Otolaryngologic Manifestations of Systemic Vasculitis | Acta Otorrinolaringológica Española

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Raquel Ríos-Fernández, Manuel Sainz-Quevedo, Norberto Ortego-Centeno" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Ginés David" "apellidos" => "Parra-García" "email" => array:1 [ 0 => "ginpagar@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "¿" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "José Luis" "apellidos" => "Callejas-Rubio" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Raquel" "apellidos" => "Ríos-Fernández" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Manuel" "apellidos" => "Sainz-Quevedo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 4 => array:3 [ "nombre" => "Norberto" "apellidos" => "Ortego-Centeno" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Interna, Complejo Hospitalario Torrecárdenas, Almería, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Enfermedades Autoinmunes Sistémicas, Hospital Universitario San Cecilio, Granada, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Otorrinolaringología, Hospital Universitario San Cecilio, Granada, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Manifestaciones otorrinolaringológicas de las vasculitis sistémicas" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 715 "Ancho" => 955 "Tamanyo" => 71053 ] ] "descripcion" => array:1 [ "en" => "“Saddle nose” in a patient with Wegener's granulomatosis." ] ] ] "textoCompleto" => "IntroductionSystemic vasculitis comprises a heterogeneous group of diseases with varied aetiologies and clinical manifestations which often overlap, making their differentiation very complicated. The common feature to all cases is inflammation of the lining of blood vessels, causing occlusion of the lumen and, consequently, tissue necrosis and ischemic phenomena. This, in turn, results in a deterioration of the function of the affected organ.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>Numerous pathogenic mechanisms have been described, including immunocomplex-mediated vascular damage, production of antineutrophil cytoplasmic antibody (ANCA), anti-endothelial cell antibodies, cellular immunity, etc. Often, these mechanisms coexist.Clinical manifestations may be varied, depending on the size, number and type of affected vessels and the organs involved. Most patients present obvious constitutional symptoms, such as weakness, fever, and weight loss, which are associated with others such as limb pain in cases of peripheral neuropathy, arthralgia or arthritis in cases of musculoskeletal involvement, abdominal pain or even visceral perforation in cases of gastrointestinal involvement or different types of elementary lesions in cases of skin involvement. Patients often present otolaryngological (ENT) clinical manifestations which, occasionally, are the initial symptoms. Therefore, it is important for ENT specialists to become familiar with these diseases.In this review we have carried out a description of the ENT symptoms of the most common types of vasculitis, thus complementing a previous review in this publication of audiovestibular manifestations in cases of systemic vasculitis.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>Classification of VasculitisThere are numerous possible classifications of vasculitis. For example, from the standpoint of their aetiology they are classified into primary or secondary, depending on whether they appear in isolation or as part of another condition (systemic lupus erythematosus, rheumatoid arthritis, infections, drugs, etc.). However, from the practical standpoint, the most widely used classification is the so-called Chapel Hill classification, published in 1992, which is based on the size of the affected vessels (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). This gives rise to characteristic clinical manifestations, not only from the general point of view, but also from standpoint of ENT (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Moreover, in 1990, the American College of Rheumatology (ACR) developed a set of classification criteria for systemic vasculitis. These were intended to standardise clinical definitions for epidemiological and therapeutic use, rather than for diagnosis, but they are sometimes used for this purpose.Presentation Forms According to the Type of VasculitisLarge Vessel VasculitisGiant Cell Arteritis (Temporal Arteritis)This type of vasculitis is common in our environment, with an annual incidence around 12/100000 population, mainly in subjects aged over 50 years and predominantly in females.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> It mainly affects the branches of the extracranial carotid artery, and 2 out of 3 patients suffer headache at the beginning of the disease. In general it is a headache of recent onset which, if the patient has a previous history of headache, is reported as having different characteristics from the usual. It is generally located in the temporal region, but may also appear in the frontal and occipital regions, so a differential diagnosis with ENT pathologies should be conducted. Half of patients suffer jaw claudication, characterised by rapid onset from the start of mastication. Sometimes, patients downplay this symptom, so it must searched for explicitly.Jaw claudication was the most specific symptom of giant cell arteritis (GCA) in a study which correlated positive biopsies with clinical symptoms.