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Upper Respiratory Tract Presentations

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PART 1 - OPD (Outpatient) Presentations

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1. Common Cold (Viral URI)

• Cause: Rhinovirus (most common), coronavirus, RSV, parainfluenza
• Presentation: Nasal congestion, runny nose, sneezing, mild sore throat, low-grade or no fever, mild myalgia
• Duration: 7-15 days; airway hyperreactivity may persist up to 8 weeks
• Management: Symptomatic - decongestants, antihistamines, analgesics. No antibiotics.
• Key point: Children average 6-8 URIs per year. Elective surgeries requiring airway manipulation should be deferred 4 weeks after active URI.
• Cummings Otolaryngology, p. 1494-1498

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2. Pharyngitis / Tonsillitis

• Cause: Viral (majority) or Group A Streptococcus (S. pyogenes) - the most common bacterial cause (20-40% of pediatric cases, 5-15% of adult cases)
• Presentation: Abrupt onset fever, sore throat, pain on swallowing, submandibular lymphadenopathy. Hypertrophied tonsils, palatal petechiae, confluent tonsillar exudate. Cough and hoarseness are rare with streptococcal infection.
• Other bacterial causes: Diphtheria (thick grey membrane), Gonorrhea (in sexually active patients)
• Other viral causes: EBV (infectious mononucleosis), HSV (stomatitis + pharyngitis), Coxsackie A (herpangina, hand-foot-mouth)

• Diagnosis (Modified Centor Score):

• Score 0-1: No testing, no antibiotics
• Score ≥2: Rapid strep test or throat culture
• Rapid NAAT sensitivity 97.5%, specificity 95% (preferred); antigen test sensitivity only ~85%
• Gold standard: Throat swab culture
• Treatment: Penicillin V (10 days) or amoxicillin; prevents rheumatic fever (not glomerulonephritis). Symptomatic: paracetamol 15 mg/kg/dose q4h or ibuprofen 10 mg/kg/dose q6h.
• Sequelae if untreated: Scarlet fever, rheumatic fever, post-streptococcal GN, bacteremia, peritonsillar abscess
• Goldman-Cecil Medicine, p. 174-185

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3. Acute Rhinosinusitis

• Cause: Viral (majority); bacterial (S. pneumoniae, H. influenzae, M. catarrhalis) in <2% of cases
• Presentation: Nasal congestion, purulent nasal discharge, facial pain/pressure, headache, anosmia, post-nasal drip
• Acute: <4 weeks; Subacute: 4-12 weeks; Chronic: >12 weeks
• Management: Viral - symptomatic (nasal saline irrigation, decongestants). Bacterial - amoxicillin/clavulanate if persistent >10 days, worsening, or severe symptoms. Nasal corticosteroids for recurrent/chronic disease.
• Red flags (refer/escalate): Periorbital swelling, proptosis, diplopia (orbital extension), severe headache, neck stiffness, altered consciousness (intracranial extension)

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4. Allergic Rhinitis

• Presentation: Sneezing, bilateral watery rhinorrhoea, nasal pruritus, itchy watery eyes, nasal congestion. Seasonal (pollens) or perennial (dust mites, mold, pet dander).
• Signs: Pale/bluish swollen turbinates, clear discharge, "allergic salute," allergic shiners, Dennie-Morgan lines
• Management: Allergen avoidance, intranasal corticosteroids (first line), oral/intranasal antihistamines, leukotriene receptor antagonists, allergen immunotherapy for refractory cases.

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5. Laryngitis (Hoarseness in OPD)

• Acute: Viral infection, voice overuse. Hoarseness, aphonia, mild throat discomfort, dry cough. Self-limiting in 1-3 weeks. Voice rest.
• Chronic: GERD (reflux laryngitis), smoking, vocal cord nodules, polyps, or early malignancy - requires laryngoscopy.

