Histopathology of neurosensory deafness in sarcoidosis

Rare case of sudden onset sensorineural hearing loss in a patient diagnosed with sarcoidosis

We report the case of a woman in her 30s who was referred to the ear, nose and throat department with sudden onset left-sided sensorineural hearing loss (SNHL), left anterior uveitis and erythematous lower limb lesions with bilateral pitting oedema. Based on her symptoms, an underlying inflammatory systemic disease was suspected. Autoantibodies were negative but an X-ray and high-resolution CT scan of the chest were suggestive of sarcoidosis, which was confirmed on endoscopic bronchial biopsy. Following treatment with a course of oral steroids, the patient's hearing has improved but she still suffers from episodes of uveitis. While immune-mediated inner ear disorders are a recognised cause of SNHL, sarcoidosis is a very rare cause. This case demonstrates the importance of screening for systemic autoimmune aetiology in SNHL and highlights the importance of an effective multidisciplinary team in the diagnosis and management of these patients.

Cochlear Implantation in Sporadic Vestibular Schwannoma and Other Retrocochlear Pathology: A Case Series

OBJECTIVE

To describe outcomes with cochlear implantation (CI) for rehabilitation of hearing loss in patients with sporadic vestibular schwannomas (VS) and other retrocochlear pathologies.

STUDY DESIGN

Retrospective review.

SETTING

Tertiary-care center.

PATIENTS

Twenty three cases in 19 patients (53% men, mean age 55.8 yr) with non-neurofibromatosis type 2 related retrocochlear pathology.

INTERVENTIONS

Unilateral or bilateral CI.

MAIN OUTCOME MEASURES

Word recognition score, device usage.

RESULTS

Etiology of deafness included sporadic VS (n = 9, 39%), radiation after head and neck or central nervous system (CNS) malignancy (n = 8, 35%), superficial siderosis (n = 3, 13%), neurosarcoidosis (n = 2, 9%), and pontine stroke (n = 1, 4%). Mean follow-up duration was 2.3 years (standard deviation [SD] 3.0; range, 0.2-9.4). Auditory perception was achieved in 20 out of 22 patients (91%) who have been activated. Mean WRS in patients with sporadic VS was 18% (SD 20; range, 0-44). Mean WRS in patients with non-VS retrocochlear pathology was 55% (SD 30; range, 0-94). Data logs showed 7.0 h/d of average use (SD 4.3; range, 0-13).

CONCLUSIONS

Appropriately selected patients with retrocochlear pathology may benefit from CI so long as the patient has a cochlear fluid signal and an intact cochlear nerve. Patients with sporadic VS patients and normal contralateral hearing exhibited guarded outcomes with CI, whereas most patients with non-VS retrocochlear pathologies demonstrated open-set speech understanding scores comparable to or slightly worse than conventional CI candidates. Since variable performance benefit is observed with CI in patients with retrocochlear pathology, counseling is imperative to align patient expectations with realistic outcomes.

Cochlear Implant Outcomes in Patients with Neurosarcoidosis

INTRODUCTION

Audiovestibular symptoms are rare in sarcoidosis, but they may also be the first manifestation of the disease. Sudden or progressive bilateral hearing loss is usually associated with vestibular impairment. The mechanism of hearing loss remains unclear, but clinical presentation and magnetic resonance imaging suggest a retrocochlear site for the lesion in most patients. Several cases of hearing recovery after corticosteroid treatment have been reported. In patients with severe or profound hearing loss, the benefit of cochlear implantation is challenging to predict in the case of auditory neuropathy and is rarely described. We present a case series of cochlear implantation in patients with documented neurosarcoidosis.

RESULTS

Seven cases of cochlear implantation in 4 patients with neurosarcoidosis are reported. All of the patients showed a great improvement very quickly in both quiet and noise. Speech performance remained stable over time with a follow-up ranging from 4 to 11 years, even in patients who had disease exacerbation.

CONCLUSION

Cochlear implantation is possible in deaf patients with neurosarcoidosis. The excellent benefit obtained in our patients suggests a particular type of neuropathy, but endocochlear involvement cannot be entirely ruled out.

