Nasal, sinus issues in ear, nose, and throat patients may point to AAV

In people with ear, nose, and throat (ENT) symptoms, having nasal crusting, body-wide symptoms, and a poor response to conventional treatments for sinusitis or nosebleeds strongly points to ANCA-associated vasculitis (AAV) as the cause, according to a study.

Nasal crusting refers to the buildup of dried mucus and scabs inside the nose, while sinusitis is an inflammation of the nasal cavity and sinuses, the air-filled spaces in the skull around the nose, eyes, and forehead.

In addition, the survey study of 29 ENT specialists in the Netherlands showed that, on examination, nasal crusting, nosebleeds, and septal perforation (a hole or tear in the wall that separates the nostrils) are also highly suggestive of AAV.

These red flags may help to distinguish AAV from more common conditions affecting the ear, nose, and throat. In addition, the specialists highlighted the importance of AAV patients with ENT involvement maintaining good nasal hygiene and undergoing frequent monitoring visits.

“These findings could support the development of a standardized scoring system to optimize the diagnostic process and follow-up for AAV,” researchers wrote.

The study, “Recognition of ear, nose and throat involvement in patients with ANCA-associated vasculitis: from in-depth interviews to insights for the future,” was published in European Archives of Oto-Rhino-Laryngology.

Online survey developed based on interviews with specialists

AAV is caused by the immune system mistakenly attacking small blood vessels, leading to inflammation and organ damage. ENT involvement is also common, particularly in people with the AAV types granulomatosis with polyangiitis and eosinophilic granulomatosis with polyangiitis.

Because ENT symptoms may resemble more common conditions, AAV diagnosis can be delayed, increasing the risk of permanent damage. Currently, there is no standardized method to help differentiate between AAV and other diseases that present similar ENT symptoms.

In this study, a team of researchers in the Netherlands conducted an exploratory multicenter study aimed at identifying the main factors that can help doctors detect and monitor AAV-related ENT disease activity, potentially providing a basis for a standardized examination and scoring system.

The team conducted in-depth interviews with four Dutch otorhinolaryngologists (specialists in ENT diseases) with at least five years of experience with treating AAV. They extracted information regarding AAV diagnosis based on ENT symptoms, strategies for appropriate follow-up, and hygiene recommendations for AAV patients with ENT involvement.

Results from the interviews allowed the researchers to develop an online survey that included statements regarding symptoms, physical examination findings, diagnosis, and follow-up.

Of the 29 specialists who initiated the survey, 25 completed them. Most participants (79.3%) worked in regional hospitals, 41.4% had over 10 years of experience, and 37.9% had treated more than 20 AAV patients.

Patients should receive clear instructions on nasal hygiene

ENT specialists identified nasal crusting, body-wide symptoms, and treatment-resistant chronic sinusitis and/or nosebleeds as the presenting symptoms most suggestive of ENT involvement in AAV.

In terms of findings via examination of the nasal cavities, nasal crusting was identified as being the most suggestive of AAV, followed by nose bleeds and septal perforation.

“Identification of AAV activity and distinguishing it from other more common diseases, infections or symptoms due to tissue damage is vital since each clinical presentation warrants a different treatment strategy,” the researchers wrote.

For instance, persistent AAV activity may require changes to immunosuppressive treatment, while infections benefit from nasal hygiene and/or antibiotics.

Specialists also recommended nasal care for people with AAV affecting the nose and sinuses, due to limited availability of effective local treatments. Recommendations included avoiding manipulating the nose, using high-flow saline rinses at least twice daily, and applying a gentle ointment to keep the nasal lining moist.

They also strongly agreed that patients should receive clear instructions on nasal hygiene.

Further research is needed to develop a scoring system helping ENT-specialists to differentiate active AAV from other more common diseases, infections or symptoms due to tissue damage.

For ongoing monitoring, specialists recommended a nasal examination at every follow-up visit, even in the absence of symptoms, because signs of active disease may be present without symptoms. They also recommended documenting signs of tissue damage over time to monitor disease progression.

According to the specialists, follow-up visits often range from every two to six months depending on disease activity and existing damage. During follow up, respondents emphasized that ENT doctors should work closely with specialists in inflammatory diseases or internal medicine when managing AAV.

Additionally, respondents fairly agreed that nasal lavage (saline wash) should be performed before examination.

Researchers noted this study is the first to comprehensively explore ENT specialists’ views on recognizing, treating, and monitoring AAV-related ENT disease. However, they cautioned that the study was exploratory and involved a relatively small number of specialists, meaning the findings cannot yet be used to create a standardized scoring system.

“Further research is needed to develop a scoring system helping ENT-specialists to differentiate active AAV from other more common diseases, infections or symptoms due to tissue damage,” they wrote. Such a scoring instrument could improve follow-up and inform treatment decisions for people with AAV, they added.