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> Of a total of 134 patients who underwent biopsy, jaw claudication was present in 54% of those who tested positive, compared with only 3% of those whose biopsies were negative.Approximately 10% of patients with GCA present symptoms related to the upper respiratory tract. In particular, non-productive cough is a common symptom which can lead to diagnostic confusion.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> It is believed to be an effect of vasculitis on cough receptors, which are found throughout the respiratory tree.Other symptoms are lingual pain or lingual infarction (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>),<a class="elsevierStyleCrossRefs" href="#bib0030">6,7</a> odynophagia,<a class="elsevierStyleCrossRefs" href="#bib0030">6,7</a> sensorineural hearing loss,<a class="elsevierStyleCrossRef" href="#bib0040">8</a> vestibular dysfunction, benign peripheral positional vertigo (BPPV) of ischemic origin, smell alterations and even pain, swelling, redness and necrosis of the face or scalp (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), oral mucosa and/or nose.<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>It was observed that, out of 44 patients with GCA who were monitored for 2 years, 20% developed BPPV, with the majority associating nystagmus, compared with 2.3% out of the healthy population.<a class="elsevierStyleCrossRef" href="#bib0045">9</a>Loss of vision due to optic nerve ischemia is among the most important complications. About 50% of patients present polymyalgia rheumatica.According to the ACR classification, its diagnosis requires at least 3 of the following 5 criteria: age over 50 years, characteristic headache, temporal artery alterations, elevated ESR and compatible biopsy of the temporal artery.Takayasu ArteritisTakayasu arteritis (TA) is a rare vasculitis in our environment, with only 1–3 cases per million population each year. It mainly affects women younger than 40 years,<a class="elsevierStyleCrossRef" href="#bib0065">13</a> and usually damages the aorta and its major branches.There have been reports in the literature of patients with ENT manifestations. These appear especially with symptoms of sinusitis, such as persistent localised headache and purulent rhinorrhea.<a class="elsevierStyleCrossRefs" href="#bib0050">10,11</a> In most cases, findings are incidental and are revealed after an imaging study, whose result shows the sinusal involvement.The has been one report of confirmed TA in which the presence of vasculitis was correlated with the nasal deformity known as “saddle nose”.<a class="elsevierStyleCrossRef" href="#bib0060">12</a>The finding of differences in blood pressure in both arms, decreased brachial artery pulse or a pathological arteriography (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) are useful for its diagnosis.<elsevierMultimedia ident="fig0015"></elsevierMultimedia>Medium Vessel VasculitisPolyarteritis NodosaThe prevalence of this type of vasculitis is currently declining (its incidence in Spain is 1 case per million population). It is occasionally associated to infection by hepatitis B virus (HBV) and, more rarely, by hepatitis C virus (HCV).<a class="elsevierStyleCrossRef" href="#bib0065">13</a> The otological condition of polyarteritis nodosa (PAN) is relatively common, since it appears in up to 30% of cases.PAN may affect the middle ear; the main symptom is hearing loss, which may be conductive or sensory.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> Facial paralysis may be associated with loss of hearing.<a class="elsevierStyleCrossRefs" href="#bib0075">15–18</a> Based on the foregoing, PAN should be included in the differential diagnosis of patients with otic disease which is difficult to control.The main diagnostic test is to obtain histological material which confirms vasculitis or, in its absence and in an appropriate clinical setting, a pathological arteriography (aneurysms, usually of small size). The presence of subcutaneous nodules or livedo reticularis in the limbs, especially the lower ones (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>), may guide the diagnosis.<elsevierMultimedia ident="fig0020"></elsevierMultimedia>Kawasaki DiseaseThis type of vasculitis has a very low prevalence and mainly affects children. Classically, the disease is characterised by the appearance of erythema and fissures in the lips and oral mucosa, leading to a characteristic image of “strawberry tongue”, caused by the detachment of the filiform papillae. The appearance of oral lesions such as vesicles or ulcers and tonsillar exudate is also common.<a class="elsevierStyleCrossRef" href="#bib0095">19</a>Between 50% and 70% of cases present cervical lymphadenopathies which tend to involve all the anterior cervical lymph nodes covering the sternocleidomastoid muscle.<a class="elsevierStyleCrossRefs" href="#bib0100">20,21</a> About 35% of patients report cough and rhinorrhea.In a retrospective series, Yoskovitch et al. collected the ENT manifestations of 155 patients with Kawasaki disease (KD).