Audiovestibular Symptoms in Systemic Autoimmune Diseases

Immune-mediated inner ear disease can be primary, when the autoimmune response is against the inner ear, or secondary. The latter is characterized by the involvement of the ear in the presence of systemic autoimmune conditions. Sensorineural hearing loss is the most common audiovestibular symptom associated with systemic autoimmune diseases, although conductive hearing impairment may also be present. Hearing loss may present in a sudden, slowly, rapidly progressive or fluctuating form, and is mostly bilateral and asymmetric. Hearing loss shows a good response to corticosteroid therapy that may lead to near-complete hearing restoration. Vestibular symptoms, tinnitus, and aural fullness can be found in patients with systemic autoimmune diseases; they often mimic primary inner ear disorders such as Menière's disease and mainly affect both ears simultaneously. Awareness of inner ear involvement in systemic autoimmune diseases is essential for the good response shown to appropriate treatment. However, it is often misdiagnosed due to variable clinical presentation, limited knowledge, sparse evidence, and lack of specific diagnostic tests. The aim of this review is to analyse available evidence, often only reported in the form of case reports due to the rarity of some of these conditions, of the different clinical presentations of audiological and vestibular symptoms in systemic autoimmune diseases.

Two Cases of Heerfordt's Syndrome: A Rare Manifestation of Sarcoidosis

Heerfordt's syndrome is a rare manifestation of sarcoidosis characterized by the presence of facial nerve palsy, parotid gland enlargement, anterior uveitis, and low grade fever. Two cases of Heerfordt's syndrome and a literature review are presented. Case  1. A 53-year-old man presented with swelling of his right eyelid, right facial nerve palsy, and swelling of his right parotid gland. A biopsy specimen from the swollen eyelid indicated sarcoidosis and he was diagnosed with incomplete Heerfordt's syndrome based on the absence of uveitis. His symptoms were improved by corticosteroid therapy. Case  2. A 55-year-old woman presented with left facial nerve palsy, bilateral hearing loss, and swelling of her bilateral parotid glands. She had been previously diagnosed with uveitis and bilateral hilar lymphadenopathy. Although no histological confirmation was performed, she was diagnosed with complete Heerfordt's syndrome on the basis of her clinical symptoms. Swelling of the bilateral parotid glands and left facial nerve palsy were improved immediately by corticosteroid therapy. Sarcoidosis is a relatively uncommon disease for the otolaryngologist. However, the otolaryngologist may encounter Heerfordt's syndrome as this syndrome presents with facial nerve palsy and swelling of the parotid gland. Therefore, we otolaryngologists should diagnose and treat Heerfordt's syndrome appropriately in cooperation with pneumologists and ophthalmologists.

Cranial neuropathies in sarcoidosis

Sarcoidosis is a multisystem, chronic inflammatory disease that is characterized by the development of non-caseating granulomas in multiple body tissues and organ systems. Neurological complications of systemic sarcoidosis include peripheral and cranial neuropathies, myopathies, seizures, gait dysfunction, and cognitive decline. Because sarcoidosis has a predilection to involve the basilar meninges, cranial neuropathy is the most prevalent neurological deficit seen when the nervous system is involved. Sarcoidosis cranial neuropathy may occur at different stages of the disease and even as the initial clinical manifestation of central nervous system involvement. Attributing a cranial neuropathy to sarcoidosis can be challenging, particularly in the setting of normal imaging studies. In this review, cranial neuropathies in sarcoidosis are discussed in detail.

Heerfordt's Syndrome Presenting with Recurrent Facial Nerve Palsy: Case report and 10-year literature review

Heerfordt's syndrome is defined as a combination of facial palsy, parotid swelling, uveitis and fever in sarcoidosis cases. Heerfordt's syndrome as a cause of facial palsy is very rare. We report a case of alternating facial nerve palsy in a 52-year-old female initially treated for Bell's palsy. The patient was referred to the All India Institute of Medical Sciences, Bhubaneswar, India, in January 2013 for clinical evaluation. She was found to have a parotid swelling and anterior intermediate uveitis. A pathoradiological evaluation suggested sarcoidosis and a final diagnosis of Heerfordt's syndrome was made. Steroid treatment was initiated which led to an improvement in the facial palsy and uveitis as well as the disappearance of the parotid swelling with a corresponding decrease in angiotensin-converting enzyme levels. An English literature review was carried out to analyse the varied presentation of this syndrome. The analysis focused on presenting symptoms, biochemical markers and radiological findings of Heerfordt's syndrome cases.

