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GPA ENT Management — SCE Rheumatology MCQ

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ModerateVasculitisGPA ENT ManagementSCE Rheumatology

A 58-year-old man with established granulomatosis with polyangiitis reports persistent nasal crusting and intermittent blood-stained discharge. His systemic immunosuppressive treatment is being reviewed by rheumatology. Nasal endoscopy shows a septal perforation with friable granular mucosa but no purulent collection. He has no stridor, dyspnoea or voice change. Which adjunctive ENT management strategy is most appropriate?

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Correct answer: B — Ongoing ENT review with saline irrigation and local treatment or debridement as indicated

Explanation lettering: D = shown as A · E = shown as B · B = shown as D · A = shown as E

E is correct. GPA causes impaired mucociliary clearance, friable mucosa, crusting and progressive destructive sinonasal disease. Adjunctive ENT care therefore includes scheduled assessment, regular saline irrigation and, when indicated, topical or culture-directed treatment and careful removal of adherent crusts. This complements rather than replaces rheumatological assessment of active vasculitis. Empirical systemic antibiotics alone are inappropriate without evidence of bacterial infection. Cautery does not address the underlying mucosal disease and may worsen tissue injury around a perforation. Immediate septal repair is unsuitable while the mucosa is inflamed; reconstruction is reserved for carefully selected patients with stable, minimally active disease after conservative treatment. Continued ENT surveillance is required because upper-airway damage may progress and GPA can also cause clinically important subglottic stenosis.

Reference: Alam DS et al. Upper airway manifestations of granulomatosis with polyangiitis. Cleveland Clinic Journal of Medicine. 2012;79 Suppl 3:S16-S21. https://pubmed.ncbi.nlm.nih.gov/23203639/