Obstructive Sleep Apnea and Sarcoidosis Interactions

Obstructive sleep apnea (OSA) is very prevalent in sarcoidosis patients. Sarcoidosis of the upper respiratory tract may affect upper airway patency and increase the risk of OSA. Weight gain due to steroid use, upper airway myopathy due to steroids and sarcoidosis itself, and interstitial lung disease with decreased upper airway patency are other reasons for the higher OSA prevalence seen in sarcoidosis. Several clinical manifestations such as fatigue, hypersomnolence, cognitive deficits, and pulmonary hypertension are common to both OSA and sarcoidosis. Therefore, early screening and treatment for OSA can improve symptoms and overall patient quality of life.

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.

Obstructive sinonasal granuloma: a rare complication of systemic sarcoidosis

Sarcoidosis is a granulomatous disorder which presents with pulmonary involvement in >90% of cases. Sinonasal involvement is rare, occurring in 1% of all patients with sarcoidosis. It typically presents in the setting of active pulmonary disease. Here, we present a rare case of sinonasal sarcoidosis (SNS) in a patient with latent pulmonary sarcoidosis. The patient presented to our clinic with several years of nasal obstruction, rhinorrhea and cough unresponsive to medical management. Eventually, radiographic imaging was performed, revealing a large obstructive mass in the left nasal cavity. The mass was resected, and pathology demonstrated epithelioid granulomas, consistent with sarcoidosis. The patient was subsequently placed on systemic therapy with improvement in her symptoms. In summary, SNS is a rare clinical entity that infrequently presents in patients without active pulmonary involvement. Clinicians should have a low threshold to obtain imaging in patients with sarcoidosis who present with sinonasal complaints.

Sarcoidosis Causing Complete Nasal Obstruction

Our case demonstrates the rare presentation of sinonasal sarcoidosis causing severe nasal obstruction. While the patient had a remote history of pulmonary sarcoidosis, she was in remission and had no prior history of sinonasal involvement. Sarcoidosis should be considered in a patient with nasal obstruction especially when there is a history of systemic sarcoid disease.

Sinonasal and Laryngeal Sarcoidosis-An Uncommon Presentation and Management Challenge

Sarcoidosis is a chronic inflammatory disease of uncertain etiology characterized by the formation of noncaseating granulomas. The thorax is involved in 95% of cases, but any organ can be involved. Sinonasal or laryngeal involvement is uncommon and can be difficult to diagnose. The reported incidence of sarcoidosis in the upper airway clearly depends on study characteristics, and this creates uncertainty about the actual incidence. In a large prospective study in the United States, upper respiratory tract involvement occurred in 3% of the patients. Some patients have upper airway involvement without thoracic disease, and this presentation may cause delays in diagnosis. These patients have nonspecific symptoms which range from minimal nasal stuffiness to life-threatening upper airway obstruction. Currently, there is no established standard therapy for the management of upper airway sarcoidosis. These patients often respond poorly to nasal and/or inhaled corticosteroids and require long courses of oral corticosteroids. Patients with poor responses to oral corticosteroids or severe side effects may respond to tumor necrosis factor alpha inhibitors. In this review, we will discuss the clinical presentation, pathogenesis, diagnostic tests, drug treatment, surgical management options and the challenges clinicians have managing these patients.

Systemic and Odontogenic Etiologies in Chronic Rhinosinusitis

Systemic and odontogenic etiologies of chronic rhinosinusitis, although rare, are an integral consideration in the comprehensive management of patients with sinonasal disease. Proper knowledge and timely recognition of each disease process, with referrals to appropriate consultants, will facilitate treatment, because many of these conditions require both local and systemic therapy. In some instances, medical therapy plays a pivotal role, with surgery being a supplemental treatment technique. We review the most commonly encountered systemic etiologies of chronic rhinosinusitis and odontogenic sinusitis, including clinical presentation, diagnosis, management, and treatment outcomes.

