Otolaryngologic Manifestations of Systemic Vasculitis | Acta Otorrinolaringológica Española

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Systemic vasculitis comprises a heterogeneous group of diseases with varied aetiologies and clinical manifestations which often overlap&#44; making their differentiation very complicated&#46; The common feature to all cases is inflammation of the lining of blood vessels&#44; causing occlusion of the lumen and&#44; consequently&#44; tissue necrosis and ischemic phenomena&#46; This&#44; in turn&#44; results in a deterioration of the function of the affected organ&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Numerous pathogenic mechanisms have been described&#44; including immunocomplex-mediated vascular damage&#44; production of antineutrophil cytoplasmic antibody &#40;ANCA&#41;&#44; anti-endothelial cell antibodies&#44; cellular immunity&#44; etc&#46; Often&#44; these mechanisms coexist&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Clinical manifestations may be varied&#44; depending on the size&#44; number and type of affected vessels and the organs involved&#46; Most patients present obvious constitutional symptoms&#44; such as weakness&#44; fever&#44; and weight loss&#44; which are associated with others such as limb pain in cases of peripheral neuropathy&#44; arthralgia or arthritis in cases of musculoskeletal involvement&#44; abdominal pain or even visceral perforation in cases of gastrointestinal involvement or different types of elementary lesions in cases of skin involvement&#46; Patients often present otolaryngological &#40;ENT&#41; clinical manifestations which&#44; occasionally&#44; are the initial symptoms&#46; Therefore&#44; it is important for ENT specialists to become familiar with these diseases&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In this review we have carried out a description of the ENT symptoms of the most common types of vasculitis&#44; thus complementing a previous review in this publication of audiovestibular manifestations in cases of systemic vasculitis&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Classification of Vasculitis</span><p id="par0025" class="elsevierStylePara elsevierViewall">There are numerous possible classifications of vasculitis&#46; For example&#44; from the standpoint of their aetiology they are classified into primary or secondary&#44; depending on whether they appear in isolation or as part of another condition &#40;systemic lupus erythematosus&#44; rheumatoid arthritis&#44; infections&#44; drugs&#44; etc&#46;&#41;&#46; However&#44; from the practical standpoint&#44; the most widely used classification is the so-called Chapel Hill classification&#44; published in 1992&#44; which is based on the size of the affected vessels &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; This gives rise to characteristic clinical manifestations&#44; not only from the general point of view&#44; but also from standpoint of ENT &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Moreover&#44; in 1990&#44; the American College of Rheumatology &#40;ACR&#41; developed a set of classification criteria for systemic vasculitis&#46; These were intended to standardise clinical definitions for epidemiological and therapeutic use&#44; rather than for diagnosis&#44; but they are sometimes used for this purpose&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Presentation Forms According to the Type of Vasculitis</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Large Vessel Vasculitis</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Giant Cell Arteritis &#40;Temporal Arteritis&#41;</span><p id="par0035" class="elsevierStylePara elsevierViewall">This type of vasculitis is common in our environment&#44; with an annual incidence around 12&#47;100000 population&#44; mainly in subjects aged over 50 years and predominantly in females&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> It mainly affects the branches of the extracranial carotid artery&#44; and 2 out of 3 patients suffer headache at the beginning of the disease&#46; In general it is a headache of recent onset which&#44; if the patient has a previous history of headache&#44; is reported as having different characteristics from the usual&#46; It is generally located in the temporal region&#44; but may also appear in the frontal and occipital regions&#44; so a differential diagnosis with ENT pathologies should be conducted&#46; Half of patients suffer jaw claudication&#44; characterised by rapid onset from the start of mastication&#46; Sometimes&#44; patients downplay this symptom&#44; so it must searched for explicitly&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Jaw claudication was the most specific symptom of giant cell arteritis &#40;GCA&#41; in a study which correlated positive biopsies with clinical symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Of a total of 134 patients who underwent biopsy&#44; jaw claudication was present in 54&#37; of those who tested positive&#44; compared with only 3&#37; of those whose biopsies were negative&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Approximately 10&#37; of patients with GCA present symptoms related to the upper respiratory tract&#46; In particular&#44; non-productive cough is a common symptom which can lead to diagnostic confusion&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> It is believed to be an effect of vasculitis on