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6. Infectious Mononucleosis (EBV)

• Presentation: Sore throat (exudative pharyngitis), fever, severe fatigue, posterior cervical lymphadenopathy, splenomegaly (50%), hepatomegaly
• Diagnosis: Heterophile antibody (Monospot) - positive in 60-90% by weeks 2-3; EBV IgM (>90% sensitive, preferred in children <4 years)
• OPD management: Supportive, rest, analgesics. Avoid contact sports (spleen rupture risk). Do NOT give amoxicillin/ampicillin (causes maculopapular rash in >90% of EBV patients).
• Caution: Massive tonsillar enlargement can cause URT obstruction - monitor carefully. Glucocorticoids should be used with caution and avoided in children <14 years (may delay lymphoid malignancy diagnosis).
• Rosen's Emergency Medicine, p. 3685

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PART 2 - Emergency Department Presentations

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1. Epiglottitis (Supraglottitis) - ⚠️ AIRWAY EMERGENCY

• Cause: Post-Hib vaccine era: now more common in adults. Causes include S. aureus, S. pyogenes, S. pneumoniae, H. influenzae type b (still in unvaccinated), thermal/chemical injury.
• Presentation (Classic triad + more):
  • 3 Ds: Drooling, Dysphagia, Distress
  • High fever, rapidly progressive severe sore throat, muffled/"hot potato" voice, restlessness, lethargy
  • Tripod/sniffing position (leaning forward to open airway)
  • Stridor (inspiratory), signs of air hunger
  • Sore throat disproportionate to pharyngeal findings - key clue
  • Adults: more subtle and insidious onset; anterior neck tenderness
  • Mortality in adults: 6-7% if mismanaged
• Lateral neck X-ray: "Thumbprint sign" (enlarged epiglottis) - diagnostic but do NOT delay airway management for imaging
• Management:
  • Do NOT agitate the patient; do NOT examine throat with a tongue depressor in children (may precipitate complete obstruction)
  • Secure airway first - OR/ICU setting with ENT/anesthesia standby
  • IV antibiotics: ceftriaxone + add vancomycin for MRSA concern
  • Heliox, nebulized epinephrine as temporizing measures
• Textbook of Family Medicine, p. 47-65; Rosen's Emergency Medicine, p. 3533-3537

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2. Croup (Laryngotracheobronchitis) - Common Pediatric Emergency

• Cause: Parainfluenza virus type 1 (most common), also RSV, influenza. Most common URT infection causing airway obstruction in young children (6 months - 3 years).
• Presentation:
  • Barking (seal-like) cough, hoarseness, inspiratory stridor
  • Low-grade fever, preceded by viral prodrome (1-2 days)
  • Worse at night, worse with agitation
  • Mild: barking cough, no resting stridor; Moderate: resting stridor ± retractions; Severe: resting stridor + significant retractions + agitation/altered consciousness
• X-ray: AP neck - "Steeple sign" (subglottic narrowing)
• Westley Croup Score used for severity grading
• Management:
  • Mild: single oral dose dexamethasone 0.15-0.6 mg/kg - reduces symptoms, hospitalizations, ED length of stay
  • Moderate-severe: dexamethasone + nebulized epinephrine (L-epinephrine 5 mL of 1:1000, or racemic epinephrine)
  • Observe for 2-4 hours post-epinephrine before discharge (rebound effect)
  • Discharge when free of resting stridor and distress
• Rosen's Emergency Medicine, p. 3540-3546

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3. Bacterial Tracheitis - ⚠️ Critical Emergency

• Cause: S. aureus (most common, including MRSA), also S. pneumoniae, H. influenzae. Secondary bacterial infection on viral croup.
• Presentation:
  • Croup-like illness that suddenly deteriorates
  • High fever, toxic appearance, marked respiratory distress, stridor
  • Does NOT respond to croup treatment (nebulized epinephrine)
  • Can progress rapidly to complete airway obstruction
• Imaging: Subglottic membrane or irregularity on lateral neck X-ray
• Diagnosis and treatment: Bronchoscopy is both diagnostic (pseudomembrane in trachea) and therapeutic
• Antibiotics: Cephalosporin + MRSA coverage (vancomycin or clindamycin)
• Usually requires ICU admission and often intubation
• Rosen's Emergency Medicine, p. 3549-3553

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4. Peritonsillar Abscess (PTA) - Emergency/Urgent