<a class="elsevierStyleCrossRef" href="#bib0110">22</a> The totality of patients (100%) presented changes in the oral mucosa and “strawberry tongue”, 97% suffered pharyngitis, 65% cervical lymphadenopathies, 29% rhinitis, 15% otitis media and less than 1% presented epiglottitis, trismus and external otitis.Other manifestations of this disease include mastoiditis, glossitis, airway obstruction, retropharyngeal and parapharyngeal abscesses, external otitis, supraglottitis, sialadenitis and facial nerve palsy.In addition to the classical ones, KD may be manifested through a wide variety of symptoms including diarrhoea, hepatomegaly, jaundice, arthritis, myocarditis, pericarditis, etc.Diagnosis should be based on the presence of a number of criteria: fever, rash, scaling and erythema multiforme in the limbs, bilateral conjunctival injection, cervical lymphadenopathies, and changes in the oral mucosa.Small Vessel VasculitisThis group includes 3 entities with a characteristic serological marker: ANCA. This marker may appear in different percentages, depending on each variety. In addition to its role in the pathophysiology of the disease, it is essential due to its importance during diagnosis and monitoring.Wegener's GranulomatosisThis is an idiopathic systemic vasculitis characterised by the formation of necrotising granulomas which are sometimes accompanied by small-vessel vasculitis, leading to the classic triad of kidney and upper and lower airway involvement. Its incidence in our environment is 3 cases per million population.<a class="elsevierStyleCrossRef" href="#bib0065">13</a>There are limited forms of the disease, with clinical findings located in the upper airways or lungs in about a quarter of patients, although most of these patients (up to 80%) subsequently develop systemic involvement.Both Wegener's granulomatosis (WG) and microscopic polyangiitis (MPA) may present ENT symptoms, although they are far more common in the former than in the latter, 90% versus 35% of cases.In most cases, 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. Hence, the importance of a rapid and correct diagnosis and treatment by the otolaryngologist, in order to prevent the natural progression of the disease.<a class="elsevierStyleCrossRef" href="#bib0115">23</a>This entity should be taken into account in all cases of repeated sinusitis, otitis media or rhinitis which do not improve with treatment. Nevertheless, it may also debut as repeated epistaxis, nasal ulcers, septal perforations and “saddle nose” deformities (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). Furthermore, up to 25% of cases may present subglottic stenosis.<a class="elsevierStyleCrossRef" href="#bib0120">24</a><elsevierMultimedia ident="fig0025"></elsevierMultimedia>Separating by organs, the most representative ENT manifestations in WG are:External EarThe disease rarely affects the outer ear. External otitis may appear in the context of chronic otitis media and it rarely occurs in isolation. Auricular chondritis can sometimes appear along with oedema, erythema and pain, in a similar manner to relapsing polychondritis.Middle EarOtitis media with effusion is the most common otological manifestation of WG. It is the result of a dysfunction of the Eustachian tube, derived from granulomatous involvement of the nasopharynx, nasal cavity or the Eustachian tube itself. Chronic otitis media with effusion may be complicated by contiguity with mastoiditis and this is associated with facial nerve palsy in up to 8%–10% of cases.<a class="elsevierStyleCrossRef" href="#bib0125">25</a>Inner EarAfter renal failure, sensorineural hearing loss is the most common long-term morbidity in these patients (affecting 35% of patients).<a class="elsevierStyleCrossRef" href="#bib0130">26</a> Hearing loss may develop quickly or gradually, over several days or weeks. Sensorineural hearing loss has been postulated as the result of vasculitic involvement of the cochlear blood supply or deposition of immunocomplexes within the cochlea. Surprisingly, vertigo is exceptional.<a class="elsevierStyleCrossRefs" href="#bib0125">25,26</a>NosePatients with WG may present nonspecific symptoms, such as nasal congestion, rhinorrhea and anosmia, which may be misinterpreted as nasal allergies or viral infections of the upper respiratory tract. They may develop rhinitis, sinusitis (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>), septal perforation or stenosis of the nasal airway. A nasal examination may reveal “cobblestone mucosa”, oedema and formation of crusts.<a class="elsevierStyleCrossRef" href="#bib0135">27</a> The anterior nasal septum, within the vascular convergence region known as the Kiesselbach area, is one of the most commonly affected regions.<elsevierMultimedia ident="fig0030"></elsevierMultimedia>Patients with advanced disease may present scarred areas in the nasal mucosa or erosion of the turbinates and septum. In cases where a septal perforation progresses substantially, the structural framework of the nose may become compromised, leading to nasal deformity and even to total nasal collapse.<a class="elsevierStyleCrossRef" href="#bib0135">27</a>Oral Cavity and Salivary GlandsOral involvement is relatively rare, although a classic type of presentation is “strawberry” gingival hyperplasia (<a class="elsevierStyleCrossRef" href="#fig0035">Fig. 7</a>).<a class="elsevierStyleCrossRef" href="#bib0130">26</a> There may be ulcerations of the oropharyngeal mucosa. Involvement of the parotid and submandibular glands is infrequent.