cough receptors&#44; which are found throughout the respiratory tree&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Other symptoms are lingual pain or lingual infarction &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a> odynophagia&#44;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a> sensorineural hearing loss&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> vestibular dysfunction&#44; benign peripheral positional vertigo &#40;BPPV&#41; of ischemic origin&#44; smell alterations and even pain&#44; swelling&#44; redness and necrosis of the face or scalp &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#44; oral mucosa and&#47;or nose&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">It was observed that&#44; out of 44 patients with GCA who were monitored for 2 years&#44; 20&#37; developed BPPV&#44; with the majority associating nystagmus&#44; compared with 2&#46;3&#37; out of the healthy population&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Loss of vision due to optic nerve ischemia is among the most important complications&#46; About 50&#37; of patients present polymyalgia rheumatica&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">According to the ACR classification&#44; its diagnosis requires at least 3 of the following 5 criteria&#58; age over 50 years&#44; characteristic headache&#44; temporal artery alterations&#44; elevated ESR and compatible biopsy of the temporal artery&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Takayasu Arteritis</span><p id="par0070" class="elsevierStylePara elsevierViewall">Takayasu arteritis &#40;TA&#41; is a rare vasculitis in our environment&#44; with only 1&#8211;3 cases per million population each year&#46; It mainly affects women younger than 40 years&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> and usually damages the aorta and its major branches&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">There have been reports in the literature of patients with ENT manifestations&#46; These appear especially with symptoms of sinusitis&#44; such as persistent localised headache and purulent rhinorrhea&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a> In most cases&#44; findings are incidental and are revealed after an imaging study&#44; whose result shows the sinusal involvement&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The has been one report of confirmed TA in which the presence of vasculitis was correlated with the nasal deformity known as &#8220;saddle nose&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The finding of differences in blood pressure in both arms&#44; decreased brachial artery pulse or a pathological arteriography &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41; are useful for its diagnosis&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Medium Vessel Vasculitis</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Polyarteritis Nodosa</span><p id="par0090" class="elsevierStylePara elsevierViewall">The prevalence of this type of vasculitis is currently declining &#40;its incidence in Spain is 1 case per million population&#41;&#46; It is occasionally associated to infection by hepatitis B virus &#40;HBV&#41; and&#44; more rarely&#44; by hepatitis C virus &#40;HCV&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> The otological condition of polyarteritis nodosa &#40;PAN&#41; is relatively common&#44; since it appears in up to 30&#37; of cases&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">PAN may affect the middle ear&#59; the main symptom is hearing loss&#44; which may be conductive or sensory&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Facial paralysis may be associated with loss of hearing&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#8211;18</span></a> Based on the foregoing&#44; PAN should be included in the differential diagnosis of patients with otic disease which is difficult to control&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The main diagnostic test is to obtain histological material which confirms vasculitis or&#44; in its absence and in an appropriate clinical setting&#44; a pathological arteriography &#40;aneurysms&#44; usually of small size&#41;&#46; The presence of subcutaneous nodules or livedo reticularis in the limbs&#44; especially the lower ones &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#44; may guide the diagnosis&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Kawasaki Disease</span><p id="par0105" class="elsevierStylePara elsevierViewall">This type of vasculitis has a very low prevalence and mainly affects children&#46; Classically&#44; the disease is characterised by the appearance of erythema and fissures in the lips and oral mucosa&#44; leading to a characteristic image of &#8220;strawberry tongue&#8221;&#44; caused by the detachment of the filiform papillae&#46; The appearance of oral lesions such as vesicles or ulcers and tonsillar exudate is also common&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Between 50&#37; and 70&#37; of cases present cervical lymphadenopathies which tend to involve all the anterior cervical lymph nodes covering the sternocleidomastoid muscle&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;21</span></a> About 35&#37; of patients report cough and rhinorrhea&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">In a retrospective series&#44; Yoskovitch et al&#46; collected the ENT manifestations of 155 