Sarcoidosis of the head and neck

When inflammation is not just inflammation-A review of systemic diseases of the nose and sinuses part 1: IgG4-related disease and sarcoidosis

BACKGROUND

Chronic rhinosinusitis is a very common condition. IgG4-related disease (IgG4-RD) and sarcoidosis are systemic diseases which can contribute to the development of chronic rhinosinusitis in select patients.

OBJECTIVE

Characterize the presenting features, diagnostic criteria, workup, and management of sinonasal IgG4-RD and sarcoidosis as they are encountered in otolaryngology clinics.

METHODS

Full length manuscripts published 2000 or later were reviewed. A separate search was conducted for each disease. Pertinent clinical features related to sinonasal manifestations of IgG4-RD and sarcoidosis were collected and reported in this review.

RESULTS

404 references were discovered during literature review process. In total, 42 references for IgG4-RD and 34 references for sarcoidosis were included in this review.

CONCLUSION

IgG4-RD and sarcoidosis are autoimmune inflammatory conditions that can affect many systems of the body. For both disease entities, sinonasal disease is a less common presentation which can lead to delayed diagnosis. Sinonasal IgG4-RD commonly presents in the setting of multisystem disease. All with other clinical features, biopsy plays a key role in the diagnosis for both diseases. Treatment for IgG4-RD consists primarily of steroids and rituximab which can lead to excellent and durable remission. A variety of immunosuppressive agents are used in the management of sarcoidosis. Surgery for IgG4-RD is primarily utilized for tissue biopsy, although resection or debulking may be considered. For sarcoidosis, surgery can be used for tissue biopsy and functional sinus surgery can offer symptomatic relief in many patients.

Beyond the Usual Suspects: Primary Premaxilla Sarcoidosis

Introduction

Sarcoidosis is an idiopathic systemic granulomatous disorder that can affect multiple organs, including rare extrapulmonary sites like the premaxilla. This case report presents a rare occurrence of premaxillary sarcoidosis, a condition scarcely reported in medical literature.

Case Report

The patient, a 62-year-old male, presented with a progressively enlarging painless swelling on the right cheek over a three-year period. Despite multiple Fine Needle Aspiration Cytology (FNAC) examinations yielding no conclusive diagnosis, a contrast-enhanced computed tomographic (CT) scan revealed an ill-defined lesion in the premaxillary soft tissue. Biopsy and subsequent excision procedures confirmed the presence of non-caseating granulomas with asteroid bodies, indicative of sarcoidosis. With no systemic involvement and complete excision of the disease, further treatment was not necessary.

Conclusion

This case highlights the challenges in diagnosing premaxillary (Extrapulmonary Sarcoidosis) sarcoidosis due to its rarity and resemblance to other dental and maxillofacial conditions and granulomatous lesions. Accurate diagnosis requires a high index of suspicion, multidisciplinary approach, involving clinical assessment, histopathological analysis, and imaging modalities. By deepening our understanding of these uncommon presentations, this report aims to enhance clinical awareness and contribute to improved patient outcomes.

Autoimmune disease of head and neck, imaging, and clinical review

Autoimmune disease of the head and neck (H&N) could be primary or secondary to systemic diseases, medications, or malignancies. Immune-mediated diseases of the H&N are not common in daily practice of radiologists; the diagnosis is frequently delayed because of the non-specific initial presentation and lack of familiarity with some of the specific imaging and clinical features. In this review, we aim to provide a practical diagnostic approach based on the specific radiological findings for each disease. We hope that our review will help radiologists expand their understanding of the spectrum of the discussed disease entities, help them narrow the differential diagnosis, and avoid unnecessary tissue biopsy when appropriate based on the specific clinical scenarios.

Evaluation and Management of a Neck Mass

Neck masses are common physical examination findings seen in the outpatient setting but identifying an underlying cause can be challenging. A careful medical history should be obtained, and a thorough physical examination should be performed, which will guide the need for follow-up examination with imaging, biopsies, and specialist referrals. The goal of this article is to provide a working framework to evaluate and manage some of the most common causes of adult neck masses.

