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\begin{document}

\title{Sarcoidosis of the Ear, Nose and Throat: a review of the literature}



\author[1]{Nicholas Cereceda-Monteoliva}%
\author[2]{Maral Rouhani}%
\author[2]{Elizabeth Maughan}%
\author[2]{Anthony Rotman}%
\author[3]{Nara Orban}%
\author[1]{Chadwan Al Yaghchi}%
\author[1]{Guri Sandhu}%
\affil[1]{Imperial College Healthcare NHS Trust}%
\affil[2]{Charing Cross Hospital}%
\affil[3]{Barts Health NHS Trust}%


\vspace{-1em}



  
  \date{June 17, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
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 review of the literature to determine the evidence-base
supporting this. Results. ENT manifestations are present in 10-15\% 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.%
\end{abstract}%



\sloppy


\textbf{Abstract}

\textbf{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.

\textbf{Design} .

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

\textbf{Results} .

ENT manifestations are present in 10-15\% 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.

\textbf{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.

\textbf{Keywords}

Sarcoidosis, Otorhinolaryngologic Diseases, Larynx, Granuloma

\textbf{Objectives}

Sarcoidosis is a chronic inflammatory disease of unknown aetiology,
characterised by the formation of non-caseating granulomata involving
one or more organs. Extrathoracic manifestations of the disease can
include otorhinolaryngological problems, with a particular predilection
for upper and lower airway involvement. This article will outline the
background of sarcoidosis, describe recognised ENT manifestations and
discuss current treatment options.

\textbf{Design}

We performed a review of the literature to determine the evidence-base
surrounding the management of ENT manifestations of this disease. We
report the background of sarcoidosis first followed by the implications
in ENT.

\textbf{Results -- Sarcoidosis}

\emph{Epidemiology}

The prevalence of sarcoidosis varies geographically between 1-40 cases
per 100,000 and is more prevalent in south-eastern USA and Scandinavia.
It occurs more commonly in a bimodal distribution affecting the young
and middle-aged populations, females are affected more frequently than
men, and black people more than white (1).

\emph{Pathophysiology}

The cause of sarcoidosis is not yet well understood but an
antigen-triggered, cell-mediated immune response is known to initiate
the sarcoidosis disease process (2). Genetic susceptibility and specific
environmental or infectious triggers combine to perpetuate a chronic
cell-mediated immunological response (3). T lymphocytes and macrophages
accumulate and produce inflammatory mediators such as cytokines
(particularly TNF-alpha, IL-12 and IL-18), which lead to the formation
of granulomata (2, 4). Certain HLA haplotypes are suggested to
predispose to the disease and bacterial triggers have also been
proposed, although evidence for this remains inconclusive (1, 2, 5).

\emph{Diagnosis}

Sarcoidosis is diagnosed on the basis of clinical and radiological
suspicion, combined with biopsy evidence of non-caseating granulomata,
in the absence of any other cause of granulomatous disorders (1).

The Kveim reaction is important as a clinical observation in making a
diagnosis of sarcoidosis (3, 4), however its use has fallen out of
favour over the years. Imaging techniques routinely employed include CT
(HRCT is particularly useful in chest sarcoid diagnosis) and MRI (with
gadolinium contrast) (6, 7). Biopsy typically yields multiple
epithelioid cell granulomata made from mononuclear cells, with variable
degrees of necrosis, leucocyte infiltration and hyaline fibrosis (4).
Supporting evidence can include a high CD4/CD8 T lymphocyte ratio on
bronchoalveolar lavage (1, 2).

Blood tests can provide supporting evidence for the diagnosis of
sarcoidosis. Serum Angiotensin-converting enzyme (ACE) levels are often
raised in sarcoidosis, however the nonspecific and insensitive nature of
this rise relegates its use to monitoring the course of the disease (8).
Hypercalcaemia may also be seen (1) and other acute phase reactants,
such as ESR, may also be raised.

\emph{General Clinical Manifestations}

Intrathoracic manifestations of sarcoidosis include pulmonary
infiltrates and hilar lymphadenopathy, as well as cardiac sarcoidosis
(more common in older Japanese females), which can be life-threatening
(1, 7). Extrathoracic disease occurs in around 50\% of patients, and
virtually every organ can be affected (1). The extent and degree of
disease is extremely variable between patients. Skin, lymph node, eye
and liver involvement are most common outside of the thorax, each being
found in between 10-25\% of patients (1).