• Definition: Most common deep neck space infection. Collection between the tonsil capsule and the superior pharyngeal constrictor muscle.
• Age group: Older children, teenagers, young adults
• Presentation:
  • Severe unilateral throat pain, odynophagia, trismus (2/3 of patients)
  • Muffled "hot potato" voice, drooling
  • Uvula displaced away from the abscess (50%)
  • Peritonsillar bulge, asymmetric tonsillar swelling
  • Otalgia (referred pain)
  • Severe respiratory distress is unusual (differentiates from epiglottitis)
• Microbiology: Polymicrobial - S. pyogenes, S. aureus (including MRSA), anaerobes
• Investigation: Posterior pharynx ultrasound (confirms abscess, guides aspiration); CT if deep neck extension suspected (carotid artery lies 25 mm posterolateral to tonsillar pillar)
• Treatment:
  • Needle aspiration or incision and drainage (antibiotics alone insufficient for formed abscess; adequate for phlegmon/cellulitis)
  • IV antibiotics: ampicillin-sulbactam or clindamycin
  • Tonsillectomy ("quinsy tonsillectomy") for recurrent cases (10-20% recurrence)
• Rosen's Emergency Medicine, p. 3676-3680

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5. Retropharyngeal Abscess (RPA) - ⚠️ Airway Emergency

• Age group: Primarily children <4 years (retropharyngeal nodes regress with age); occasionally adults post-trauma/instrumentation
• Presentation:
  • High fever, neck pain, dysphagia, refusal to eat, neck stiffness
  • Posterior pharyngeal wall bulging (subtle, may be missed)
  • Stridor and respiratory distress if airway compressed
  • Torticollis, drooling
  • Potentially life-threatening: Risk of airway obstruction, mediastinitis, aspiration (abscess rupture), carotid artery erosion (Lemierre's syndrome)
• Imaging: Lateral neck X-ray (increased prevertebral soft tissue >7mm at C2, >14mm at C6 in children); CT neck with contrast is preferred to define extent
• Treatment: IV antibiotics + surgical drainage in OR. Do NOT examine pharynx vigorously - may rupture the abscess.
• Rosen's Emergency Medicine, p. 3690

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6. Airway Foreign Body - ⚠️ Emergency

• Age group: Children 6 months - 4 years (most common), also elderly
• Presentation:
  • Sudden onset choking, coughing in a previously well child (classic history)
  • Stridor (upper airway), wheeze (lower airway)
  • Unilateral decreased breath sounds
  • In adults: history of eating + sudden choking episode
  • Esophageal FB: drooling, refusal to eat, no stridor
• Imaging: Plain films often negative (radiolucent food material); asymmetric hyperinflation or atelectasis on CXR. X-rays must not delay bronchoscopy if strongly suspected.
• Treatment:
  • Complete obstruction: Heimlich maneuver (adults/older children), back blows + chest thrusts (infants)
  • Bronchoscopy: diagnostic and therapeutic
  • Emergency cricothyroidotomy if cannot intubate/ventilate (needle cricothyroidotomy preferred in infants)
• Textbook of Family Medicine, p. 69-73; Rosen's Emergency Medicine, p. 3556-3562

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7. Epistaxis (Severe) - Emergency

• Common cause (OPD): Anterior nasal bleeding from Kiesselbach's plexus (Little's area) - nasal dryness, digital trauma, anticoagulants
• Emergency causes: Posterior epistaxis, hypertension, coagulopathy, sinonasal tumors
• Risk factors: Nasal sicca, trauma, hypertension, coagulopathy (often therapeutic/iatrogenic), sinonasal neoplasia. Adolescent boys with recurrent epistaxis: consider juvenile nasopharyngeal angiofibroma.
• Life-threatening if: Posterior bleed, patient on anticoagulants, underlying coagulopathy - can cause respiratory compromise or hypovolemic shock
• Management:
  • Direct pressure (anterior)
  • Silver nitrate cautery
  • Anterior packing (Vaseline gauze, Merocel) - can cause hypoxemia, especially in cardiopulmonary disease
  • Posterior packing or balloon (Foley catheter)
  • Nasal packing complication: toxic shock syndrome
  • Interventional radiology embolization or ENT ligation for refractory cases
• Textbook of Family Medicine, p. 75-86

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Quick Reference Summary Table

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• Rosen's Emergency Medicine: Concepts and Clinical Practice - URT Emergency presentations
• Goldman-Cecil Medicine - Pharyngitis, Streptococcal disease
• Textbook of Family Medicine (9e) - Epiglottitis, Key URT points
• Cummings Otolaryngology Head and Neck Surgery - URI in clinical context

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Chronic Granulomatous Conditions of the Nasal Cavity

Overview

• Scott-Brown's Otorhinolaryngology Vol. 1, p. 5392-5404

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Classification of Chronic Nasal Granulomata