Sarcoidosis of the ear, nose and throat: A review of the literature

OBJECTIVES

Sarcoidosis is a multisystemic inflammatory disease with extrathoracic manifestations, most commonly affecting the young and middle-aged, female and Black populations. Diagnosis usually requires evidence of non-caseating granulomata and, when treated, prognosis is usually favourable. We aim to establish the incidence, clinical features and optimal treatment of ENT manifestations of this disease.

DESIGN

We performed a PubMed literature review to determine the evidence base supporting this.

RESULTS

ENT manifestations are present in 5%-15% of patients with sarcoidosis, often as a presenting feature, and require vigilance for swift recognition and coordinated additional treatment specific to the organ. Laryngeal sarcoidosis presents with difficulty in breathing, dysphonia and cough, and may be treated by speech and language therapy (SLT) or intralesional injection, dilatation or tissue reduction. Nasal disease presents with crusting, rhinitis, nasal obstruction and anosmia, usually without sinus involvement. It is treated by topical nasal or intralesional treatments but may also require endoscopic sinus surgery, laser treatment or even nasal reconstruction. Otological disease is uncommon but includes audiovestibular symptoms, both sensorineural and conductive hearing loss, and skin lesions.

CONCLUSIONS

The consequences of ENT manifestations of sarcoidosis can be uncomfortable, disabling and even life-threatening. Effective management strategies require good diagnostic skills and use of specific therapies combined with established treatments such as corticosteroids. Comparisons of treatment outcomes are needed to establish best practice in this area.

Otorhinolaryngology Manifestations of Systemic Illness

Ear-nose-throat (ENT) manifestations are among the most frequently observed clinical features of systemic illnesses. The patients often present with overt findings of head and neck lesions such as salivary gland swelling or lymphadenopathy. In contrast, patients may present with covert findings of auditory, nasal, and laryngeal symptoms that are less obvious and are often overlooked. Therefore, clinicians should have a high index of suspicion to identify the underlying disease. Early recognition and prompt treatment or referral to specialists may prevent morbidity and mortality. This article discusses various systemic illnesses with ENT manifestations that are commonly encountered.

Evaluation of Lamina Cribrosa by Using Enhanced Depth Imaging Optical Coherence Tomography in Ocular Sarcoidosis during Quiescent Phase

SIGNIFICANCE

Enhanced depth imaging optical coherence tomography is a useful method to allow for the evaluation of deep ocular structures, such as choroid and lamina cribrosa (LC), which are affected by ocular diseases. We hypothesized that choroidal and optic nerve inflammation in patients with ocular sarcoidosis (OS) might affect the LC structure.

PURPOSE

This study aimed to evaluate changes in the LC and anterior LC depth (ALCD) in patients with OS.

METHODS

Forty-eight eyes of 26 patients with OS who received the treatment of panuveitis and were in the quiescent phase for at least 6 months were included in the study. Thirty healthy subjects' randomly selected eyes were selected as a control group. Eyes with OS were divided into two subgroups according to the presence (OS eyes with glaucoma [OSWG], n = 23) or absence of glaucoma (OS eyes without glaucoma [OSWOG], n = 25). The LC thickness, ALCD, and peripapillary choroidal thickness were measured using enhanced depth imaging optical coherence tomography in eyes with OS and in controls.

RESULTS

The mean LC thickness was found significantly thinner in both OSWG and OSWOG eyes compared with the healthy controls (P < .001 and P = .001, respectively). The mean ALCD was found significantly higher in OSWG eyes (462 ± 65 μm) compared with OSWOG eyes (417 ± 58 μm) and the healthy control eyes (397 ± 59 μm; P = .03 and P = .001, respectively). The average peripapillary choroidal thickness was found to be significantly thinner in OSWG eyes compared with the control eyes (P = .05).

CONCLUSIONS

The present study revealed that OS is associated with a thinned LC independent of the presence of glaucoma. The degenerative changes in the LC, which is the transition point of the retinal nerve fibers, may cause long-term visual dysfunction in OS. These degenerative changes should be prevented by controlling inflammation with early diagnosis and treatment in patients with OS.