Vestibular test findings in individuals with auditory neuropathy: review

Background:

The vestibulocochlear nerve is a sensory nerve that serves the organs of hearing and equilibrium. Neuropathies of the nerve, particularly auditory neuropathy, may be caused by primary demyelination or axonal disease. Cochlear amplification function is normal in cases of auditory neuropathy, but afferent neural conduction in the auditory pathway is disordered. It is highly probable that the vestibular nerve has some involvement in disorders affecting the cochlear nerve.

Objective:

To provide an overview of vestibular test findings in individuals with auditory neuropathy.

Method:

A structured literature search was carried out, with no restrictions to the dates searched.

Conclusion:

Auditory neuropathy implicated the vestibular branch of the VIIIth cranial nerve as well as the cochlear nerve. However, there was variability in terms of vestibular test findings.

Bilateral Vestibular Hypofunction in Neurosarcoidosis: A Case Report

We describe the case of a 59-year-old woman who presented with progressive bilateral vestibidar hypofunction and who was found to have bilateral granulomatous mass lesions of the mesial temporal lobe. Initially, her condition stabilized neurologically with corticosteroids, but a diagnosis of neurosarcoidosis was delayed because of the unusual presentation and persistently normal chest imaging results and serum angiotensin-converting enzyme (ACE) levels. Approximately 1 year after her initial presentation, the patient died of complications of a myocardial infarction and pulmonary embolism. Sarcoidosis should be considered in the differential diagnosis of idiopathic bilateral vestibular hypofunction even if the chest imaging and serum ACE levels are normal, particularly when there is evidence of a multisystem process.

A difficult case: sarcoidosis of the middle ear

Sarcoidosis is a common multisystemic granulomatous disorder affecting several organs and tissues. However, the respiratory tract is the region commonly involved in more than 90% of patients, and the middle ear is a direct extension of it. In spite of this, direct middle ear and/or mastoid involvement of sarcoidosis is more rarely seen. Otological involvement may mimic a number of other diseases of the ear; sarcoidosis will probably not be considered prospectively. In addition, pulmonary symptoms of the patients often go unnoticed for some time. We report a patient presenting with hearing loss and tinnitus as the primary manifestation of sarcoidosis of the ear.

Neurosarcoïdose : état des connaissances

The origins of neurosarcoidosis, a multisystemic granulomatous disease, remain unknown. Nervous system localizations remain rare, but severe. Lymphocytic meningitis, psychiatric disorders, diabetes insipidus and cranial nerve palsy are the most frequent signs. Cerebral fluid test and cervical medullar and cerebral MRI with gadolinium have to be performed first. In some cases, histological evidence of granuloma have to be obtained with neuromuscular, meningeal or cerebral biopsies. Functional impairment and life-threatening conditions require early corticosteroid therapy. In worsening cases or in the event of no therapeutic response or poor tolerance to corticosteroids, other immunosuppressive agents should be associated. Maintenance therapy and most often life long maintenance therapy allow a continuous success while avoiding relapse.

Sarcoidosis presenting with hearing loss and granulomatous interstitial nephritis in an adolescent

Granulomatous interstitial nephritis is an uncommon finding in a kidney biopsy. The differential diagnosis is broad and includes infections, drug exposure, and sarcoidosis. Sarcoidosis, a systemic disorder of unknown etiology characterized by the presence of noncaseating granulomata in affected organs, is rare in children. We discuss an adolescent boy with the unusual presentation of granulomatous interstitial nephritis and acute deafness. Sarcoidosis should be considered as part of the differential diagnosis for children and adolescents with hearing loss and kidney disease.