A. AUTOIMMUNE / VASCULITIC

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1. Granulomatosis with Polyangiitis (GPA) - formerly Wegener's Granulomatosis

• Mean age at diagnosis: 40-50 years; equal sex distribution
• Incidence: 10-15 per million per year; predominantly Caucasian (>90%)
• Prevalence up to 5 per 100,000 in Europe

• Classic triad: necrotizing granulomatous inflammation of the upper and lower airways + systemic necrotizing vasculitis of small-to-medium vessels + focal/proliferative glomerulonephritis
• Autoimmune: ANCA (anti-neutrophil cytoplasmic antibody) activates neutrophils causing vascular endothelial damage
• Association with chronic nasal S. aureus carriage (associated with relapses)

• Chronic nasal obstruction, purulent or bloody nasal discharge, nasal crusting, epistaxis, malodorous discharge
• Mucosal cobblestoning of septum and lateral nasal wall (endoscopic appearance)
• Septal perforation and saddle nose deformity from ischemic cartilage necrosis
• Subglottic stenosis in ~20% (life-threatening)

• Upper airway: 90-95% | Lungs: 54-85% (nodules, cavitation, alveolar hemorrhage) | Kidneys: 51-80% (GN) | Eyes: 35-52% (conjunctivitis, episcleritis, proptosis, visual loss)
• Oral: gingival hyperplasia ("strawberry gums"), oropharyngeal ulcers
• Skin: ulcers, nodules | Neuro: meningitis, mononeuritis multiplex, cranial nerve neuropathy

• c-ANCA (PR3-ANCA): Sensitivity 91%, specificity 99% in generalized active disease; positive in >90% of active generalized disease; falls to 60% in localized disease; 10-20% may be ANCA-negative (30% in localized disease)
• False-positive c-ANCA: cocaine abuse
• 1990 ACR Classification Criteria (2 of 4):
  • Nasal/oral inflammation (painful oral ulcers, purulent/bloody nasal discharge)
  • Abnormal CXR (nodules, infiltrates, cavities)
  • Abnormal urinary sediment (microscopic hematuria ± red cell casts)
  • Granulomatous inflammation on biopsy
• ESR, CRP, serum creatinine, urea, urinalysis, chest X-ray
• Biopsy: Histology shows granulomatous inflammation + vasculitis + necrosis. Paranasal sinus biopsies more diagnostic than nasal specimens. Non-diagnostic in up to 50% of head and neck specimens.
• CT/MRI: Mucosal thickening early; bone destruction (62%) + neo-osteogenesis (78%) later. CT: combination of bone destruction + new bone formation is virtually diagnostic. MRI: 'tramlining' (fat signal from sclerotic sinus wall on T2); orbital involvement in 37%.

• Untreated: fatal - mean survival 5 months
• Steroids alone: 50% mortality
• Remission induction: High-dose corticosteroids + cyclophosphamide (2 mg/kg/day, max 200 mg/day) - remission rate 93%
• Alternative to cyclophosphamide: Methotrexate (effective in limited/less severe GPA); Rituximab (anti-CD20, as effective as cyclophosphamide - proven in RAVE trial)
• Maintenance: Azathioprine or methotrexate (to reduce cyclophosphamide toxicity)
• Cyclophosphamide toxicities: alopecia, hemorrhagic cystitis, opportunistic infections; 11x risk of leukemia/lymphoma, 33x risk of bladder cancer
• Nasal surgery should be avoided - instrumentation exacerbates disease; treat superinfection of sinuses for local symptoms
• Over half of patients relapse at least once; monitored by c-ANCA titers
• Scott-Brown's Otorhinolaryngology Vol. 1, p. 7879-8100; Cummings Otolaryngology, p. 1354-1363; Fishman's Pulmonary Diseases, p. 2709-2713

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2. Eosinophilic Granulomatosis with Polyangiitis (EGPA) - Churg-Strauss Syndrome

• Nasal involvement: 50-60% (vs 90-95% for GPA)
• Triad: asthma, eosinophilia, necrotizing vasculitis
• p-ANCA (MPO) positive
• Nasal: allergic rhinitis, nasal polyposis
• Systemic: eosinophilic pneumonia, cardiac disease, mononeuritis multiplex
• Treatment: corticosteroids ± cyclophosphamide