Interrelationship between sleep-disordered breathing and sarcoidosis

Sleep-disordered breathing (SDB) has a high prevalence in sarcoidosis. This high prevalence may be the result of increased upper airways resistance from sarcoidosis of the upper respiratory tract, corticosteroid-induced obesity, or parenchymal lung involvement from sarcoidosis. OSA is a form of SDB that is particularly common in patients with sarcoidosis. Sarcoidosis and SDB share many similar symptoms and clinical findings, including fatigue, gas exchange abnormalities, and pulmonary hypertension (PH). Sarcoidosis-associated fatigue is a common entity for which stimulants may be beneficial. Sarcoidosis-associated fatigue is a diagnosis of exclusion that requires an evaluation for the possibility of OSA. Hypercapnia is unusual in a patient with sarcoidosis without severe pulmonary dysfunction and, in this situation, should prompt evaluation for alternative causes of hypercapnia, such as SDB. PH is usually mild when associated with OSA, whereas the severity of sarcoidosis-associated PH is related to the severity of sarcoidosis. PH caused by OSA usually responds to CPAP, whereas sarcoidosis-associated PH commonly requires the use of vasodilators. Management of OSA in sarcoidosis is problematic because corticosteroid treatment of sarcoidosis may worsen OSA. Aggressive efforts should be made to place the patient on the lowest effective dose of corticosteroids, which involves early consideration of corticosteroid-sparing agents. Because of the significant morbidity associated with SDB, early recognition and treatment of SDB in patients with sarcoidosis may improve their overall quality of life.

Sinonasal Sarcoidosis: A New System of Classification Acting as a Guide to Diagnosis and Treatment

Background

The signs and symptoms of sinonasal sarcoidosis are diverse and nonspecific. It easily mimics more common sinonasal disorders such as allergic rhinitis, bacterial sinusitis, and atrophic rhinitis. The purpose of this study was to develop a classification system of sinonasal sarcoidosis that will help serve as a guide for both diagnosis and treatment.

Methods

A retrospective chart review was performed of all patients diagnosed with sinonasal sarcoidosis from 1974 to 2013. A PubMed literature review of all published case series of sinonasal sarcoidosis was also reviewed.

Results

The charts of 14 patients with biopsy-proven sinonasal sarcoidosis were reviewed. Follow-up time ranged from 6 months to 28 years. Presenting signs included hypertrophic mucosa, nasal polyps, crusting, nasal enlargement, and destructive processes. Eight patients underwent medical management alone and six patients underwent endoscopic sinus surgery. Five of the six patients were successfully treated with surgery. On review of the literature, 256 cases of sinonasal sarcoidosis were found, of which 43 patients underwent surgery. Clinical outcomes of the patients who underwent surgery were not consistently reported.

Conclusion

Based on critical analysis of the clinical presentation of sinonasal sarcoidosis in our case series and on review of the literature, sinonasal sarcoidosis can be classified into four subgroups: atrophic, hypertrophic, destructive, and nasal enlargement. Each subgroup responds differently to treatment and has its own differential diagnosis. Surgery is only indicated for a select group of patients and the vast majority of patients benefit from medical management alone.

Sarcoidosis with involvement of the paranasal sinuses - a retrospective analysis of 12 biopsy-proven cases

BACKGROUND

Extrapulmonary involvement by sarcoidosis is observed in about 30-40% of patients with sarcoidosis. Little is known about the frequency and clinical characteristics of sinonasal sarcoidosis.

METHODS

We retrospectively analyzed 12 cases of biopsy-proven sinonasal sarcoidosis. Patients were identified from a patient population of 1360 patients with sarcoidosis at the Outpatient Clinic for Sarcoidosis and Rare Lung Diseases at LungClinic Grosshansdorf, a tertiary care hospital for respiratory medicine.

RESULTS

The most frequent signs and symptoms were nasal polyps (4 cases), epistaxis (3 cases), nasal crusts (8 cases) and anosmia (5 cases). Pulmonary sarcoidosis of the patients was staged as stage I (n = 1) and stage II (n = 11) on chest radiographs. Spirometry was normal in 11 patients. 7 patients had a diffusion capacity of the lung for carbon monoxide of less than 90% of predicted. Other organs were affected in 8 patients. All patients received systemic corticosteroid treatment and most patients received topical steroids. 5 patients received steroid sparing agents. Repeated sinus surgery had to be performed in 4 patients.

CONCLUSIONS

Sinonasal involvement is a rare disease manifestation of sarcoidosis with a frequency slightly lower than 1% in our patient population. The clinical course of sinonasal sarcoidosis can be complicated by relapse despite systemic immunosuppressive treatment and repeated sinus surgery.

Sinonasal manifestations of sarcoidosis: a single institution experience with 38 cases

BACKGROUND

Sarcoidosis is a chronic disease process characterized by non-caseating granulomatous inflammation, usually involving the lower respiratory tract. Given the rarity of rhinologic involvement, the objectives of the present study were (1) to describe clinical features, and (2) to review outcomes of rhinologic surgery for sinonasal sarcoidosis.

METHODS

Retrospective analysis was performed of patients evaluated at a tertiary care referral center between January 2006 and July 2011.

