Sinonasal Sarcoidosis
Sinonasal involvement occurs in 1-4% of sarcoidosis cases (8, 11).
Involvement tends to be mucosal but can involve the bone of the nose and
paranasal sinuses. Typical symptoms include chronic crusting rhinitis
(70-90%), nasal obstruction (unilateral or bilateral) (80-90%), and
anosmia (70%). Epistaxis (2%) and nasal deformity can occur in
advanced and destructive cases (22).
Clinical examination may discover hypertophy and a characteristic
purplish colouring of the nasal mucosa, with granulations on the septum
and inferior turbinates. Less commonly, the paranasal sinuses may be
partially or completely opacified, with mucosal thickening and
osteomeatal obstruction (8, 11). There have also been case reports of
sinonasal sarcoidosis with peripheral nerve involvement, salivary gland
extension and intracranial extension (3, 5). The sinonasal cavity are
commonly affected in vasculitic conditions and these are therefore the
primary differential diagnosis, in addition to chronic rhinosinusitis,
prior to a tissue diagnosis.
Treatment of sinonasal sarcoidosis depends on the location and severity
of the disease. Hence, a staging system is described by Krepsi et al. as
shown in Table 1 (44). Medical nasal, intralesional and systemic
treatments have been tried separately and in combination, with topical
nasal and intralesional corticosteroid therapy having the benefit of
avoiding the complications that occur with the use of systemic
corticosteroids (8, 17). However, if the symptoms and clinical
destruction are severe, systemic corticosteroids, as outlined above, are
indicated.
Surgical treatment can be effective where medical treatment has failed,
and in particular in cases which develop anatomical blockage of sinus
drainage pathways with sarcoidosis lesions. Endoscopic sinus surgery can
markedly improve quality of life and reduce the need for systemic
steroids, but it will not eradicate the disease or prevent recurrence.
Successful laser surgery with a CO2 laser has been reported, as well as
successful partial nasal reconstruction with a two-stage, right-sided
paramedical forehead flap with a rib cartilage framework (8, 10, 11, 18,
19, 22).