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B. GRANULOMATOUS DISEASE OF UNKNOWN ETIOLOGY

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3. Sarcoidosis

• Tiny pale granulomas on hypertrophic erythematous friable mucosa; ulceration, crusting, adhesions
• Anterior nasal septum most often affected - may perforate (especially after surgery)
• Lupus pernio (purplish thickening of overlying nasal skin) = cutaneous marker of chronic systemic sarcoid

• Nasal bone: rarefaction, punctate osteolysis (up to 25%); soft tissue mass/expansion of nasal bridge
• Uveoparotid fever (Heerfordt's syndrome): salivary gland enlargement + uveitis + facial palsy (5-10%)
• Laryngeal involvement (1-5%): most commonly supraglottis

• No pathognomonic test; diagnosis by exclusion + combination of clinical features, imaging, histology, biochemistry
• Biopsy of abnormal nasal mucosa: >90% positive if mucosa looks abnormal; random biopsy of normal mucosa: 92% negative
• Serum ACE: Elevated in up to 85% during active disease (non-specific; also elevated in TB, leprosy, primary biliary cirrhosis)
• Serum and urinary calcium elevated in ~15%
• CXR/CT chest for staging: Stage I = bilateral hilar LN; II = hilar LN + pulmonary infiltrates; III = infiltrates alone; IV = pulmonary fibrosis
• CT nasal: soft tissue nodules on septum/turbinates (characteristic); sclerosis and osteolysis
• MRI brain: granulomatous basal meningeal involvement

• Variable course: 2/3 spontaneously remit (usually stage I and II)
• 10-30% follow chronic course despite therapy
• Topical nasal: Intranasal steroids, glucose/glycerine drops, nasal douching
• Systemic: Oral corticosteroids for life-threatening disease or critical organ involvement (steroid-sparing: methotrexate, azathioprine)
• Hydroxychloroquine for cutaneous/sinonasal disease (<50% response; risk of ocular toxicity)
• TNF-alpha inhibitors (infliximab, etanercept) for refractory disease
• Intra-lesional steroid injections for focal lesions; lupus pernio may respond dramatically
• Endoscopic sinus surgery: limited role - only for obstructing lesions or secondary infection in selected cases; avoid septal surgery (increased perforation risk); surgery should be avoided in active disease
• Scott-Brown's Otorhinolaryngology Vol. 1, p. 7743-7877; Cummings Otolaryngology, p. 1364-1365

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C. INFECTIOUS GRANULOMATA

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4. Rhinoscleroma (Scleroma)

• Endemic: Central America, Chile, Central Africa, India, Indonesia, Middle East
• More common in females (13:1 female:male ratio); 2nd-3rd decade
• Crowded, rural areas with poor hygiene and nutrition
• Contracted by direct inhalation; begins at areas of epithelial transition (nasal vestibule)

• Mikulicz cells: Large macrophages with clear cytoplasm containing bacilli (Klebsiella)
• Russell bodies: Bloated plasma cells with birefringent eosinophilic inclusions
• Pseudoepitheliomatous hyperplasia

• Long-term antibiotics: tetracycline, fluoroquinolones (ciprofloxacin), aminoglycosides, cephalosporins
• Biopsy + debridement of lesions
• K.J. Lee's Essential Otolaryngology, p. 8099-8127; Scott-Brown's Vol. 2, p. 4277-4289

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5. Rhinosporidiosis

• Endemic: Africa, Pakistan, Sri Lanka, India
• Transmission: Exposure to spores in contaminated dust, soil, or stagnant water (public bathing)

• Surgical excision (primary treatment - infection not highly responsive to medical therapy alone)
• Long-term dapsone therapy (especially for multisite disease)
• K.J. Lee's Essential Otolaryngology, p. 8132-8146; Cummings Otolaryngology, p. 1683-1687

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6. Nasal Tuberculosis (TB) / Lupus Vulgaris

• Lupus vulgaris: nodular, ulcerative, scarring lesions in nasal cavities; apple-jelly nodules on diascopy
• Secondary TB pharyngitis: multiple painful shallow ulcers - only with massive cavitating pulmonary TB
• Resurgence parallels HIV epidemic; extrapulmonary TB increased in HIV-infected individuals

• Ziehl-Neelsen stain (acid-fast bacilli) / phenol auramine stain (more sensitive)
• Culture (gold standard); PCR; ELISA for antigens
• Association with pulmonary disease on CXR/CT
• Serum ACE may be elevated (non-specific)

