19th INTERNATIONAL SYMPOSIUM ON RECENT ADVANCES IN OTITIS MEDIA

Slides:



Advertisements
Similar presentations
BDS, LDSRCS, MSc, FFDRCSI Specialist Oral Surgeon
Advertisements

MAGNETIC RESONANCE IMAGING OF CYSTIC KNEE LESIONS M. GONGI, W
DIFFUSE ALVEOLAR HEMORRHAGE SYNDROM Katarina Osolnik University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia Portorož, May 8th 2009.
Evaluation and management of Bell’s palsy Chunfu Dai Otolaryngology Department Fudan University.
The Persistent Disconnect Between Practice and Guidelines in the Management of Children with Otitis Media Salomeh Keyhani MD MPH Lawrence C. Kleinman MD.
A 2 year old boy with Acute Otitis Media – Case Presentation
Objectives Upon completion of the lecture, students should be able to:  Define middle ear infection  Know the classification of otitis media (OM). 
Babak Saedi Imam Khomeini Hospital
King Abdulaziz University Hospital
WEGENER’S GRANULOMATOSIS
Utility of Post-Therapy Surveillance Scans in Diffuse Large B-Cell Lymphoma Thompson C et al. Proc ASCO 2013;Abstract 8504.
Thyroid and Parathyroid diseases Surgical Approach Dr Mohammad AlShehri, Can. Board, FACS, D Med Edu. Professor of Surgery.
Deafness Dr. Abdulrahman Alsanosi Associate professor King Saud University Otolaryngology consultant Otologist, Neurotologist &Skull Base Surgeon Head.
The Variations and Deviations in the Use of Tympanostomy Tubes for Children with Otitis Media Salomeh Keyhani MD MPH Lawrence C. Kleinman MD MPH Michael.
What is Otolaryngology  A medical and surgical subspecialty  Expert care of disorders of the Ear, Nose, Throat, Head and Neck  Attention to form and.
Discussion Otitis media is an infection of the middle section of the ear, as compared to external otitis (also known as swimmer's ear), which is an infection.
Dr.Khabti Muhanna Mr.Khalid Alaqeel Department of Otolaryngology,
Vasculitis Vasculitis arises when immune system mistakenly attacks blood vessels. What causes this attack isn't fully known, but it can result from infection.
ICD-10 Getting There….. Otolaryngology. What Physicians Need To Know Claims for ambulatory and physician services provided on or after 10/1/2015 must.
Diagnostic Approach to Vasculitis
Definitions of Otitis Media
A 40 year old female is complaining of attacks of lacrimation and watery nasal discharge accompanied by sneezing. She had a severe attack one spring morning.
NYU Medicine Grand Rounds Clinical Vignette James Kim, M.D., PGY-2 February 26, 2014 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.
MIDDLE EAR INFECTIONS.
Neurosyphilis is often considered a disease of the past. With early detection and the availability of treatment with Penicillin G, there should be no reason.
Primary hyperparathyroidism Surgical Approach Dr Mohammad AlShehri, Can. Board, FACS, D Med Edu. Professor of Surgery.
Cochlear implantation in patients with chronic otitis media: 7 years’ experience in Maastricht POSTELMANS, J. Et. Al.. Eur Arch Otorhinolaryngol (2009)