Audiovestibular manifestations of sarcoidosis: a review of the literature

OBJECTIVE/HYPOTHESIS

Sarcoidosis is a multisystem disease of unknown etiology. Audiovestibular involvement is rare but has been reported in a number of cases. The objective of this review is to provide an evidence-based summary of the audiovestibular manifestations of sarcoidosis by collating the findings of these case reports.

STUDY DESIGN

Retrospective review of 48 published case reports and 2 cases recently encountered in audiovestibular medicine clinics.

METHODS

Case reports were identified using a key word search of Medline database. Clinical details, audiovestibular test results, and radiological findings were recorded for each patient when available.

RESULTS

When type of hearing loss (HL) was recorded, all losses were sensorineural, with only two patients found to have an additional conductive loss. The severity of HL ranged from mild to profound. Median thresholds were moderately raised. The HL was bilateral in 75% of patients and asymmetrical in 75% of these cases. Seventy percent of HLs demonstrated some recovery. Many of the patients with recovery were treated with corticosteroids, but no statistically significant association between treatment and HL outcome was observed. Symptoms of vestibular impairment were common. Vestibular testing was performed in 24 cases and was abnormal in 23. Eighty-one percent of patients had additional features of neurosarcoidosis. Six patients had radiological evidence of a retrocochlear lesion.

CONCLUSION

In taking into account the evidence from the clinical features, audiovestibular testing, radiological investigations, and postmortem findings, it is concluded that the audiovestibular manifestations of sarcoidosis are likely to be primarily a result of vestibulocochlear nerve neuropathy.

Ear, nose, and throat manifestations of sarcoidosis

Sarcoidosis rarely affects the head and neck and represents a diagnostic challenge to the otolaryngologist. The signs and symptoms of sarcoidosis in this area are not specific and can mimic much more common disorders. Biopsy is usually necessary to make the diagnosis. Appropriate evaluations and referrals should be made once there is suspicion of sarcoidosis. Steroids remain the mainstay of the therapeutic options; however, newer agents are being used more frequently. Long-term treatment and follow-up are necessary, because the disease tends to progress and to respond unpredictably to treatment.

Osseous sarcoidosis presenting as a destructive petrous apex lesion

We report a case of sarcoidosis presenting as a destructive petrous apex lesion of the temporal bone. Sarcoidosis is a disease of unknown etiology, featuring granulomatous inflammation in a number of organs and tissues. Osseous involvement of the temporal bone by sarcoidosis is uncommon and rarely encountered clinically. When osseous tissue is involved, it commonly affects the phalangeal bones of the hands and feet with noncaseating granulomas occupying the marrow space and creating a destructive pattern. A similar clinico-pathologic process was found to occur within the petrous apex of the temporal bone in an individual presenting with otalgia, hearing loss, and aural fullness. Imaging of the temporal bones revealed a unilateral destructive lesion of the petrous apex and adjacent skull base. A review of sarcoidosis and petrous apex lesions is presented. Sarcoid involvement of the petrous apex should be considered in the number of pathologies that feature bony destruction of the petrous apex of the temporal bone.

Endoscopic diagnosis of sarcoidosis in a patient presenting with bilateral exophthalmos and pansinusitis

Sarcoidosis is a chronic granulomatous disease of unknown etiology. Otolaryngologic and ophthalmologic manifestations occur in 15 to 55% of afflicted individuals, respectively. Neck masses, parotid enlargement, and facial nerve palsy are the most common presenting otolaryngologic complaints, while lacrimal gland enlargement, uveitis, and upper eyelid masses often call the attention of the ophthalmologist. Biopsy reveals non-caseating granulomas, while the angiotensin converting enzyme (ACE) level may be elevated. We report an unusual case of a patient who presented with severe bilateral exophthalmos as the sole initial complaint. A prior workup included a negative conjunctival biopsy. On magnetic resonance imaging (MRI) and computed tomography (CT), the patient had pansinusitis. Endoscopic ethmoidectomies with tissue analysis revealed sarcoidosis. Further evaluation revealed no evidence of systemic disease, and all symptoms resolved with a course of oral steroids. Thus, nasal endoscopy and biopsy of affected paranasal sinus mucosa may prove a useful adjunct to the diagnosis of sarcoidosis, particularly in atypical cases.

