Sinonasal Sarcoidosis: Diagnosis and Management

Thomas A. Tami, MD

Disclosures

Semin Respir Crit Care Med. 2002;23(6) 

In This Article

Abstract and Introduction

Abstract

Sinonasal sarcoidosis is a fairly uncommon, yet clinically challenging, manifestation of this systemic disease. The diagnosis is often difficult to establish, treatment options are often unclear, and ultimate clinical responses can be quite variable. This article discusses the varied clinical presentations of this unusual nasal inflammatory process, as well as various treatment options, from simple local nasal hygiene measures to more aggressive systemic therapy. Although the role of surgical intervention is controversial, a simple review of some of the indications for surgery in these patients helps to clarify this somewhat cloudy clinical area. Aggressive clinical management in conjunction with long-term surveillance can often produce dramatic clinical responses for these difficult patients with sarcoidosis in the sinonasal area.

Objectives: Upon completion of this article, the reader will be able to: (1) describe the common presentations of sinonasal sarcoidosis; (2) apply the staging system for sinonasal sarcoidosis; (3) treat both mild and severe cases of sinonasal sarcoidosis; and (4) discuss the role of both medical and surgical management for patients with sarcoidosis of the nose and paranasal sinuses.
Accreditation: The University of Michigan is accredited by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians.
Credits: The University of Michigan designates this educational activity for a maximum of 1.0 hour in category one credits toward the AMA Physicians Recognition Award.

Introduction

Although most physicians who think about sarcoidosis consider primarily the pulmonary manifestations of this disease, otolaryngologists are often confronted with patients who have findings in the head and neck region. As a multisystem disease, sarcoidosis can display a wide array of presentations in this anatomical region. Salivary gland sarcoidosis can produce inflammation and swelling of any of the major or minor salivary glands. Severe xerostomia can result from inflammation and ultimate replacement of the secretory components of these glands. Ocular involvement can present as conjunctivitis or uveitis, both often severe and difficult problems to manage. Facial nerve paralysis has also been associated with sarcoidosis, and the combination of uveitis, parotitis, and facial paralysis is a well-known syndrome often referred to as uveoparotid fever (Heerfordt's disease). The skin of the face can also display the typical lesions of lupus pernio or cutaneous sarcoidosis. Otologic sarcoidosis has also been described with problems ranging from otitis media to vestibular symptoms to neurosensory hearing loss.

Some of the most difficult to manage patients are those who present with symptoms in the nose and paranasal sinuses. The incidence of sinonasal sarcoidosis is not precisely known but appears to be reasonably low. Initial reports from the Mayo Clinic estimated that < 1% of patients with sarcoidosis ultimately display sinonasal involvement.[1] However, a recent prospective study done at our institution suggested that the incidence is at least 4%, and may actually be much higher.[2] The diagnosis of sinonasal sarcoidosis, although occasionally obvious, is usually difficult to make because differentiating typical chronic sinusitis from granulomatous inflammation associated with sarcoidosis can be challenging. Even in those cases where the diagnosis can be definitely established, effective treatment can be difficult. This paper will discuss the various presentations of sinonasal sarcoidosis and present various treatment strategies that can reduce and often eliminate the symptoms associated with sinonasal sarcoidosis.

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