Phenotypes of Chronic Rhinosinusitis

Chronic rhinosinusitis (CRS) is a complex heterogeneous disease with different phenotypes and endotypes. Recent advances in our understanding of the pathogenetic mechanisms of CRS endotypes have led to the introduction of effective biologic agents for CRS management. Traditionally, CRS phenotypes have been divided into with or without nasal polyps depending on the presence of polyps. Although this classification does not reflect the various endotypes that are recently emerging, it is simple and easily recognized by clinicians. Other phenotypes of CRS are fungal rhinosinusitis (including invasive and noninvasive subtypes), infectious rhinosinusitis, aspirin-exacerbated respiratory disease, cystic fibrosis, pediatric CRS, and CRS associated with systemic diseases. This article reviews the diagnostic approaches and up-to-date treatment strategies for each CRS phenotype with the hope that a better understanding of endotypes will result in a more scientific understanding of phenotypes and precise, personalized treatments.

Saprochaete clavata Infection in Immunosuppressed Patients: Systematic Review of Cases and Report of the First Oral Manifestation, Focusing on Differential Diagnosis

Background: Saprochaete clavata infection is an emerging issue in immunosuppressed patients, causing fulminant fungaemia. The purpose of this systematic review of cases is to retrieve all cases of S. clavata infection and describe oral lesions as the first manifestation of S. clavata infection. Methods: We report the first case of intraoral S. clavata infection in Acute Myeloid Leukemia (AML) affected subject, presenting as multiple grayish rapidly growing ulcerated swellings, and provide a review of all published cases of infection caused by S. clavata, according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, conducted by searching SCOPUS, Medline, and CENTRAL databases. Only articles in English were considered. Individual patient data were analyzed to identify risk factors for S. clavata infection. Results: Seventeen of 68 retrieved articles were included in the review reporting data on 96 patients (mean age 51.8 years, 57 males and 38 females). Most cases were disseminated (86) with a 60.2% mortality rate. Ninety-five were hematological patients, with AML being the most common (57 cases). Conclusions:S. clavata infection in immunosuppressed patients has a poor prognosis: middle-age patients, male gender and Acute Myeloid Leukemia should be considered risk factors. In immunosuppressed patients, the clinical presentation can be particularly unusual, imposing difficult differential diagnosis, as in the reported case.

Localised laryngotracheal amyloidosis: a differential diagnosis not to forget

We present a case of multifocal laryngotracheal amyloidosis (LTA) in a 43-year-old man with persistent and progressive dysphonia and dyspnoea, and a first inconclusive histology. Although laryngeal amyloidosis accounts for fewer than 1% of all benign laryngeal tumours, it is in fact the most common site of amyloid deposition in the head, neck and respiratory tract. The clinical scenario is non-specific and diagnosis depends on a high degree of suspicion and on histology. Imaging is useful in mapping lesions, which are often more extensive than they appear during laryngoscopy. Despite being a benign entity, the prognosis is variable with a high-rate and long-latency recurrences, requiring long-term follow-up.

Extensive bony sarcoidosis of the head and neck region: a rare presentation

We present a rare case of sarcoidosis with extensive bony destruction of the maxillofacial and skull base bones. A 65-year-old woman was referred with an asymptomatic, non-healing dental socket. Examination revealed an oroantral fistula that was biopsied and repaired under general anaesthesia. Investigations included plain and cross-sectional imaging. Serological tests, in particular ACE, were normal. Histology showed benign florid granulomatous inflammation. At 6 months, the patient remained asymptomatic. She was re-referred 3 years later with further bony destruction of her maxilla and mandible. Repeat imaging showed intrathoracic lymphadenopathy and skull base involvement. Repeat biopsy confirmed granulomatous inflammation. Given the pulmonary, histological and radiological findings, a sarcoidosis diagnosis was made. Following multidisciplinary team meetings, the patient was treated with methotrexate and arrangements made for close monitoring. This case highlights the need for a consensus in identifying, treating and developing a follow-up protocol in such patients.