<a class="elsevierStyleCrossRef" href="#bib0140">28</a><elsevierMultimedia ident="fig0035"></elsevierMultimedia>Larynx and TracheaUnlike most other ENT manifestations of WG, laryngeal and tracheal symptoms may become fatal if left untreated. Subglottic and tracheal stenosis is present in approximately 16% of patients. The most common symptom is progressive breathing difficulty, although patients may also present acute stridor, requiring urgent tracheostomy.<a class="elsevierStyleCrossRef" href="#bib0145">29</a> Subglottic stenosis is 5 times more common among children.<a class="elsevierStyleCrossRef" href="#bib0130">26</a>According to ACR criteria, in order to diagnose WG, a patient must show at least 2 of these 4 criteria: nasal or oral inflammation, altered chest radiograph, altered urinary sediment and granulomatous inflammation visualised in a biopsy. However, these criteria did not take ANCA into account. Their presence, especially the cytoplasmic type (c-ANCA) and with anti-proteinase 3 (PR3) specificity, in a patient with compatible clinical symptoms has a sensitivity of 85% and a specificity of 98%.<a class="elsevierStyleCrossRef" href="#bib0150">30</a> Nevertheless, in patients with limited forms, the prevalence of ANCA (+) may be as low as 60% in cases limited to ENT manifestations.Sinusal biopsy is the best option when a biopsy is required for the diagnosis of WG and there is ENT involvement.<a class="elsevierStyleCrossRef" href="#bib0150">30</a>Churg–Strauss SyndromeThis type of vasculitis occurs in patients between the second and fourth decades of life and has a prevalence in our environment of 1.3 cases per million population.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> It is often associated with eosinophilia, bronchial asthma and allergic rhinitis. The typical presentation is in the form of migratory infiltrates, unlike WG which presents fixed infiltrates which usually cavitate (<a class="elsevierStyleCrossRef" href="#fig0040">Fig. 8</a>).<elsevierMultimedia ident="fig0040"></elsevierMultimedia>ENT symptoms are frequent in Churg–Strauss syndrome (CSS), the most common being paranasal sinus and nasal involvement, appearing with nasal obstruction, recurrent sinusitis and nasal polyposis. In a series of 29 patients with this disease, nasal polyposis was detected in 60% of them.<a class="elsevierStyleCrossRef" href="#bib0155">31</a>Chronic serous otitis media and sensorineural hearing loss appear occasionally and may be reflective of the severity of rhinosinusitis.<a class="elsevierStyleCrossRefs" href="#bib0160">32,33</a>Classification requires the presence of at least 4 of these 6 criteria: asthma, eosinophilia, neuropathy, migratory pulmonary infiltrates, involvement of the paranasal sinuses and the finding of extravascular eosinophils in a histological sample.In other types of vasculitis, such as essential mixed cryoglobulinemia and cutaneous hypersensitivity vasculitis, sensorineural hearing loss is the main ENT symptom, appearing in up to 22% of cases of the former.Cogan SyndromeAlthough it is not a form of vasculitis, this syndrome may appear as such throughout its development. It is a rare, inflammatory and autoimmune entity, which predominantly affects young adults. Ocular involvement (in 50% of cases), especially in the form of interstitial keratitis (<a class="elsevierStyleCrossRef" href="#fig0045">Fig. 9</a>) and otological involvement (in 30% of cases) are typical, with both coinciding in 15% of cases. It may give rise to systemic manifestations, such as abdominal pain, diarrhoea, peripheral neuropathy, vasculitis or heart failure.<elsevierMultimedia ident="fig0045"></elsevierMultimedia>The inner ear manifestations of Cogan syndrome (CS) may appear as a Meniere's crisis in the form of vertigo, ataxia, nausea, vomiting, tinnitus, and hearing loss.<a class="elsevierStyleCrossRef" href="#bib0170">34</a> Vestibular dysfunction may also cause oscillopsia, which consists of the perception of objects swaying back and forth abruptly after turning the head sideways. Frequently repeated involvement of the inner ear may lead to profound hearing loss.In a retrospective series of 60 patients, hearing loss was typically sudden, bilateral, fluctuating and progressive, leading to complete hearing loss in 73 of the 120 ears.<a class="elsevierStyleCrossRef" href="#bib0175">35</a> Hearing loss in both ears was reported at some point in all patients. Two, smaller studies found bilateral hearing loss in approximately two thirds of patients.<a class="elsevierStyleCrossRefs" href="#bib0180">36,37</a>Recurrent episodes of the disease may also lead to cochlear hydrops.<a class="elsevierStyleCrossRef" href="#bib0180">36</a>Diagnosis is based on symptoms, requiring only ocular and inner ear involvement.ConclusionsVasculitis includes a group of diseases which may appear with otolaryngological manifestations with relative frequency, both in their debut and during their evolution. Therefore, they should be considered by ENT specialists during the differential diagnosis of patients suffering ENT manifestations which are atypical or difficult to control.Conflict of InterestsThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres95024" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec82176" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres95025" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec82177" "titulo" => "Palabras clave" ] 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 (Temporal Arteritis)" ] 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" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Kawasaki Disease" ] ] ] 2 => array:3 [ "identificador" => "sec0050" "titulo" => "Small Vessel Vasculitis" "secciones" => array:3 [ 0 => array:3 [ "identificador" => "sec0055" "titulo" => "Wegener's Granulomatosis" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0060" "titulo" => "External Ear" ] 1 => array:2 [ "identificador" => "sec0065" "titulo" => "Middle Ear" ] 2 => array:2 [ "identificador" => "sec0070" "titulo" => "Inner Ear" ] 3 => array:2 [ "identificador" => "sec0075" "titulo" => "Nose" ] 4 => array:2 [ "identificador" => "sec0080" "titulo" => "Oral Cavity and Salivary Glands" ] 5 => array:2 [ "identificador" => "sec0085" "titulo" => "Larynx and Trachea" ] ] ] 1 => array:2 [ "identificador" => "sec0090" "titulo" => "Churg–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 sistémicas" 1 => "Manifestaciones otorrinolaringológicas" 2 => "Granulomatosis de Wegener" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Systemic vasculitis is a heterogeneous group of diseases of various aetiologies and manifestations. In general, the clinical results derive from ischemia caused by vascular inflammation, which depends on the organ affected. Such vasculitis cases are classified according to the classification of the Chapel Hill conference. They can present with relative frequency as ENT manifestations in both their debut and throughout their evolution. Consequently, the ENT specialist should include them in the differential diagnosis in patients with ENT manifestations that are difficult to control or of atypical presentation. Our objective was to review the most common ENT clinical signs and symptoms in each of these diseases." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Las vasculitis sistémicas son un grupo muy heterogéneo de enfermedades de diversas etiologías y manifestaciones. En general, la clínica se deriva de la isquemia producida por la inflamación vascular de la cual depende el órgano afecto. Se clasifican según el consenso de la conferencia de Chapel Hill. Se pueden presentar con relativa frecuencia como manifestaciones otorrinolaringológicas tanto en su debut como a lo largo de su evolución, por lo tanto deben incluirse en el diagnóstico diferencial del especialista en otorrinolaringología en pacientes de difícil control o presentación atípica de manifestaciones ORL. Es nuestra intención revisar la clínica otorrinolaringológica más frecuente en cada una de estas enfermedades." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Parra-García GD, et al. Manifestaciones otorrinolaringológicas de las vasculitis sistémicas. Acta Otorrinolaringol Esp. 2012;63:303–10." ] ] "multimedia" => array:11 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 713 "Ancho" => 952 "Tamanyo" => 97900 ] ] "descripcion" => array:1 [ "en" => "Giant cell arteritis. Tongue necrosis." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 711 "Ancho" => 949 "Tamanyo" => 166381 ] ] "descripcion" => array:1 [ "en" => "Scalp necrosis in patients with temporal arteritis." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 714 "Ancho" => 953 "Tamanyo" => 79645 ] ] "descripcion" => array:1 [ "en" => "Takayasu arteritis. Areas of dilatation and stenosis of the aortic arch and descending aorta." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1260 "Ancho" => 946 "Tamanyo" => 179184 ] ] "descripcion" => array:1 [ "en" => "Livedo reticularis in a patient with polyarteritis nodosa." ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 715 "Ancho" => 955 "Tamanyo" => 71053 ] ] "descripcion" => array:1 [ "en" => "“Saddle nose” in a patient with Wegener's granulomatosis." ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 713 "Ancho" => 952 "Tamanyo" => 74281 ] ] "descripcion" => array:1 [ "en" => "Involvement of maxillary sinuses and nasal fossae in a patient with Wegener's granulomatosis." ] ] 6 => array:7 [ "identificador" => "fig0035" "etiqueta" => "Figure 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 604 "Ancho" => 953 "Tamanyo" => 96985 ] ] "descripcion" => array:1 [ "en" => "“Strawberry” gums in a patient with Wegener's granulomatosis." ] ] 7 => array:7 [ "identificador" => "fig0040" "etiqueta" => "Figure 8" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr8.jpeg" "Alto" => 715 "Ancho" => 953 "Tamanyo" => 77784 ] ] "descripcion" => array:1 [ "en" => "Multiple cavitated pulmonary nodules in a patient with Wegener's granulomatosis." ] ] 8 => array:7 [ "identificador" => "fig0045" "etiqueta" => "Figure 9" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr9.jpeg" "Alto" => 1200 "Ancho" => 902 "Tamanyo" => 143127 ] ] "descripcion" => array:1 [ "en" => "Interstitial keratitis in a patient with Cogan syndrome." ] ] 9 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 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">Primary vasculitis \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">Large vessel vasculitis \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 \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">– Giant cell arteritis \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">– Cogan syndrome \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">Medium vessel vasculitis \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 \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">– Kawasaki disease \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">Small vessel vasculitis \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">– Mediated by immunocomplexes: \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">• Cutaneous leukocytoclastic vasculitis \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">• Schönlein–Henoch purpura \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">• Essential cryoglobulinemia \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">– Associated to ANCA: \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's granulomatosis \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 \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–Strauss syndrome \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"> \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">Secondary vasculitis \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">Connective tissue diseases (rheumatoid vasculitis, lupus erythematosus, Sjögren syndrome and inflammatory myopathies) \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">Paraneoplastic \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">Infections \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">Intestinal inflammatory disease \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">Drugs \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab179864.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Classification of Systemic Vasculitis According to the Size of the Affected Vessels." ] ] 10 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "ANCA: antineutrophil cytoplasmic antibodies; CNS: central nervous system; ESR: erythrocyte sedimentation rate; HBV: hepatitis B virus; HCV: hepatitis C virus." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><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">Vasculitis \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 \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">Diagnosis \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><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">Giant cell arteritis \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, hypersensitive scalp.Polymyalgia rheumatica, jaw claudication and visual symptoms. \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.Temporal artery biopsy. \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 \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.Absent or decreased pulse in limbs.Arterial hypertension. \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. \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 nodosaKawasaki disease \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, heart alterations, rheumatic alterations, peripheral neuropathy and/or digestive alterations.Fever.Cardiovascular symptoms.Bilateral conjunctivitis.Exanthema. \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: skin, muscle and peripheral nerve.Echocardiogram.Electrocardiogram.Laboratory tests (ESR and C reactive protein). \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 \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.Nephropathy (focal necrotising glomerulonephritis).Skin lesions (purpura).Mononeuritis multiplex.Pulmonary symptoms (haemoptysis). \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+radiology+pathological anatomy+laboratory data (pANCA). \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's granulomatosis \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.Pulmonary involvement.Nephropathy.Mononeuritis multiplex.Heart symptoms.Palpable purpura.Arthralgia and/or arthritis. \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+laboratory data (cANCA)+histology \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–Strauss syndrome \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.Mononeuropathy or polyneuropathy.Migrating pulmonary infiltrates.Paranasal sinuses involvement. \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.Biopsy: extravascular eosinophils. \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 \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, intermittent purpura in lower limbs.Renal involvement, sensitive peripheral neuropathy.Pulmonary (asthma, haemoptysis) and CNS involvement. \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.Skin biopsy.Hypocomplementemia.Determination of HCV or HBV. \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 vasculitisCogan syndrome \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: palpable purpura.Arthralgias and general symptoms: fever, discomfort and arthralgias.Ocular: interstitial keratitis, red eyes, blurred vision.Audiovestibular: hypoacusis, Meniere-like, vertigo.Systemic involvement. \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.Skin biopsy.Symptoms.Ophthalmological and ENT assessment. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab179863.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Clinical and Diagnostic Characteristics of Systemic Vasculitis." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:37 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Vasculitis, 1815 to 1991: classification and diagnostic specificity (Dunlop-Dottridgelecture)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.T. 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Otolaryngologic Manifestations of Systemic Vasculitis