Differential Diagnoses
Otitis Media. OM Case 1 5 y/o Female Incomplete cleft of secondary palate Pain in left ear Tubes 4 years ago No Medications Cleft has been repaired in.
Hearing Testing Characteristics of a Hearing Loss Hearing Testing Middle Ear Measurement.
Bakhshaee M, MD Mordad 1389 Patient of The Month.
Department of Otorhinolaryngology. Ossama Mahmoud Professor of Otorhinolaryngology Ain Shams University ILO’s of ENT Course.
Primary hyperparathyroidism Surgical Approach Dr Mohammad AlShehri, Can. Board, FACS, D Med Edu. Professor of Surgery.
Glaucoma “ The Sneak Thief of Sight." Julie DeMore Professor Don Williams NS215G.
An Inflammatory condition involving the paranasal sinuses and linings of the nasal passages that lasts 12 week or longer This diagnosis requires objective.
Hearing Loss In The Child With Downs Syndrome. Frequency a year are born with Downs syndrome 75-89% of children with Downs have associated hearing.
Computer Architecture and Networks Lab. 컴퓨터 구조 및 네트워크 연구실 Auditory Brainstem Response : Differential Diagnosis(3/3) 윤준철.
Slide 6 Twenty years old male patient with recurrent ear discharge for 5 years. 1- what is the diagnosis? 2- what is the surgical treatment?
Microscopic Polyangiitis and Pauci-immune Glomerulonephritis
Usher syndrome By Andy Beer.
1st case Dr Nedi Zannettou hadjichristofi Physician rheumatologist
Site(s) of Involvement Serum IgG4 Level (mg/dL) Treatment with Steroid
Dept. of ENT-HNS Kathmandu Medical College and Teaching Hospital
SEVERITY OF PNEUMOCOCCAL VS
16 Otolaryngology.
HEARING LOSS CME TOPICS TYPES OF HEARING LOSS CAUSES OF HEARING LOSS
STudying Acute exaceRbations and Response: The COPD STARR 2 study
NECK MASSES.
Fig 2. Arrow indicating obliteration of the oval window
MICROBIOLOGY OF MIDDLE EAR INFECTION (OTITIS MEDIA)
Microbiology of Middle Ear Infections
Foremost and Leading Ear Nose & Throat Doctor BaysideEar Nose & Throat Doctor Bayside
Neuropathology Case Study
Cholesteatoma.
Otitis Media.
Hemotympanum.
Tympanosclerosis.
Tympanic Membrane Perforation
Retraction Pocket.
TSA016 Rare Autoimmune Cholangitis which Mimics an Extrahepatic Cholangiocarcinoma Guo-Zhi Wang, Ting-Yen Huang, Yu-Ying Wu, Yu-Bing Lim, Chia-Chun Hung,
Chronic otitis media.
Nat. Rev. Rheumatol. doi: /nrrheum
Skull base osteomyelitis: A rare entity
Jugular bulb abnormalities
Fig. 2. Otologic manifestations and facial expressions of case 1
Antineutrophil cytoplasmic antibody-associated vasculitis: Experience from Taichung Veterans General Hospital 施凱翔 梁凱莉 顏廷廷.
Recurrent Sudden Sensorineural Hearing loss: Review of 30 Cases with the Clinical manifestations and Outcomes Pei-Hsuan Wu, Cheng-Ping Shih Department.
MICROBIOLOGY OF MIDDLE EAR INFECTION (OTITIS MEDIA)
DIFFUSE ALVEOLAR HEMORRHAGE SYNDROM
Frequency of PR3-ANCA and MPO-ANCA positivity in ANCA-positive patients with a particular organ system involvement in an inception cohort of 502 ANCA vasculitis.
Presentation transcript:

19th INTERNATIONAL SYMPOSIUM ON RECENT ADVANCES IN OTITIS MEDIA Characteristic findings of the tympanic membrane in otitis media with ANCA-associated vasculitis (OMAAV) patients in relation to relapse Yuka Morita, Kuniyuki Takahashi, Shuji Izumi, Yamato Kubota, Shinsuke Ohshima, Arata Horii Department of Otolaryngology Head and Neck Surgery Niigata University Graduate School of Medical and Dental Sciences June 4-8, 2017 Gold Coast, Australia

ANCA-associated vasculitis (AAV) GPA :Granulomatosis with polyangitiis Otologic symptoms MPA :Microscopic polyangiitis EGPA AAV consists of 3 groups: microscopic polyangiitis (MPA), granulomatosis with polyangiitis (GPA; formerly Wegener’s granulomatosis), and eosinophilic granulomatosis polyangiitis (EGPA; formerly Churg-Strauss syndrome). Recently, the occurrence of otologic symptoms such as otitis media and hearing loss frequently have been reported in patients with AAV. :Eosinophilic granulomatousis with polyangiitis

ANCA-associated vasculitis (AAV) GPA :Granulomatosis with polyangitiis MPA Otitis media with AAV :OMAAV :Microscopic polyangiitis EGPA AAV consists of 3 groups: microscopic polyangiitis (MPA), granulomatosis with polyangiitis (GPA; formerly Wegener’s granulomatosis), and eosinophilic granulomatosis polyangiitis (EGPA; formerly Churg-Strauss syndrome). Recently, the occurrence of otologic symptoms such as otitis media and hearing loss frequently have been reported in patients with AAV. :Eosinophilic granulomatousis with polyangiitis

ANCA-associated vasculitis (AAV) GPA :Granulomatosis with polyangitiis MPA Otitis media with AAV :OMAAV :Microscopic polyangiitis EGPA AAV consists of 3 groups: microscopic polyangiitis (MPA), granulomatosis with polyangiitis (GPA; formerly Wegener’s granulomatosis), and eosinophilic granulomatosis polyangiitis (EGPA; formerly Churg-Strauss syndrome). Recently, the occurrence of otologic symptoms such as otitis media and hearing loss frequently have been reported in patients with AAV. :Eosinophilic granulomatousis with polyangiitis

Diagnostic criteria of OMAAV Japan otological society A clinical diagnosis of OMAAV was done, if the following three criteria (A, B, C) were fulfilled. A) Experience of suffering from intractable otitis media with effusion or granulation, which was resistant to antibiotics and insertion of tympanic ventilation tube, accompanied by progressive hearing loss over less than 2 months. B) At least one of the following four findings: 1)positivity for serum MPO- or PR3-ANCA 2)histopathology consistent with AAV 3)diagnosis of AAV (GPA, MPA, EGPA) by the presence of other involvements prior    to occurrence of ear symptoms 4)at least one sign/symptoms of AAV-related involvements other than ear (eye, nose, pharynx/ larynx, lung, kidney, facial palsy, hypertrophic pachymeningitis, and the others). C) Exclusion of the other intractable otitis media such as bacterial otitis media, cholesterol granuloma, cholesteatoma, malignant osteomyelitis, tuberculosis, neoplasms and eosinophilic otitis media, as well as exclusion of the other auto-immune and vasculitis diseases other than AAV such as Cogan‘s disease and PN, etc. There are no tympanic membrane findings in this criteria. This slide shows Diagnostic criteria of OMAAV that we propose. Using the criteria, we can diagnose AAV without lung or renal dysfunction. Harabuchi et al. Modern Rheumatol 2016

69 M MPO-ANCA (+) / lung dysfunction before treatment posterior wall swelling vascular dilatation of pars tensa thickening of pars tensa

69 M MPO-ANCA (+) / lung dysfunction before treatment 2 weeks 6 weeks 10weeks Tympanic membrane findings may reflect the disease activity of OMAAV. posterior wall swelling vascular dilatation of pars tensa thickening of pars tensa

Objectives What are the characteristic findings of tympanic membrane(TM) in OMAAV ? Are TM findings useful for early detection of relapse? We would like to explore the possibility to detect the relapse by changes of TM findings in OMAAV. Our question is What is the clinical feature in the OMAAV patients with facial nerve palsy and/or hypertrophic pachymeningitis? Furthermore, What is the clinical feature in the OMAAV patients with relapse? Because AAV including OMAAV is easy to relapse. By investigating of them, we would like to explore the clues of early diagnosis and early detection of relapse.

unilateral / bilateral Material & Methods Among 33 OMAAV patients who were treated in our hospital, 17 patients whose TM findings could be retrieved by photographs were enrolled into the study. age 41~81 (median 70) male/ female 5 / 12 affected side unilateral / bilateral 3 / 14 (Total 31 ears) Otoscopic findings were retrospectively examined.

The points of tympanic membrane findings ① vascular dilatation of pars tensa ② thickening of pars tensa ③ posterior wall swelling ③ ② ①

posterior wall swelling Results TM findings of 31 OMAAV ears (%) vascular dilatation of pars tensa thickening of pars tensa posterior wall swelling These findings are not usually seen in the patients with OME.

Case Presentation

Case 1: 68 F Chief complaint: Bil. hearing loss History of present illness: The patient initially visited the hospital with complaint of bilateral hearing loss for two months. She was diagnosed as having OME. Hearing loss gradually progressed along with worsening of bone conduction hearing thresholds.