Sarcoidosis, the master mimicker

Sarcoidosis is an idiopathic multisystem disorder characterized by noncaseating granulomas. The article focuses on the typical imaging manifestations of sarcoid and the common differentials that need to be included when appropriate. Mistaking a sarcoid-mimicking disease for sarcoid can result in increased patient morbidity and mortality. The pulmonary system is the most common system involved and is typically the best understood by the radiologist, however a deeper knowledge of the pulmonary findings and features of sarcoid in other organ systems is critical. There is a myriad of sarcoid imaging manifestations that can involve every organ system. Often a confidant diagnosis of sarcoid can be made, however a broad differential may need to be considered- differential diagnoses include primary neoplasm, metastatic disease, infectious, and inflammatory etiologies. Radiologist familiarity with the multimodality multisystem imaging findings of sarcoid can help guide clinical management and optimize patient care.

What Can Mimic Multiple Sclerosis?

This article discusses mimics of multiple sclerosis (MS). Excluded in this discussion are neuromyelitis optica and vasculitis, discussed in other articles in this journal. Covered entities include posterior reversible encephalopathy syndrome, reversible vasoconstriction syndrome, acute disseminated encephalomyelitis, Sussac's Syndrome, and chronic idiopathic demyelinating polyneuropathy. There are also multiple infectious entities that mimic MS including; progressive multi-focal leukoencephalopathy (PML), Toxoplasmosis, Tuberculosis, Herpes Simplex Virus, Cytomegalovirus, Varicella zoster virus, Epstein Barr virus, Cryptococcus and Human immunodeficiency virus. In addition, there are leukoencephalopathies that can present in adulthood including Adrenoleukodystrophy, Metachromatic leukodystrophy, Cerebral autosomal dominant idiopathic leukoencephalopathy, Leigh's and Alexanders disease that could be mistaken for MS.

Head and neck involvement with histoplasmosis; the great masquerader

INTRODUCTION

Head and neck involvement with histoplasmosis usually occurs as a part of the disseminated illness. There are no pathognomic features of the upper aerodigestive tract involvement and the lesion may mimic a host of other conditions. The current report presents our experience with head and neck histoplasmosis in a non-endemic tertiary care center.

MATERIALS AND METHODS

We present a case of disseminated histoplasmosis with oral symptoms and lesions as the chief complaints. A 10 years' retrospective institutional database search was undertaken to identify the patients with histoplasmosis affecting head and neck region treated at our institution. The demographic and treatment details of the patients were reviewed.

RESULTS

In addition to the index patient, four more patients (two with gingivobuccal and one each with nasal and laryngeal histoplasmosis) were found. Out of the five patients, only one patient was found to have underlying immunosuppression. All of the patients were diagnosed with biopsy showing typical appearance of the intracellular organism. All the patients were satisfactorily treated with systemic antifungal treatment.

CONCLUSION

Upper aerodigestive tract involvement with histoplasmosis can present as an intriguing clinical puzzle. A high index of suspicion is needed and biopsy is the gold standard for the diagnosis. Intravenous Liposomal Amphotericin B and oral Itraconazole are standard treatment agents of choice and are highly efficacious in achieving cure.

Hybrid Imaging in Head and Neck Sarcoidosis

Abstract: To determine the prevalence of head and neck sarcoidosis (HNS) and evaluate the role of hybrid molecular imaging in HNS. Between 2010 and 2018, 222 patients with chronic sarcoidosis and presence of prolonged symptoms of active disease were referred to FDG PET/CT. Active disease was found in 169 patients, and they were all screened for the presence of HNS. All patients underwent MDCT and assessment of the serum ACE level. Follow-up FDG PET/CT examination was done 19.84 ± 8.98 months after the baseline. HNS was present in 38 out of 169 patients. FDG uptake was present in: cervical lymph nodes (38/38), submandibular glands (2/38), cerebrum (2/38), and bone (1/38). The majority of patients had more than two locations of disease. After FDG PET/CT examination, therapy was changed in most patients. Fourteen patients returned to follow-up FDG PET/CT examination in order to assess the therapy response. PET/CT revealed active disease in 12 patients and complete remission in two patients. Follow-up ACE levels had no correlation with follow-up SUVmax level (ρ = -0.18, p = 0.77). FDG PET/CT can be useful in the detection of HNS and in the evaluation of the therapy response. It may replace the use of non-purposive mounds of insufficiently informative laboratory and radiological procedures.