patients with Kawasaki disease &#40;KD&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> The totality of patients &#40;100&#37;&#41; presented changes in the oral mucosa and &#8220;strawberry tongue&#8221;&#44; 97&#37; suffered pharyngitis&#44; 65&#37; cervical lymphadenopathies&#44; 29&#37; rhinitis&#44; 15&#37; otitis media and less than 1&#37; presented epiglottitis&#44; trismus and external otitis&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Other manifestations of this disease include mastoiditis&#44; glossitis&#44; airway obstruction&#44; retropharyngeal and parapharyngeal abscesses&#44; external otitis&#44; supraglottitis&#44; sialadenitis and facial nerve palsy&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">In addition to the classical ones&#44; KD may be manifested through a wide variety of symptoms including diarrhoea&#44; hepatomegaly&#44; jaundice&#44; arthritis&#44; myocarditis&#44; pericarditis&#44; etc&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Diagnosis should be based on the presence of a number of criteria&#58; fever&#44; rash&#44; scaling and erythema multiforme in the limbs&#44; bilateral conjunctival injection&#44; cervical lymphadenopathies&#44; and changes in the oral mucosa&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Small Vessel Vasculitis</span><p id="par0135" class="elsevierStylePara elsevierViewall">This group includes 3 entities with a characteristic serological marker&#58; ANCA&#46; This marker may appear in different percentages&#44; depending on each variety&#46; In addition to its role in the pathophysiology of the disease&#44; it is essential due to its importance during diagnosis and monitoring&#46;</p><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Wegener&#39;s Granulomatosis</span><p id="par0140" class="elsevierStylePara elsevierViewall">This is an idiopathic systemic vasculitis characterised by the formation of necrotising granulomas which are sometimes accompanied by small-vessel vasculitis&#44; leading to the classic triad of kidney and upper and lower airway involvement&#46; Its incidence in our environment is 3 cases per million population&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">There are limited forms of the disease&#44; with clinical findings located in the upper airways or lungs in about a quarter of patients&#44; although most of these patients &#40;up to 80&#37;&#41; subsequently develop systemic involvement&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Both Wegener&#39;s granulomatosis &#40;WG&#41; and microscopic polyangiitis &#40;MPA&#41; may present ENT symptoms&#44; although they are far more common in the former than in the latter&#44; 90&#37; versus 35&#37; of cases&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">In most cases&#44; the disease debuts with an involvement of the upper respiratory tract which does not improve with the usual treatments and becomes the reason for patient referral to ENT consultation&#46; Hence&#44; the importance of a rapid and correct diagnosis and treatment by the otolaryngologist&#44; in order to prevent the natural progression of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">This entity should be taken into account in all cases of repeated sinusitis&#44; otitis media or rhinitis which do not improve with treatment&#46; Nevertheless&#44; it may also debut as repeated epistaxis&#44; nasal ulcers&#44; septal perforations and &#8220;saddle nose&#8221; deformities &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; Furthermore&#44; up to 25&#37; of cases may present subglottic stenosis&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0170" class="elsevierStylePara elsevierViewall">Separating by organs&#44; the most representative ENT manifestations in WG are&#58;</p><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">External Ear</span><p id="par0175" class="elsevierStylePara elsevierViewall">The disease rarely affects the outer ear&#46; External otitis may appear in the context of chronic otitis media and it rarely occurs in isolation&#46; Auricular chondritis can sometimes appear along with oedema&#44; erythema and pain&#44; in a similar manner to relapsing polychondritis&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Middle Ear</span><p id="par0180" class="elsevierStylePara elsevierViewall">Otitis media with effusion is the most common otological manifestation of WG&#46; It is the result of a dysfunction of the Eustachian tube&#44; derived from granulomatous involvement of the nasopharynx&#44; nasal cavity or the Eustachian tube itself&#46; Chronic otitis media with effusion may be complicated by contiguity with mastoiditis and this is associated with facial nerve palsy in up to 8&#37;&#8211;10&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Inner Ear</span><p id="par0185" class="elsevierStylePara elsevierViewall">After renal failure&#44; sensorineural hearing loss is the most common long-term morbidity in these patients &#40;affecting 35&#37; of patients&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> Hearing loss may develop quickly or gradually&#44; over several days or weeks&#46; Sensorineural hearing loss has been postulated as the result of vasculitic involvement of the cochlear blood supply or deposition of immunocomplexes within the cochlea&#46; Surprisingly&#44; vertigo is exceptional&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;26</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Nose</span><p