Skip to main content

Advertisement

SpringerLink
Log in

Nasal reconstructive surgery for vasculitis affecting the nose: our two-centre international experience

  • Rhinology
  • Published:
European Archives of Oto-Rhino-Laryngology Aims and scope Submit manuscript

Abstract

Purpose

To recommend an international multidisciplinary medical and surgical algorithm of treatment in nasal vasculitis, which will create a more streamlined approach.

Methods

A two-centre, international retrospective analysis of granulomatosis with polyangiitis (GPA) and levamisole-associated vasculitis (LAV) cases presenting between 2005 and 2019 was carried out. Demographic data, and surgical and medical treatment were recorded. Patients’ signs and symptoms were analysed, and recommended treatment strategies outlined with key surgical procedures described.

Results

Forty-one GPA patients and 11 LAV patients were included in the study with a mean age of 38.6 and 38.8 years, respectively. A stepwise surgical management approach with reconstructive options is described and includes: (1) examination under general anaesthesia, biopsy, and insertion of silastic nasal splints; (2) septal perforation repair (with caution); (3) mild-to-moderate saddle nose reconstruction with costal cartilage; (4) severe saddle nose reconstruction with osseocartilaginous rib grafts; (5) soft-tissue reconstruction techniques.

Conclusions

The management of nasal vasculitis is a particular challenge in facial plastic surgery. It requires a close collaborative approach with a physician skilled in the medical management of vasculitis. Surgery must be planned judiciously, with realistic patient expectations and only after a sustained period of remission. For more severe saddle deformities, the modified osseocartilaginous Andrews technique gives excellent long-term results.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

References

  1. Watts RA, Lane SE, Scott DG, Koldingsnes W, Nossent H, Gonzalez-Gay MA et al (2001) Epidemiology of vasculitis in Europe. Ann Rheum Dis 60(12):1156–1157

    Article  CAS  Google Scholar 

  2. Panupattanapong S, Stwalley DL, White AJ, Olsen MA, French AR, Hartman ME (2018) Epidemiology and outcomes of granulomatosis with polyangiitis in pediatric and working-age adult populations in the United States: analysis of a Large National Claims Database. Arthritis Rheumatol 70(12):2067–2076

    Article  Google Scholar 

  3. Wojciechowska J, Krajewski W, Krajewski P, Kręcicki T (2016) Granulomatosis with polyangiitis in otolaryngologist practice: a review of current knowledge. Clin Exp Otorhinolaryngol 9(1):8–13

    Article  CAS  Google Scholar 

  4. Tran H, Tan D, Marnejon TP (2013) Cutaneous vasculopathy associated with levamisole-adulterated cocaine. Clin Med Res 11(1):26–30

    Article  Google Scholar 

  5. https://www.drugabuse.gov/publications/research-reports/cocaine/what-scope-cocaine-use-in-united-states. Accessed 9 May 2020

  6. Sayadi L, Laub D (2018) Levamisole-induced vasculitis. Eplasty 18:ic5 (eCollection 2018)

    PubMed  PubMed Central  Google Scholar 

  7. Trimarchi M, Gregorini G, Facchetti F, Morassi ML, Manfredini C, Maroldi R et al (2001) Cocaine-induced midline destructive lesions: clinical, radiographic, histopathologic and serologic features and their differentiation from Wegener granulomatosis. Medicine 80:391–404

    Article  CAS  Google Scholar 

  8. Kwame I, Pusey C, Andrews P (2018) Surgery for vasculitic diseases of the nose and sinuses. Int J Head Neck Surg 9(1):1–6

    Article  Google Scholar 

  9. Fokkens WJ, Lund VJ, Hopkins C, Hellings PW, Kern R, Reitsma S et al (2020) European position paper on rhinosinusitis and nasal polyps 2020. Rhinology 58(Suppl S29):1–464

    PubMed  Google Scholar 

  10. Christobel JJ, Hilger PA (2011) Osseocartilaginous rib graft rhinoplasty: a stable, predictable technique for major dorsal reconstruction. Arch Facial Plast Surg 13(2):78–83

    Google Scholar 

  11. Poirrier AL, Ahluwalia S, Kwami I, Chau H, Bentley M, Andrews P (2014) External nasal valve collapse: validation of novel outcome measurement tool. Rhinology 52(2):127–132

    Article  CAS  Google Scholar 

  12. Srouji IA, Andrews P, Edwards C, Lund VJ (2007) Patterns of presentation and diagnosis of patients with Wegener’s granulomatosis: ENT aspects. J Laryngol Otol 121(7):653–658