RESULTS

The mean age of the 38 patients with sinonasal sarcoidosis was 52 years, with a female:male ratio of 2.8:1. The most common presenting symptoms included nasal obstruction (65.8%), crusting (29.9%), and epistaxis (18.4%). Most frequent endoscopic findings included crusting (55.3%), mucosal thickening (44.7%), and subcutaneous nodules (21%). Computed tomography (CT) imaging demonstrated turbinate or septal nodularity (21%), osteoneogenesis (15.8%), and bone erosion (10.5%). Medical management was typically comprised of saline irrigations (73.3%), topical nasal steroids (68.4%), and oral steroids (63.2%). Refractory sinus symptoms required sinonasal surgery in 4 cases. Overall subjective symptom improvement was noted in 39.5% at mean follow-up of 16.2 months.

CONCLUSION

Sinonasal involvement was noted in approximately 30% of patients with known sarcoidosis evaluated in the otolaryngology clinic. Patients typically present with nasal obstruction and endoscopic evidence of crusting and mucosal thickening. Medical therapy with irrigations and topical/oral steroids suffices in majority of patients, with surgery for refractory symptoms being required in a small subset of cases.

Intracranial sarcoid granuloma as an extension of severe sinonasal sarcoidosis

Sarcoidosis is a chronic, multisystem, granulomatous disease of unknown etiology. It manifests with a wide range of symptoms and clinical findings, including some that occur in the head and neck. Sinonasal sarcoidosis, in particular, frequently demonstrates a rather recalcitrant course and a potential for severe complications if left untreated. We present the case of a 46-year-old woman with extensive sinonasal sarcoidosis that progressed to involve the skull base and olfactory tract and ultimately led to the formation of a granuloma within the frontal lobe that required craniotomy and excision. Although surgery is not considered the primary treatment modality for sarcoidosis, it may have a role in managing this highly variable disease in certain patients.

Sarcoidosis of the upper and lower airways

Sarcoidosis is a systemic granulomatous disease of undetermined etiology characterized by a variable clinical presentation and disease course. Although clinical granulomatous inflammation may occur within any organ system, more than 90% of sarcoidosis patients have lung disease. Sarcoidosis is considered an interstitial lung disease that is frequently characterized by restrictive physiologic dysfunction on pulmonary function tests. However, sarcoidosis also involves the airways (large and small), causing obstructive airways disease. It is one of a few interstitial lung diseases that affects the entire length of the respiratory tract - from the nose to the terminal bronchioles - and causes a broad spectrum of airways dysfunction. This article examines airway dysfunction in sarcoidosis. The anatomical structure of the airways is the organizational framework for our discussion. We discuss sarcoidosis involving the nose, sinuses, nasal passages, larynx, trachea, bronchi and small airways. Common complications of airways disease, such as, atelectasis, fibrosis, bullous leions, bronchiectasis, cavitary lesions and mycetomas, are also reviewed.

Sinonasal involvement in sarcoidosis: a report of seven cases and review of literature

Sarcoidosis is a chronic systemic disease of unknown etiology characterized by non-caseating inflammation involving one or more organs with predilection for pulmonary and upper respiratory tract involvement. It presents with a variety of signs and symptoms which can be generalized or focused on a single organ. Sinonasal involvement is reported in about 1% of cases of sarcoidosis. Sarcoidosis can involve both the mucosa as well as bony structures in the nose and the paranasal sinuses. We present seven cases of sarcoidosis with sinonasal involvement. Four cases presented with nasal and sinus symptoms, and the other three cases developed or presented with nasal and sinus symptoms after the diagnosis of sarcoidosis was confirmed. The nasal and sinus symptoms in these patients were managed by local and systemic steroids. In four patients, endoscopic sinus surgery was performed with good outcome. Nasal and sinus symptoms, differential diagnosis and the treatment are discussed.

Recent advances in sarcoidosis

Sarcoidosis, a systemic granulomatous disease of undetermined etiology, is characterized by a variable clinical presentation and course. During the past decade, advances have been made in the study of sarcoidosis. The multicenter ACCESS (A Case Control Etiologic Study of Sarcoidosis) trial recruited > 700 subjects with newly diagnosed sarcoidosis and matched control subjects. Investigators were unable to identify a single cause of sarcoidosis, but ACCESS paved the way for subsequent etiologic studies. The Mycobacterium tuberculosis catalase-peroxidase protein has been identified as a potential sarcoidosis antigen. Genetic aspects of the disease have been elucidated further. Genome-wide scans have identified candidate genes. Gene expression analyses have defined cytokine dysregulation in sarcoidosis more clearly. Although the criteria for diagnosis have not changed, sarcoidosis remains a diagnosis of exclusion best supported by a tissue biopsy specimen that demonstrates noncaseating granulomas in a patient with compatible clinical and radiologic features of the disease. Endobronchial ultrasound-guided transbronchial needle aspiration of mediastinal lymph nodes has facilitated diagnosis, often eliminating the need for more invasive procedures, such as mediastinoscopy. PET scanning has proven valuable in locating occult sites of active disease. Currently, no reliable prognostic biomarkers have been identified. The tumor necrosis factor inhibitors, a relatively new class of agents, have been used in patients with refractory disease. It is unclear whether phosphodiesterase-5 inhibitors, prostaglandin analogs, or endothelin antagonists should be used for the treatment of sarcoidosis-associated pulmonary hypertension.