Pathology of sarcoidosis

This article reviews the pathology of sarcoidosis that covers the general and systemic aspects of the disease. Macroscopic and microscopic descriptions of the disease process are given for selected organs.

Selective vestibular damage in neurosarcoidosis

We report a patient with neurosarcoidosis who developed bilateral benign paroxysmal positional vertigo (BPPV) of the posterior canals, deafness, and absent responses to conventional caloric and rotational vestibular testing. Additional rotation in the planes of the vertical semicircular canals revealed relative sparing of vertical canal function. This vertical-horizontal canal dissociation explains the presence of BPPV and suggests that the vestibular damage in this patient is secondary to a vasculitic neuropathy.

Otolaryngologic manifestations of sarcoidosis: presentation and diagnosis

Neuro-otologic manifestations of sarcoidosis are rare. Dizziness in particular is a rare presenting complaint of the patient afflicted with this systemic granulomatous disorder. Head and neck and sinonasal presentations of this disease are more common. We reviewed our experience with six such patients who presented for management of their otolaryngologic (ORL) manifestations in order to delineate the involvement of the otolaryngologist in the treatment and diagnosis of these patients, with a focus upon the relevant tests and procedures in the otolaryngologist's de novo diagnosis of sarcoidosis. Studies ordered in the course of otolaryngologic evaluation and their utility in the diagnosis of sarcoidosis by the otolaryngologist are reviewed and classified into useful, supportive, and ancillary. The otolaryngologist played an important role in diagnosis, with four of six patients diagnosed to have sarcoidosis on the basis of their otolaryngologic presentations. Biopsy was performed by the otolaryngologist for diagnosis of sarcoidosis in all four of these cases. Steroids were central to treatment. Oral steroid therapy was the principal treatment: both patients with neuro-otologic sarcoid were successfully managed with oral steroids. Intralesional steroids were necessary to treat the skin lesion. One of six patients patients experienced complications related to steroid use.

VIIIth cranial nerve involvement in sarcoidosis

Hearing loss and vertigo are uncommon but well-recognized complications of neurosarcoidosis. Until recently the site of the lesion has been debatable and the efficacy of steroids commonly prescribed for this type of hearing loss has been said to be doubtful. A case is presented of sarcoidosis-induced hearing loss in which bilateral VIIIth nerve lesions were demonstrable by MRI with gadolinium enhancement. Treatment with high-dose steroids and azathioprine produced a symptomatic improvement and virtual resolution of the lesions.

Recognition and management of sarcoidosis in the emergency department

Sarcoidosis is a chronic granulomatous disease of uncertain etiology. It can affect essentially every organ system in the human body and its manifestations are protean. Sarcoidosis can present in the emergency department (ED) as de novo disease, as preexisting disease with acute exacerbations, or as chronic debilitation. The authors provide a review of the various manifestations of this disease with emphasis on ED presentation and evaluation.

Sudden hearing loss as the sole manifestation of neurosarcoidosis

Sarcoidosis is a chronic, idiopathic granulomatous disease with frequent pulmonary, ocular, and lymphatic systemic manifestations. Central nervous system involvement is rare (1% to 5%), yet the most frequent presenting symptoms (48%) in patients with neurosarcoidosis are neurologic. Eighth cranial nerve abnormalities occur in 20% of these patients, typically in association with other cranial neuropathies or overt systemic disease. Isolated eighth nerve disease is very rare. We report two cases of neurosarcoidosis manifest as isolated, sudden onset sensorineural hearing loss, one of which had a cerebellopontine angle (CPA) granuloma that mimicked an acoustic neuroma. Both patients experienced marked steroid-induced hearing improvement that persisted after termination of therapy. Brainstem evoked response audiometry (BSER) abnormality persisted despite normalization of audiologic parameters. The implications for diagnosis and treatment of sarcoidosis-induced hearing loss are described. Neurosarcoidosis must be considered when evaluating patients with sudden hearing loss. Prompt steroid therapy offers hope for significant hearing recovery in these patients.