id="par0190" class="elsevierStylePara elsevierViewall">Patients with WG may present nonspecific symptoms&#44; such as nasal congestion&#44; rhinorrhea and anosmia&#44; which may be misinterpreted as nasal allergies or viral infections of the upper respiratory tract&#46; They may develop rhinitis&#44; sinusitis &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#44; septal perforation or stenosis of the nasal airway&#46; A nasal examination may reveal &#8220;cobblestone mucosa&#8221;&#44; oedema and formation of crusts&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> The anterior nasal septum&#44; within the vascular convergence region known as the Kiesselbach area&#44; is one of the most commonly affected regions&#46;</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0195" class="elsevierStylePara elsevierViewall">Patients with advanced disease may present scarred areas in the nasal mucosa or erosion of the turbinates and septum&#46; In cases where a septal perforation progresses substantially&#44; the structural framework of the nose may become compromised&#44; leading to nasal deformity and even to total nasal collapse&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Oral Cavity and Salivary Glands</span><p id="par0200" class="elsevierStylePara elsevierViewall">Oral involvement is relatively rare&#44; although a classic type of presentation is &#8220;strawberry&#8221; gingival hyperplasia &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> There may be ulcerations of the oropharyngeal mucosa&#46; Involvement of the parotid and submandibular glands is infrequent&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p><elsevierMultimedia ident="fig0035"></elsevierMultimedia></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Larynx and Trachea</span><p id="par0205" class="elsevierStylePara elsevierViewall">Unlike most other ENT manifestations of WG&#44; laryngeal and tracheal symptoms may become fatal if left untreated&#46; Subglottic and tracheal stenosis is present in approximately 16&#37; of patients&#46; The most common symptom is progressive breathing difficulty&#44; although patients may also present acute stridor&#44; requiring urgent tracheostomy&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> Subglottic stenosis is 5 times more common among children&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">According to ACR criteria&#44; in order to diagnose WG&#44; a patient must show at least 2 of these 4 criteria&#58; nasal or oral inflammation&#44; altered chest radiograph&#44; altered urinary sediment and granulomatous inflammation visualised in a biopsy&#46; However&#44; these criteria did not take ANCA into account&#46; Their presence&#44; especially the cytoplasmic type &#40;c-ANCA&#41; and with anti-proteinase 3 &#40;PR3&#41; specificity&#44; in a patient with compatible clinical symptoms has a sensitivity of 85&#37; and a specificity of 98&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> Nevertheless&#44; in patients with limited forms&#44; the prevalence of ANCA &#40;&#43;&#41; may be as low as 60&#37; in cases limited to ENT manifestations&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Sinusal biopsy is the best option when a biopsy is required for the diagnosis of WG and there is ENT involvement&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Churg&#8211;Strauss Syndrome</span><p id="par0220" class="elsevierStylePara elsevierViewall">This type of vasculitis occurs in patients between the second and fourth decades of life and has a prevalence in our environment of 1&#46;3 cases per million population&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> It is often associated with eosinophilia&#44; bronchial asthma and allergic rhinitis&#46; The typical presentation is in the form of migratory infiltrates&#44; unlike WG which presents fixed infiltrates which usually cavitate &#40;<a class="elsevierStyleCrossRef" href="#fig0040">Fig&#46; 8</a>&#41;&#46;</p><elsevierMultimedia ident="fig0040"></elsevierMultimedia><p id="par0225" class="elsevierStylePara elsevierViewall">ENT symptoms are frequent in Churg&#8211;Strauss syndrome &#40;CSS&#41;&#44; the most common being paranasal sinus and nasal involvement&#44; appearing with nasal obstruction&#44; recurrent sinusitis and nasal polyposis&#46; In a series of 29 patients with this disease&#44; nasal polyposis was detected in 60&#37; of them&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">Chronic serous otitis media and sensorineural hearing loss appear occasionally and may be reflective of the severity of rhinosinusitis&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">32&#44;33</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">Classification requires the presence of at least 4 of these 6 criteria&#58; asthma&#44; eosinophilia&#44; neuropathy&#44; migratory pulmonary infiltrates&#44; involvement of the paranasal sinuses and the finding of extravascular eosinophils in a histological sample&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">In other types of vasculitis&#44; such as essential mixed cryoglobulinemia and cutaneous hypersensitivity vasculitis&#44; sensorineural hearing loss is the main ENT symptom&#44; appearing in up to 22&#37; of cases of the former&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Cogan Syndrome</span><p id="par0245" class="elsevierStylePara elsevierViewall">Although it is not a form of