Clinical features of sarcoid rhinosinusitis

OBJECTIVE

We asked if certain clinical features were useful predictors of sarcoid rhinosinusitis in general populations of patients with chronic rhinosinusitis.

METHODS

Our patients with sarcoid rhinosinusitis and those from the literature formed the study group. A group of 21 randomly selected patients from The University of Mississippi Medical Center Allergy Clinic with chronic rhinosinusitis composed the control group.

RESULTS

Our literature search identified 73 patients with sarcoid rhinosinusitis reported since 1999. Twenty patients met inclusion criteria and were added to 16 of our patients to compose the study group of 36 patients. The majority of the study group was African-American (61%) and female (69%) and had pulmonary sarcoidosis (67%) and other forms of extrapulmonary sarcoidosis in addition to sarcoid rhinosinusitis (86%). The 5 most common upper respiratory signs/symptoms were nasal obstruction (86%), nasal crusting (47%), anosmia (44%), epistaxis (28%), and nasal polyposis (25%). Odds ratios for sarcoid rhinosinusitis were 2.5 for persistent nasal obstruction, 7.7 for epistaxis, 16.0 for anosmia, and 18.8 for nasal crusting. For each symptom, the odds of sarcoid rhinosinusitis increased by 9.4 (95% confidence interval, 1.8-49.9). Nasal crusting was associated with the coexistence of atrophic rhinosinusitis at nasal endoscopy. Treatment with oral corticosteroids and other immunosuppressive therapy, primarily methotrexate, was frequently required.

CONCLUSION

The coexistence of chronic rhinosinusitis and 2 of the signs of nasal crusting, anosmia, or epistaxis are highly specific for sarcoid rhinosinusitis. Even in the absence of an established diagnosis of sarcoidosis, sinonasal biopsy should be considered for diagnosing these patients with chronic rhinosinusitis.

Sarcoidosis and its otolaryngological implications

Sarcoidosis and its aetiopathogenesis, epidemiology and diagnostic procedures (including the Kveim reaction) are presented in this paper. The clinical manifestations of this disease, especially in otolaryngological organs, including the larynx, salivary glands, nose and paranasal sinuses, are described. Treatment procedures, including surgical interventions and prognosis, are also discussed.

[Sinonasal sarcoidosis]

BACKGROUND

The sinonasal system is rarely involved in the clinical picture of sarcoidosis. In the absence of pulmonary disease, sinonasal sarcoidosis is extremely rare.

PATIENTS AND METHODS

Four patients with isolated sarcoidosis of the nose and the sinuses are reported; in one of these patients the histological evidence was found in the mucosa of the nasopharynx.

RESULTS

None of these patients was found to have a pulmonary illness or any other extrapulmonary manifestation of sarcoidosis. Retrospectively, two patients fulfilled the more specific diagnostic criteria for sinonasal sarcoidosis reported in the literature.

CONCLUSION

Sarcoidosis should be considered in the differential diagnosis of inflammatory sinonasal disease, especially if the mucosa shows signs of granulation, but it should also be considered when an incidental finding of rhinosinusitis is recorded. Rhinosurgical intervention seems to be an appropriate therapy in terms of improving the symptoms of the disease, despite the prolonged period of postoperative healing and the necessity for individual treatment with medication. Following histological confirmation of the diagnosis, adequate medication and further appropriate diagnostic procedures drawing on internal medicine are essential.

A rare case of sarcoidosis involving the middle turbinates: an incidental diagnosis

BACKGROUND

Sarcoidosis is a chronic, systemic granulomatous disease of unknown etiology that features noncaseating granulomas in many body regions. Sinonasal involvement is rare but is also suspected to be underreported.

CASE PRESENTATION

We present the case of a 39-year-old woman who was incidentally diagnosed with isolated sarcoidosis involving the middle turbinates. Histopathologic examination of resected concha bullosa material and an extensive panel of diagnostic tests revealed a diagnosis of isolated sarcoidosis. Since no systemic manifestations were detected, topical corticosteroid (nasal spray) was administered in the postoperative period. Throughout the 12 months after surgery, the patient remained free of symptoms and all nasal endoscopy examinations were normal.

