Upper respiratory tract involvement of sarcoidosis in the Turkish population

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.

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.

Respiratory disorders in the Middle East: a review

The spectrum of pulmonary pathology in the Middle East is as versatile as its civilizations and cultures. In this review, we outline the key challenges confronting pulmonologists in the Middle East. We shed light on the diverse conditions commonly encountered in the region, from the centuries-old illnesses of tuberculosis, to contemporary problems such as lung complications from chemical warfare. We specifically highlighted unique aspects related to respiratory illnesses in the Middle East, for example, climate factors in the desert region, cultural habits, for example, water-pipe smoking and disorders unique to the region, such as Behçet's disease. Pulmonologists are also faced with the consequences of modernization, including large immigrant population and associated social and health issues, rising incidence of obesity and sleep apnoea, and drug-resistant tuberculosis. Tackling these health issues will require an integrated approach involving public health, primary care as well as specialist pulmonology input, taking into consideration the unique cultural and environmental factors to ensure effective management and compliance to medical care.

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.

Airway involvement and obstruction from granulomas in African–American patients with sarcoidosis

Sarcoidosis is a global disorder whose breadth of organ involvement can often be underappreciated. Head and neck manifestations include involvement of the skin, salivary glands, sinonasal cavity, and larynx. Of cases of upper airway sarcoidosis, laryngeal sarcoidosis and airway compromise portend a greater risk of fatal outcomes. People representing all racial groups have been diagnosed with sarcoidosis. Although many studies have evaluated incidence and manifestations of sarcoidosis in multiple ethnicities, few studies have explored racial predilection for laryngeal involvement. However, assertions that disease severity and poor outcome may be tied to the African diaspora as well as related socio-economic and cultural realities have been recognized. We present our case series of six African-American patients diagnosed with sarcoidosis and presented with complaints of voice change and increased shortness of breath. Four of them required expeditious, surgical management of the airway. Two had limited supraglottic involvement and have avoided tracheotomy with aggressive and timely pharmacotherapeutic intervention and close clinical surveillance. Early recognition of laryngeal manifestations of sarcoidosis and airway compromise is essential to provide patients with conservative management without the need for aggressive surgical intervention.