    Article  CAS  Google Scholar 

  13. Stone JH, Hoffman GS, Merkel PA, Min YI, Uhlfelder ML, Hellmann DB et al (2001) A disease-specific activity index for Wegener’s granulomatosis: modification of the Birmingham Vasculitis Activity Score. International Network for the Study of the Systemic Vasculitides (INSSYS). Arthritis Rheum 44:912–920

    Article  CAS  Google Scholar 

  14. Kühn D, Hospowsky C, Both M, Hey M, Laudien M (2018) Manifestation of granulomatosis with polyangiitis in head and neck. Clin Exp Rheumatol. 36(Suppl 111(2)):78–84

    PubMed  Google Scholar 

  15. Felicetti M, Cazzador D, Padoan R, Pendolino AL, Faccioli C, Nardello E et al (2018) Ear, nose and throat involvement in granulomatosis with polyangiitis: how it presents and how it determines disease severity and long-term outcomes. Clin Rheumatol 37(4):1075–1083

    Article  Google Scholar 

  16. Srouji IA, Andrews P, Edwards C, Lund VJ (2006) General and rhinosinusitis-related quality of life in patients with Wegener’s granulomatosis. Laryngoscope 116(9):1621–1625

    Article  CAS  Google Scholar 

  17. Leavitt RY, Fauci AS, Bloch DA, Michel BA, Hunder GG, Arend WP et al (1990) The American College of Rheumatology 1990 criteria for the classification of Wegener’s granulomatosis. Arthritis Rheum 33(8):1101–1107

    Article  CAS  Google Scholar 

  18. Rasmussen N (2001) Management of the ear, nose, and throat manifestations of Wegener granulomatosis: an otorhinolaryngologist’s perspective. Curr Opin Rheumatol 13:3–11

    Article  CAS  Google Scholar 

  19. Cannady SB, Batra PS, Koening C, Lorenz RR, Citardi MJ, Langford C et al (2009) Sinonasal Wegener granulomatosis: a single-institution experience with 120 cases. Laryngoscope 119(4):757–761

    Article  Google Scholar 

  20. Delaney SW, Kridel RWH (2019) Contemporary trends in the surgical management of nasal septal perforations: a community survey. Facial Plast Surg 35(1):78–84

    Article  CAS  Google Scholar 

  21. Congdon D, Sherris DA, Specks U, McDonald T (2002) Long-term follow-up of repair of external nasal deformities in patients with Wegener’s granulomatosis. Laryngoscope 112(4):731–737

    Article  Google Scholar 

  22. Ezzat WH, Compton RA, Basa KC, Levi J (2017) Reconstructive techniques for the saddle nose deformity in granulomatosis with polyangiitis: a systematic review. JAMA Otolaryngol Head Neck Surg. 143(5):507–512

    Article  Google Scholar 

  23. Lee KC, Ladizinski B, Federman DG (2012) Complications associated with use of levamisole-contaminated cocaine: an emerging public health challenge. Mayo Clin Proc 87(6):581–586

    Article  CAS  Google Scholar 

  24. Chang A, Osterloh J, Thomas J (2010) Levamisole: a dangerous new cocaine adulterant. Clin Pharmacol Ther 88(3):408–411

    Article  CAS  Google Scholar 

  25. Abdul-Karim R, Ryan C, Rangel C, Emmett M (2013) Levamisole-induced vasculitis. Proc (Bayl Univ Med Cent) 26(2):163–165

    Article  Google Scholar 

Download references

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Author information

Authors and Affiliations

  1. Royal National ENT and Eastman Dental Hospitals, 47-49 Huntley Street, London, WC1E 6DG, UK

    Samit N. Unadkat, Alfonso Luca Pendolino, Ivor Kwame & Peter J. Andrews

  2. Charing Cross Hospital, London, UK

    Samit N. Unadkat

  3. Ear Institute, UCL, London, UK

    Alfonso Luca Pendolino & Peter J. Andrews

  4. Aintree University Hospital NHS Foundation Trust, Liverpool, UK

    Andrew Swift

  5. Hammersmith Hospital, London, UK

    Charles Pusey

  6. University of Toronto, Toronto, ON, Canada

    Andres Gantous

Authors
  1. Samit N. Unadkat
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Alfonso Luca Pendolino
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Ivor Kwame
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Andrew Swift
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Charles Pusey
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Andres Gantous
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Peter J. Andrews
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Samit N. Unadkat.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Unadkat, S.N., Pendolino, A.L., Kwame, I. et al. Nasal reconstructive surgery for vasculitis affecting the nose: our two-centre international experience. Eur Arch Otorhinolaryngol 277, 3059–3066 (2020). https://doi.org/10.1007/s00405-020-06180-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00405-020-06180-8

Keywords

Search

Navigation