Around 10-15\% of patients with sarcoid have ENT manifestations of
sarcoidosis (1, 5, 9) which may be the presenting symptom of their
disease (10). The differential often includes vasculitides such as
granulomatosis with polyangiitis, formerly called Wegener's, or
eosinophilic granulomatosis with polyangiitis, formerly Churg-Strauss
syndrome, granulomas of infective origin (such as tuberculosis,
aspergillosis, or actinomycosis), and inflammatory diseases with
extrasystemic manifestations, such as Crohn's disease, which should be
excluded (4). Sinonasal sarcoidosis is rare (occurring in 1-4\% of
patients), but has been described in numerous case studies, and is a
well-recognised chronic and stubborn form of the disease (8, 10, 11).
Sarcoidosis can also involve the larynx, salivary glands and ear in rare
cases (3, 12-16).

\emph{Treatment principles}

Medical management with oral corticosteroids is the mainstay of
treatment in generalised sarcoidosis and in severe otolaryngologic
disease (1, 9, 17). However, the risks of uncontrolled disease need to
be balanced against the incumbent risks and side-effects of long-term
corticosteroid therapy (10). Adjunctive or alternate drug therapies have
therefore also been used in order to reduce steroid doses (18, 19).
These include:

\begin{itemize}
\tightlist
\item
  Cytotoxic agents (such as methotrexate, azathioprine, cyclophosphamide
  and chlorambucil)
\item
  Anti-malarial drugs (chloroquine and hydroxychloroquine)
\item
  TNF-alpha inhibitors (infliximab, adalimumab, etanercept).
\end{itemize}

No control studies exist as yet comparing these therapies to steroid
treatment, but effective treatment is reported anecdotally in cases of
sarcoidosis with extrathoracic manifestations such as lupus pernio and
uveitis (18, 19). Furthermore, specific treatments can be helpful in the
local management of otorhinolaryngologic sarcoidosis, and these are
discussed below.

\textbf{Results - ENT manifestations of disease}

\emph{Laryngeal Sarcoidosis}

Laryngeal sarcoidosis is particularly rare, with a large cohort of
patients with systemic sarcoidosis demonstrating an incidence of only
0.6\% (14). As with other manifestations of sarcoidosis, age at
presentation is typically from 20 -- 40 years old (13).

The presenting complaint in the majority of patients relates to
difficulty breathing and less commonly, dysphonia and cough. Pain is not
usually a feature. Only a small proportion of patients complain of
dysphagia and if so, it is rarely the sole symptom. Those with dysphagia
inevitably modify their diet and some silently aspirate. Given the
natural history and slow progression of this granulomatous disease,
emergency department presentations are rare. Case reports of
tracheostomy exist (20, 21), however most patients present with a
gradual decline. Stridor is common but mild. Although symptom onset is
gradual, the impact on quality of life is significant with a reduction
in exercise capacity, compounding respiratory disease in affected young
patients.

Endoscopic examination typically reveals supraglottic swelling and
deformity, with the epiglottis, arytenoids and aryepiglottic folds
involved, as demonstrated in Figure 1. A `turban'-shaped epiglottis is
typically described (21), due to the resultant morphological change
after inflammatory and granulomatous infiltrate. True vocal fold paresis
is rare but there can often be an appearance of restricted glottic
mobility contributing to dysphonia due to the inflammatory process and
resultant thickening.

Prior to a diagnosis of laryngeal sarcoidosis, a broad differential must
be considered given that presenting symptoms related to airway and voice
are also seen in many more common laryngeal pathologies including vocal
fold paralysis, supraglottitis and laryngotracheal stenosis (15, 21).
The laryngeal appearance may resemble acute infection or other
granulomatous diseases such as tuberculosis and vasculitis. Malignancy
may rarely present in this way and must always be considered. It is
crucial that the entire respiratory tract has been assessed, as more
foci of disease suggest a systemic process such as sarcoidosis, where
solitary lesions are more likely to be due to localised pathology.
Investigations may be performed but only a biopsy demonstrating
non-caseating granulomata is diagnostic (5).

Conservative options typically relate to speech and language therapy for
patients with symptomatic dysphonia or dysphagia (15). Medical therapy
for those with pre-existing sarcoidosis has often been initiated as
described above. The majority of patients that require surgical
intervention have problematic airway symptoms. Microlaryngoscopy and
biopsy is performed for a definitive diagnosis, whilst also providing an
opportunity to dilate the airway if required. There have been
descriptions of intralesional steroid injection, as well as the use of
mitomycin-c to prevent recurrent scar (21). In general, surgical
techniques employ the CO2 laser for tissue reduction or excision - the
addition of the previously described `pepper pot' technique has been
demonstrated to reduce patients' Medical Research Council dyspnoea grade
(21).

\emph{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).