CONCLUSION

Although isolated nasal involvement of sarcoidosis is rare, otorhinolaryngologists should consider this condition in a differential diagnosis for sinonasal complaints.

Sinonasal involvement in sarcoidosis: a case-control study of 20 patients

We conducted a retrospective single-center study to describe the clinical features of sinonasal sarcoidosis (SNS) and to determine whether SNS is associated with a particular clinical phenotype of sarcoidosis. Twenty patients with histologically proven SNS (men/women, 7/13; mean age, 32 +/- 9 yr) were compared with control patients with sarcoid but without sinonasal (SN) involvement. Each patient was matched with 2 controls for the date of admittance in our institution. SN involvement occurred in the course of previously known sarcoidosis in 8 patients, whereas it preceded disease diagnosis in 12 patients. Among these 12 patients, 4 initially presented with strictly isolated SNS and 8 had other associated signs related to sarcoidosis. The most common symptoms were stuffiness (90%), anosmia (70%), and rhinorrhea (70%). Lupus pernio was frequent (50%). Local examination was constantly abnormal and showed hypertrophy (75%) and purplish coloring of the nasal mucosa with granulations (50%) on the septum and/or inferior turbinates. Computed tomography scans showed medial lytic lesions, mainly of the septum and/or the turbinates in about half the cases. All patients had negative antineutrophil cytoplasmic antibodies. Patients with SNS had significantly more frequent and severe involvement of vital organs than controls, had a longer history of sarcoidosis, and required systemic treatment more frequently (100% vs. 57.7%, p < 0.001) and for a longer time (78 +/- 42 mo vs. 29 +/- 18 mo, p < 0.0001). Corticosteroids maintenance dosage was high (10.5 +/- 6 mg daily) and mainly depended on SN involvement. Although rare, SN involvement is a severe and recalcitrant manifestation of sarcoidosis representing a therapeutic challenge.

Sinonasal sarcoidosis: review and report of fifteen cases

OBJECTIVES

Sinonasal sarcoidosis remains a poorly understood and uncommon chronic granulomatous disease of unclear origin. We have attempted to characterize the main clinical and radiologic criteria for diagnosis and to discuss the treatment.

METHODS

A retrospective study of 15 cases of chronic, symptomatic, and biopsy-proven sinonasal sarcoidosis and a review of the literature are realized.

RESULTS

Among the 15 patients, there were 8 women and 7 men with a mean age of 44 years. The most frequent presentation was a chronic, often crusty, rarely destructive inflammatory rhinosinusitis with nodules on the septum and/or the turbinates. Pulmonary sarcoidosis was associated in 12 cases. Involvement of the nasopharynx, the pharyngolarynx, the skin, the lachrymal and salivary glands, and the liver was associated in some cases. Levels of angiotensin-converting enzyme were elevated in 10 cases and normal in 3 cases. Gallium scan performed in three cases was positive. Radiologic studies showed nodules on the septum and/or the turbinates in 14 cases, complete or subtotal opacification of the sinuses and/or the nasal cavities in 13 cases, and nasopharyngeal or pharyngolaryngeal lesions in 4 cases. Treatment with corticosteroids, methotrexate, azathioprine, and surgery appear globally disappointing in view of the side effects and the relapses during a long follow-up (3-15 yr; mean, 6 yr).

CONCLUSION

On the basis of this study, we propose the following diagnostic criteria: 1) histopathologic confirmation of noncaseating granuloma; 2) chronic rhinosinusitis poorly responsive to conventional treatment and radiologic evidence of rhinosinusitis, often with nodules on the septum and/or the turbinates; 3) elevated level of angiotensin-converting enzyme; 4) positive gallium scan (if performed); 5) frequent evidence of systemic, especially pulmonary, sarcoidosis; 6) no evidence of other granulomatous diseases, such as Wegener granulomatosis.

Imaging evaluation of sinusitis: diagnostic performance and impact on health outcome

Sinusitis is a highly prevalent disease, with a significant impact on the health care economy. Sinus CT is the primary imaging modality for evaluation of acute and chronic sinusitis. The roles of CT for patients with sinusitis are to assist clinical diagnosis, to evaluate the extent of disease, and to provide detailed anatomy necessary for treatment planning. Although sinus CT has been criticized for lack of specificity and correlation with patients' clinical symptoms, sinus CT may provide pivotal objective information that affects treatment decisions for acute and chronic sinusitis. This article provides a clinical overview and reviews the role of imaging studies in diagnosis and treatment of sinusitis.

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.