flow-volume loops. A characteristic "honking" voice and edematous, pink, diffuse turban-like enlargement of the supraglottic structures are considered pathognomonic of laryngeal sarcoidosis. Diagnosis was confirmed by biopsies, and clinical and radiologic findings. Sarcoidosis is a variable, disseminated disease involving many body organs, self-limited or progressive, with frequent exacerbations and remissions, affecting the larynx in 0.5-1.4% of patients. Spinal cord involvement demonstrated by new magnetic resonance imaging techniques can be heralded by voice changes detected in professional voice users. Systemic corticosteroid therapy combined with intralesional steroid injections and microendoscopic surgery, with or without tracheostomy, preserved and restored both professional voice and airway.

Wegener's granulomatosis: isolated involvement of the trachea and larynx

A 26 year old man with subacute hoarseness and stridor was shown to have Wegener's granulomatosis isolated to the trachea and larynx. Although isolated laryngeal Wegener's is unusual, a review of the literature suggests that early treatment with cyclophosphamide is warranted.