vasculitis&#44; this syndrome may appear as such throughout its development&#46; It is a rare&#44; inflammatory and autoimmune entity&#44; which predominantly affects young adults&#46; Ocular involvement &#40;in 50&#37; of cases&#41;&#44; especially in the form of interstitial keratitis &#40;<a class="elsevierStyleCrossRef" href="#fig0045">Fig&#46; 9</a>&#41; and otological involvement &#40;in 30&#37; of cases&#41; are typical&#44; with both coinciding in 15&#37; of cases&#46; It may give rise to systemic manifestations&#44; such as abdominal pain&#44; diarrhoea&#44; peripheral neuropathy&#44; vasculitis or heart failure&#46;</p><elsevierMultimedia ident="fig0045"></elsevierMultimedia><p id="par0250" class="elsevierStylePara elsevierViewall">The inner ear manifestations of Cogan syndrome &#40;CS&#41; may appear as a Meniere&#39;s crisis in the form of vertigo&#44; ataxia&#44; nausea&#44; vomiting&#44; tinnitus&#44; and hearing loss&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> Vestibular dysfunction may also cause oscillopsia&#44; which consists of the perception of objects swaying back and forth abruptly after turning the head sideways&#46; Frequently repeated involvement of the inner ear may lead to profound hearing loss&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">In a retrospective series of 60 patients&#44; hearing loss was typically sudden&#44; bilateral&#44; fluctuating and progressive&#44; leading to complete hearing loss in 73 of the 120 ears&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> Hearing loss in both ears was reported at some point in all patients&#46; Two&#44; smaller studies found bilateral hearing loss in approximately two thirds of patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">36&#44;37</span></a></p><p id="par0260" class="elsevierStylePara elsevierViewall">Recurrent episodes of the disease may also lead to cochlear hydrops&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p><p id="par0265" class="elsevierStylePara elsevierViewall">Diagnosis is based on symptoms&#44; requiring only ocular and inner ear involvement&#46;</p></span></span></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0270" class="elsevierStylePara elsevierViewall">Vasculitis includes a group of diseases which may appear with otolaryngological manifestations with relative frequency&#44; both in their debut and during their evolution&#46; Therefore&#44; they should be considered by ENT specialists during the differential diagnosis of patients suffering ENT manifestations which are atypical or difficult to control&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of Interests</span><p id="par0275" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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          "identificador" => "xres95024"
          "titulo" => "Abstract"
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        1 => array:2 [
          "identificador" => "xpalclavsec82176"
          "titulo" => "Keywords"
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        2 => array:2 [
          "identificador" => "xres95025"
          "titulo" => "Resumen"
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          "titulo" => "Palabras clave"
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        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Classification of Vasculitis"
        ]
        6 => array:3 [
          "identificador" => "sec0015"
          "titulo" => "Presentation Forms According to the Type of Vasculitis"
          "secciones" => array:3 [
            0 => array:3 [
              "identificador" => "sec0020"
              "titulo" => "Large Vessel Vasculitis"
              "secciones" => array:2 [
                0 => array:2 [
                  "identificador" => "sec0025"
                  "titulo" => "Giant Cell Arteritis &#40;Temporal Arteritis&#41;"
                ]
                1 => array:2 [
                  "identificador" => "sec0030"
                  "titulo" => "Takayasu Arteritis"
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "sec0035"
              "titulo" => "Medium Vessel Vasculitis"
              "secciones" => array:2 [
                0 => array:2 [
                  "identificador" => "sec0040"
                  "titulo" => "Polyarteritis Nodosa"
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                1 => array:2 [
                  "identificador" => "sec0045"
                  "titulo" => "Kawasaki Disease"
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              ]
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            2 => array:3 [
              "identificador" => "sec0050"
              "titulo" => "Small Vessel Vasculitis"
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                  "identificador" => "sec0055"
                  "titulo" => "Wegener&#39;s Granulomatosis"
                  "secciones" => array:6 [
                    0 => array:2 [
                      "identificador" => "sec0060"
                      "titulo" => "External Ear"
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                    1 => array:2 [
                      "identificador" => "sec0065"
                      "titulo" => "Middle Ear"
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                    2 => array:2 [
                      "identificador" => "sec0070"
                      "titulo" => "Inner Ear"