Sarcoidosis of the paranasal sinuses

BACKGROUND

Sarcoidosis is a chronic disease, which predominantly affects the lung. Since sinonasal sarcoidosis is rare, little is known about the sarcoidosis manifestation at this site. Therefore, the aim of our study was to detect the prevalence of sinonasal sarcoidosis, its clinical occurrence, diagnosis, and therapy.

METHODS

The database of all patients having visited the otorhinolaryngology departments of the universities in Göttingen and in Bonn between 2003 and 2016 was searched for the diagnosis of sinonasal sarcoidosis.

RESULTS

Thirteen patients with a biopsy-proven sinonasal sarcoidosis were identified. Most patients presented non-specific clinical symptoms, which are also found in acute and chronic sinusitis. None of the patients was suspected to have sinonasal sarcoidosis by the ENT doctor before histological validation. The mean diagnostic delay was 262 (± 195) days. An additional pulmonary involvement was detected in four of six patients.

CONCLUSIONS

Sinonasal sarcoidosis is presenting with heterogeneous clinical presentations. An early biopsy of granulomatous lesions is mandatory. A multidisciplinary approach is needed to exclude serious lung or heart manifestations, because even asymptomatic organ involvement is possible. A CT-scan may be useful even if unspecific. Local or systemic therapy has to be prepared individually using local and systemic corticosteroids, antimetabolites, or anti-TNF-alpha.

Sarcoidosis from Head to Toe: What the Radiologist Needs to Know

Sarcoidosis is a multisystem granulomatous disorder characterized by development of noncaseating granulomas in various organs. Although the etiology of this condition is unclear, environmental and genetic factors may be substantial in its pathogenesis. Clinical features are often nonspecific, and imaging is essential to diagnosis. Abnormalities may be seen on chest radiographs in more than 90% of patients with thoracic sarcoidosis. Symmetric hilar and mediastinal adenopathy and pulmonary micronodules in a perilymphatic distribution are characteristic features of sarcoidosis. Irreversible pulmonary fibrosis may be seen in 25% of patients with the disease. Although sarcoidosis commonly involves the lungs, it can affect virtually any organ in the body. Computed tomography (CT), magnetic resonance imaging, and positron emission tomography/CT are useful in the diagnosis of extrapulmonary sarcoidosis, but imaging features may overlap with those of other conditions. Familiarity with the spectrum of multimodality imaging findings of sarcoidosis can help to suggest the diagnosis and guide appropriate management. ^©RSNA, 2018.

Neurosarcoidosis As a Rare Differential Diagnosis for Single Or Multiple Lesions of the Nervous System

Objective: Sarcoidosis is a multisystemic granulomatous disease of unknown cause which affects the lung or bilateral hilar lymphadenopathy in over 90% of the cases. Neurosarcoidosis (NS) is rare and accounts for approximately 5 - 15% of the cases. Involvement of all parts of the central and peripheral nervous system is possible with various clinical symptoms, e. g. seizures, hydrocephalus, optic/facial nerve palsy or hearing loss.Methods: We screened the neuropathological data bases and the medical records of two neurosurgical university hospitals for cases of NS. All these cases had been verified by surgical biopsy. We retrospectively evaluated the patient's records with special regard to the histopathology reports and specific clinical symptoms.Results: We identified 9 cases of NS between 1994 and 2014 (3 female, 6 male patients). The average age at the time of diagnosis of NS was 41,4 years. Various clinical symptoms like hydrocephalus (n = 3), seizures (n = 1), meningitis (n = 1), optical nerve involvment with vision disorder (n = 1), myelitis with paraplegia (n = 1), mastoiditis with hearing loss (n = 1), back pain syndrome (n = 2) were present. 7 patients were treated with corticosteroids, 1 patient with cyclophosphamide and 1 with a combination of corticosteroids and methotrexate.Conclusion: NS is a rare but potentially life-threatening disease. It is difficult to distinguish sarcoidosis from other granulomatous diseases, infectious diseases like tuberculosis, multiple sclerosis or neoplasm. For a definite diagnosis, a neurosurgical biopsy with histological evidence of noncaseating epithelioid cell granulomas is required, followed by multidisciplinary treatment.