Manifestaciones otorrinolaringológicas de las vasculitis sistémicas

Ginés David Parra-Garcíaa,

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ginpagar@hotmail.com

Corresponding author.

, José Luis Callejas-Rubiob, Raquel Ríos-Fernándezb, Manuel Sainz-Quevedoc, Norberto Ortego-Centenob

a Servicio de Medicina Interna, Complejo Hospitalario Torrecárdenas, Almería, Spain

b Unidad de Enfermedades Autoinmunes Sistémicas, Hospital Universitario San Cecilio, Granada, Spain

c Servicio de Otorrinolaringología, Hospital Universitario San Cecilio, Granada, Spain

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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; 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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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          "titulo" => "Resumen"
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          "titulo" => "Introduction"
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        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Classification of Vasculitis"
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        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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            2 => array:3 [
              "identificador" => "sec0050"
              "titulo" => "Small Vessel Vasculitis"
              "secciones" => array:3 [
                0 => array:3 [
                  "identificador" => "sec0055"
                  "titulo" => "Wegener&#39;s Granulomatosis"
                  "secciones" => array:6 [
                    0 => array:2 [
                      "identificador" => "sec0060"
                      "titulo" => "External Ear"
                    ]
                    1 => array:2 [
                      "identificador" => "sec0065"
                      "titulo" => "Middle Ear"
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                    2 => array:2 [
                      "identificador" => "sec0070"
                      "titulo" => "Inner Ear"
                    ]
                    3 => array:2 [
                      "identificador" => "sec0075"
                      "titulo" => "Nose"
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                    4 => array:2 [
                      "identificador" => "sec0080"
                      "titulo" => "Oral Cavity and Salivary Glands"
                    ]
                    5 => array:2 [
                      "identificador" => "sec0085"
                      "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"
                ]
              ]
            ]
          ]
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          "titulo" => "Conclusions"
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        8 => array:2 [
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          "titulo" => "Conflict of Interests"
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          "titulo" => "References"
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    "fechaRecibido" => "2011-07-19"
    "fechaAceptado" => "2011-09-30"
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          "clase" => "keyword"
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            2 => "Wegener granulomatosis"
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          "clase" => "keyword"
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            0 => "Vasculitis sist&#233;micas"
            1 => "Manifestaciones otorrinolaringol&#243;gicas"
            2 => "Granulomatosis de Wegener"
          ]
        ]
      ]
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        "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>"
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      "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>"
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        "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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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Scalp necrosis in patients with temporal arteritis&#46;</p>"
        ]
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        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
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        "mostrarFloat" => true
        "mostrarDisplay" => false
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          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 714
            "Ancho" => 953
            "Tamanyo" => 79645
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        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Takayasu arteritis&#46; Areas of dilatation and stenosis of the aortic arch and descending aorta&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr4.jpeg"
            "Alto" => 1260
            "Ancho" => 946
            "Tamanyo" => 179184
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        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Livedo reticularis in a patient with polyarteritis nodosa&#46;</p>"
        ]
      ]
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        "identificador" => "fig0025"
        "etiqueta" => "Figure 5"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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            "imagen" => "gr5.jpeg"
            "Alto" => 715
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            "Tamanyo" => 71053
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        "descripcion" => array:1 [
          "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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        "identificador" => "fig0030"
        "etiqueta" => "Figure 6"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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            "imagen" => "gr6.jpeg"
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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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        "identificador" => "fig0035"
        "etiqueta" => "Figure 7"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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        "figura" => array:1 [
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            "imagen" => "gr7.jpeg"
            "Alto" => 604
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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"
        "etiqueta" => "Figure 8"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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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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        "tipo" => "MULTIMEDIAFIGURA"
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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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        "etiqueta" => "Table 1"
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          "tablatextoimagen" => array:1 [
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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
                  \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; Takayasu arteritis&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; Giant cell arteritis&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; Cogan 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
                  \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
                  \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; 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
                  \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; 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
                  \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; 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
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></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="elsevierStyleBold">Secondary 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">Connective tissue diseases &#40;rheumatoid vasculitis&#44; lupus erythematosus&#44; Sj&#246;gren syndrome and inflammatory myopathies&#41;</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">Paraneoplastic</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">Infections</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">Intestinal inflammatory disease</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">Drugs</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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        "descripcion" => array:1 [
          "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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      10 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "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>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><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">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
                  \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">Diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><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">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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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Clinical and Diagnostic Characteristics of Systemic Vasculitis&#46;</p>"
        ]
      ]
    ]
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Article information