Case 1: 68 F Fluid collection was seen in both tympanic cavity. vascular dilatation Fluid collection was seen in both tympanic cavity. Vascular dilatation of pars tensa appeared in the left ear. CRP 1.4 mg/dl MPO-ANCA 62.2 U/ml She was diagnosed as OMAAV and 40mg of prednisolone (PSL) started.

Case 1: 68 F At the first visit vascular dilatation CRP 1.4 mg/dl MPO-ANCA 62.2 U/ml 8 months after treatment(PSL10mg, AZP25mg) CRP 0.62 mg/dl  MPO-ANCA 1.9 U/ml

Case 1: 68 F right hearing loss worsening of TM findings At 18 months after the initial treatment, vascular dilatation and thickening of pars tensa appeared in the right ear. right hearing loss worsening of TM findings no other organ failure Relapse of OMAAV CRP 0.97 mg/dl  MPO-ANCA 3.2 U/ml PSL was increased to 30 mg

Progress of hearing loss Case 1: 68 F Relapse (18 months after the initial treatment) 1 month later Progress of hearing loss No other organ failure PSL30mg PSL increased to 45mg + IVCY 4 courses CRP 0.97 mg/dl  MPO-ANCA 3.2 U/ml CRP 0.81 mg/dl  MPO-ANCA 1.1 U/ml

Case 1: 68 F Relapse (18 months after the initial treatment) 1 month later 5 month later CRP 0.97 mg/dl  MPO-ANCA 3.2 U/ml CRP 0.81 mg/dl  MPO-ANCA 1.1 U/ml CRP 0.50 mg/dl MPO-ANCA <1.0 U/ml

Summary of Case 1 ✔ Otologic symptoms were the only manifestation of OMAAV throughout the clinical course. ✔ Changes in TM findings were associated with hearing impairment and increase in ANCA titer.

Case 2: 68 F Chief complaint: Rt. hearing loss History of present illness: The patient was treated for right sudden hearing loss with vertigo, which showed no improvement. One year later, she was referred to our hospital for intractable otitis media and posterior wall swelling of the same side.

Case 2: 68 F severe posterior wall swelling intractable otitis media profound hearing loss serum ANCA: negative no other organ failure CRP 0.60 mg/dl MPO, PR3-ANCA <1.0 U/ml Follow up

thickening of pars tensa and vascular dilatation Case 2: 68 F At the first visit 6 month later thickening of pars tensa and vascular dilatation CRP 0.64 mg/dl

Case 2: 68 F At the first visit 6 month later 7 month later worsening of TM findings CRP 0.64 mg/dl CRP 0.57 mg/dl MPO-ANCA 2.8 U/ml

Case 2: 68 F At the first visit 6 month later 7 month later MRI CE-T1 (coronal) hypertrophic pachymeningitis CRP 0.64 mg/dl CRP 0.57 mg/dl MPO-ANCA 2.8 U/ml At last, she could be diagnosed as OMAAV. CRP 0.64 mg/dl MPO-ANCA 4.2 U/ml

Case 2: 68 F At the first visit 6 months 7 months 35 months PSL10mg,AZP50mg CRP 0.04 mg/dl   MPO-ANCA <1.0 U/ml

Summary of Case 2 ✔ Worsening of TM findings were preceded by ANCA changes. ✔ Hypertrophic pachymeningitis and positive ANCA were noticed as the final events.

The indicator of disease activity Discussions The indicator of disease activity In OMAAV without other organ failure・・・・ serum ANCA titer / CRP very slight rise of ANCA titer difficult to judge the disease activity associated organ disorder or worsening Ear disorder can be diagnosed only by otolaryngologist. TM findings are sensitive to the disease condition of OMAAV. These two cases showed hearing loss and the rise of ANCA titer along with the worsening of the TM findings.

> > For early detection of relapse of OMAAV TM findings hearing loss serum ANCA titer/CRP > > The changes in TM findings may reflect disease activity. We should be careful to focus not only hearing examination but also TM findings.

Conclusions Vascular dilatation, thickening of pars tensa and posterior wall swelling are the characteristic otoscopic findings in OMAAV.  TM findings may be more useful for early detection of relapse than laboratory data.