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                    3 => array:2 [
                      "identificador" => "sec0075"
                      "titulo" => "Nose"
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                      "identificador" => "sec0080"
                      "titulo" => "Oral Cavity and Salivary Glands"
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                      "titulo" => "Larynx and Trachea"
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                ]
                1 => array:2 [
                  "identificador" => "sec0090"
                  "titulo" => "Churg&#8211;Strauss Syndrome"
                ]
                2 => array:2 [
                  "identificador" => "sec0095"
                  "titulo" => "Cogan Syndrome"
                ]
              ]
            ]
          ]
        ]
        7 => array:2 [
          "identificador" => "sec0100"
          "titulo" => "Conclusions"
        ]
        8 => array:2 [
          "identificador" => "sec0105"
          "titulo" => "Conflict of Interests"
        ]
        9 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2011-07-19"
    "fechaAceptado" => "2011-09-30"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec82176"
          "palabras" => array:3 [
            0 => "Systemic vasculitis"
            1 => "ENT manifestations"
            2 => "Wegener granulomatosis"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec82177"
          "palabras" => array:3 [
            0 => "Vasculitis sist&#233;micas"
            1 => "Manifestaciones otorrinolaringol&#243;gicas"
            2 => "Granulomatosis de Wegener"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Systemic vasculitis is a heterogeneous group of diseases of various aetiologies and manifestations&#46; In general&#44; the clinical results derive from ischemia caused by vascular inflammation&#44; which depends on the organ affected&#46; Such vasculitis cases are classified according to the classification of the Chapel Hill conference&#46; They can present with relative frequency as ENT manifestations in both their debut and throughout their evolution&#46; Consequently&#44; the ENT specialist should include them in the differential diagnosis in patients with ENT manifestations that are difficult to control or of atypical presentation&#46; Our objective was to review the most common ENT clinical signs and symptoms in each of these diseases&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Las vasculitis sist&#233;micas son un grupo muy heterog&#233;neo de enfermedades de diversas etiolog&#237;as y manifestaciones&#46; En general&#44; la cl&#237;nica se deriva de la isquemia producida por la inflamaci&#243;n vascular de la cual depende el &#243;rgano afecto&#46; Se clasifican seg&#250;n el consenso de la conferencia de Chapel Hill&#46; Se pueden presentar con relativa frecuencia como manifestaciones otorrinolaringol&#243;gicas tanto en su debut como a lo largo de su evoluci&#243;n&#44; por lo tanto deben incluirse en el diagn&#243;stico diferencial del especialista en otorrinolaringolog&#237;a en pacientes de dif&#237;cil control o presentaci&#243;n at&#237;pica de manifestaciones ORL&#46; Es nuestra intenci&#243;n revisar la cl&#237;nica otorrinolaringol&#243;gica m&#225;s frecuente en cada una de estas enfermedades&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Parra-Garc&#237;a GD&#44; et al&#46; Manifestaciones otorrinolaringol&#243;gicas de las vasculitis sist&#233;micas&#46; Acta Otorrinolaringol Esp&#46; 2012&#59;63&#58;303&#8211;10&#46;</p>"
      ]
    ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Giant cell arteritis&#46; Tongue necrosis&#46;</p>"
        ]
      ]
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Scalp necrosis in patients with temporal arteritis&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Takayasu arteritis&#46; Areas of dilatation and stenosis of the aortic arch and descending aorta&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Livedo reticularis in a patient with polyarteritis nodosa&#46;</p>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">&#8220;Saddle nose&#8221; in a patient with Wegener&#39;s granulomatosis&#46;</p>"
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Involvement of maxillary sinuses and nasal fossae in a patient with Wegener&#39;s granulomatosis&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">&#8220;Strawberry&#8221; gums in a patient with Wegener&#39;s granulomatosis&#46;</p>"
        ]
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        "identificador" => "fig0040"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Multiple cavitated pulmonary nodules in a patient with Wegener&#39;s granulomatosis&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Interstitial keratitis in a patient with Cogan syndrome&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Primary vasculitis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Large vessel vasculitis</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8211; Takayasu arteritis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8211; Giant cell arteritis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8211; Cogan syndrome&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Medium vessel vasculitis</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8211; Polyarteritis nodosa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8211; Kawasaki disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Small vessel vasculitis</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8211; Mediated by immunocomplexes&#58;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8226; Cutaneous leukocytoclastic vasculitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8226; Sch&#246;nlein&#8211;Henoch purpura&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8226; Essential cryoglobulinemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8211; Associated to ANCA&#58;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8226; Wegener&#39;s granulomatosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8226; Microscopic polyangiitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8226; Churg&#8211;Strauss syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Infections</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Intestinal inflammatory disease</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Drugs</span>&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Classification of Systemic Vasculitis According to the Size of the Affected Vessels&#46;</p>"
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          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">ANCA&#58; antineutrophil cytoplasmic antibodies&#59; CNS&#58; central nervous system&#59; ESR&#58; erythrocyte sedimentation rate&#59; HBV&#58; hepatitis B virus&#59; HCV&#58; hepatitis C virus&#46;</p>"
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Vasculitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Symptoms&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Diagnosis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Giant cell arteritis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Headache&#44; hypersensitive scalp&#46;Polymyalgia rheumatica&#44; jaw claudication and visual symptoms&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Elevation of ESR&#46;Temporal artery biopsy&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Takayasu arteritis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Differences in arterial pressure&#46;Absent or decreased pulse in limbs&#46;Arterial hypertension&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pathological arteriography&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Polyarteritis nodosa<span class="elsevierStyleHsp" style=""></span>Kawasaki disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Systemic symptoms&#44; heart alterations&#44; rheumatic alterations&#44; peripheral neuropathy and&#47;or digestive alterations&#46;Fever&#46;Cardiovascular symptoms&#46;Bilateral conjunctivitis&#46;Exanthema&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Biopsies&#58; skin&#44; muscle and peripheral nerve&#46;Echocardiogram&#46;Electrocardiogram&#46;Laboratory tests &#40;ESR and C reactive protein&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Microscopic polyangiitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Systemic symptoms&#46;Nephropathy &#40;focal necrotising glomerulonephritis&#41;&#46;Skin lesions &#40;purpura&#41;&#46;Mononeuritis multiplex&#46;Pulmonary symptoms &#40;haemoptysis&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Symptoms&#43;radiology&#43;pathological anatomy&#43;laboratory data &#40;pANCA&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Wegener&#39;s granulomatosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Upper airway involvement&#46;Pulmonary involvement&#46;Nephropathy&#46;Mononeuritis multiplex&#46;Heart symptoms&#46;Palpable purpura&#46;Arthralgia and&#47;or arthritis&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Symptoms&#43;laboratory data &#40;cANCA&#41;&#43;histology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Churg&#8211;Strauss syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Asthma&#46;Mononeuropathy or polyneuropathy&#46;Migrating pulmonary infiltrates&#46;Paranasal sinuses involvement&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Eosinophilia&#46;Biopsy&#58; extravascular eosinophils&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cryoglobulinemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Arthralgia&#44; intermittent purpura in lower limbs&#46;Renal involvement&#44; sensitive peripheral neuropathy&#46;Pulmonary &#40;asthma&#44; haemoptysis&#41; and CNS involvement&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cryoglobulins in blood&#46;Skin biopsy&#46;Hypocomplementemia&#46;Determination of HCV or HBV&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Leukocytoclastic vasculitis<span class="elsevierStyleHsp" style=""></span>Cogan syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Skin&#58; palpable purpura&#46;Arthralgias and general symptoms&#58; fever&#44; discomfort and arthralgias&#46;Ocular&#58; interstitial keratitis&#44; red eyes&#44; blurred vision&#46;Audiovestibular&#58; hypoacusis&#44; Meniere-like&#44; vertigo&#46;Systemic involvement&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Symptoms limited to skin&#46;Skin biopsy&#46;Symptoms&#46;Ophthalmological and ENT assessment&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab179863.png"
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          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Clinical and Diagnostic Characteristics of Systemic Vasculitis&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
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