ISSN: 21735735
Original language: English

DOI:10.1016/j.otoeng.2012.07.012

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Year/Month	Html	Pdf	Total

2023 April	1	0	1
2023 March	1	1	2
2022 January	0	0	0
2021 March	0	45	45
2021 February	0	40	40
2021 January	0	21	21
2020 December	0	16	16
2020 November	0	12	12
2020 October	0	8	8
2020 September	0	7	7
2020 August	0	1	1
2020 July	0	2	2
2020 June	0	1	1
2020 May	0	5	5
2020 April	0	5	5
2020 March	115	18	133
2020 February	205	20	225
2020 January	229	48	277
2019 December	181	32	213
2019 November	128	35	163
2019 October	142	21	163
2019 September	157	26	183
2019 August	135	20	155
2019 July	180	32	212
2019 June	220	30	250
2019 May	391	50	441
2019 April	267	102	369
2019 March	71	22	93
2019 February	89	22	111
2019 January	81	26	107
2018 December	48	30	78
2018 November	59	23	82
2018 October	49	6	55
2018 May	19	4	23
2018 April	154	40	194
2018 March	156	31	187
2018 February	105	16	121
2018 January	93	19	112
2017 December	73	13	86
2017 November	95	18	113
2017 October	87	26	113
2017 September	86	32	118
2017 August	65	20	85
2017 July	88	18	106
2017 June	129	32	161
2017 May	134	45	179
2017 April	69	31	100
2017 March	90	28	118
2017 February	143	34	177
2017 January	69	23	92
2016 December	83	18	101
2016 November	79	24	103
2016 October	111	26	137
2016 September	101	19	120
2016 August	82	18	100
2016 July	95	10	105
2016 June	67	23	90
2016 May	99	34	133
2016 April	99	15	114
2016 March	132	16	148
2016 February	140	25	165
2016 January	120	23	143
2015 December	90	28	118
2015 November	87	23	110
2015 October	131	22	153
2015 September	76	16	92
2015 August	149	11	160
2015 July	206	6	212
2015 June	151	8	159
2015 May	152	10	162
2015 April	147	24	171
2015 March	214	14	228
2015 February	60	4	64
2015 January	39	11	50
2014 December	50	13	63
2014 November	23	5	28
2014 October	34	9	43
2014 September	41	6	47
2014 August	47	13	60
2014 July	36	9	45
2014 June	20	9	29
2014 May	25	9	34
2014 April	26	2	28
2014 March	33	10	43
2014 February	34	8	42
2014 January	12	8	20
2013 December	26	8	34
2013 November	39	13	52
2013 October	89	11	100
2013 September	53	2	55
2013 August	14	3	17

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