• First-line anti-TB therapy: isoniazid + rifampicin + pyrazinamide (triple therapy) - nasal/pharyngeal TB resolves with pulmonary treatment
• All cases managed with a TB specialist; monitor for drug resistance (MDR-TB)
• Scott-Brown's Vol. 2, p. 4457-4507

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7. Leprosy (Leprous Rhinitis)

• Mycobacterium leprae; nasal involvement is an early feature of lepromatous leprosy
• Nasal mucosa: congestion, crusting, epistaxis; may lead to collapse of nasal bridge (saddle nose)
• Histology: foamy macrophages (Virchow cells) containing bacilli; non-caseating granulomata in tuberculoid leprosy
• Diagnosis: slit-skin smear, biopsy (Wade-Fite stain for acid-fast bacilli), lepromin test
• Treatment: Multi-drug therapy (MDT) - dapsone + rifampicin ± clofazimine (WHO regimen)

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8. Syphilitic Rhinitis (Tertiary Syphilis)

• Treponema pallidum; nasal involvement in tertiary/congenital syphilis
• Gummata (granulomatous lesions) in the nose: perforation of hard palate and nasal septum, saddle nose deformity
• Diagnosis: RPR, VDRL, FTA-ABS, TPHA; biopsy (obliterative endarteritis)
• Treatment: Penicillin G (benzathine penicillin); doxycycline if penicillin-allergic

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9. Fungal Granulomata

• Organisms: Aspergillus spp., Mucor, Rhizopus (mucormycosis), Histoplasma, Blastomyces, Coccidioides
• Nasal: crusting, epistaxis, facial pain, black necrotic eschar (mucormycosis)
• Diagnosis: nasal endoscopy + biopsy (histopathology + fungal culture); CT/MRI for extent
• Treatment: Amphotericin B (mucormycosis/aspergillus) + urgent surgical debridement; voriconazole (aspergillosis); correct underlying immunosuppression

• Aspergillus mycetoma (fungus ball) in paranasal sinuses: unilateral opacification with metallic flecks on CT
• Treatment: Functional endoscopic sinus surgery (FESS) + clearance of fungal debris

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D. NEOPLASTIC MIMIC (IMPORTANT DDx)

10. NK/T-Cell Lymphoma (Lethal Midline Granuloma - historical term)

• EBV-associated; previously misclassified as "lethal midline granuloma" or "idiopathic midline destructive disease"
• Nasal: destructive midline lesion spreading as a thin sheet enveloping turbinates and septum; may extend into nasopharynx or sinuses. Usually unilateral presentation initially. Nodal involvement unusual.
• CT/MRI: cannot be distinguished from true granulomatous disease without biopsy
• Diagnosis: Biopsy with immunohistochemistry (CD56+, CD3+, EBV in situ hybridization - EBER positive)
• Treatment: Radiotherapy ± chemotherapy (CHOP-like regimens)
• Scott-Brown's Vol. 1, p. 5435-5439

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E. COCAINE-INDUCED MIDLINE DESTRUCTIVE LESION (CIMDL)

• Mimics GPA on imaging and clinically; can give false-positive c-ANCA
• Typically unilateral initially; extent of mid-face destruction often greater than GPA at presentation (due to delayed presentation)
• CT: mucosal thickening + destruction of inferior/middle turbinate; septum may be spared initially
• Diagnosis of exclusion; detailed social/drug history essential
• Management: cessation of cocaine use; no immunosuppression
• Scott-Brown's Vol. 1, p. 5425-5428; Fishman's Pulmonary Diseases, p. 2613-2629

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Diagnostic Approach - Key Investigations

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Summary Differential Diagnosis Table

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• Scott-Brown's Otorhinolaryngology Head & Neck Surgery Vol. 1 - Sarcoidosis, GPA, granulomatous imaging
• Scott-Brown's Otorhinolaryngology Head & Neck Surgery Vol. 2 - Rhinoscleroma, TB
• K.J. Lee's Essential Otolaryngology - Rhinoscleroma, Rhinosporidiosis
• Cummings Otolaryngology Head & Neck Surgery - GPA, Sarcoidosis (sinonasal)
• Fishman's Pulmonary Diseases and Disorders - GPA systemic features, CIMDL