\emph{Otologic Sarcoidosis}

Audiovestibular symptoms of sarcoidosis are uncommon but can include
sensorineural hearing loss, vertigo, gait disturbance and disequilibrium
from neurosarcoidosis affecting the vestibulocochlear nerves (16).
Middle ear sarcoidosis has also been reported as a sentinel
manifestation of the disease (23), presenting with tinnitus, hearing
loss, purulent otorrhoea and otalgia. In this scenario, audiometric
findings are mixed or conductive in nature, with CT demonstrating soft
tissue masses in the tympanic cavity extending into the mastoid antrum
and air cells. While skin is commonly involved in sarcoidosis, the
external ear is seldom involved (12, 24). Cases described include tender
and non-tender raised nodules, swelling or inflammation that can affect
the helix, lobules or external auditory canal (12, 24).

Otologic symptoms usually improve with oral or intralesional
corticosteroid therapy (12). Infliximab, a TNF-\selectlanguage{greek}α \selectlanguage{english}blocking agent, has
also been reported as successful in treating ear lobe sarcoidosis
refractory to non-biologic immunosuppressants and intralesional injected
corticosteroids (24). Case reports have suggested that surgical excision
of granulation tissue alongside systemic steroid therapy can result in
improvement of symptoms (23).

\emph{Prognosis}

Sarcoidosis generally shows spontaneous remission in 12-36 months
(50-60\% of cases). Prognosis is usually favourable, although a 3-9\%
mortality is reported, usually from lung or cardiac complications (7,
17). It is difficult to recommend ENT-specific treatments given the
scarcity of data that exists on the management and prognosis of
site-specific manifestations. For example, laryngeal sarcoidosis is a
rare head and neck manifestation of what is already a rare condition.
Since most patients with sarcoidosis do not have ENT manifestations of
their disease, there is little data regarding rates of remission. As
such, there are only limited case series with which to base best
practice.

\textbf{Conclusions}

The consequences of ENT manifestations of sarcoidosis can be
uncomfortable, disabling and disfiguring and those affecting the larynx
can be life threatening (10, 20). The coordinated management of these
requires good diagnostic skills and multimodal treatment. Established
treatments using corticosteroids are observed to be effective but not
without risks of long-term use. Intralesional treatments are commonly
reported and surgical excision of tissue may be necessary.

For clinical care to evolve and improve, it is vital for affected
patients to be managed using all the resources available to the
multidisciplinary team and that outcomes are studied and recorded so as
to establish best practice in this area.

\textbf{Acknowledgements}

The authors would like to thank colleagues who shared their clinical
experience and encouraged this research.

\textbf{Disclosure Statement}

The authors have no potential sources of conflict of interest to
declare.

\textbf{References}

1. Nunes H, Bouvry D, Soler P, Valeyre D. Sarcoidosis. Orphanet J Rare
Dis. 2007;2:46.

2. Chen ES, Moller DR. Etiology of sarcoidosis. Clin Chest Med.
2008;29(3):365-77, vii.

3. Mr\selectlanguage{ngerman}ówka-Kata K, Kata D, Lange D, Namys\selectlanguage{polish}ł\selectlanguage{english}owski G, Czecior E, Banert K.
Sarcoidosis and its otolaryngological implications. European Archives of
Oto-Rhino-Laryngology. 2010;267(10):1507-14.

4. Rosen, Y. The Pathology of Sarcoidosis. Seminars in respiratory and
critical care medicine. 2007;28:36-52.

5. Badhey AK, Kadakia S, Carrau RL, Iacob C, Khorsandi A. Sarcoidosis of
the head and neck. Head Neck Pathol. 2015;9(2):260-8.

6. van Beek EJ, Hoffman EA. Functional imaging: CT and MRI. Clinics in
chest medicine. 2008;29(1):195-216.

7. Kirkil G, Lower EE, Baughman RP. Predictors of Mortality in Pulmonary
Sarcoidosis. CHEST. 2018;153(1):105-13.

8. Braun JJ, Gentine A, Pauli G. Sinonasal sarcoidosis: review and
report of fifteen cases. The Laryngoscope. 2004;114(11):1960-3.

9. Aladesanmi OA. Sarcoidosis: an update for the primary care physician.
MedGenMed. 2004;6(1):7.

10. Gulati S, Krossnes B, Olofsson J, Danielsen A. Sinonasal involvement
in sarcoidosis: a report of seven cases and review of literature.
European Archives of Oto-Rhino-Laryngology. 2012;269(3):891-6.

11. Aubart FC, Ouayoun M, Brauner M, Attali P, Kambouchner M, Valeyre D,
et al. Sinonasal involvement in sarcoidosis: a case-control study of 20
patients. Medicine. 2006;85(6):365-71.

12. Adelola OA, Fernandez R, Ahmad R, Leamy M, Moriarty BG. Sarcoidosis
of the external ear--literature review and report of a case. J Laryngol
Otol. 2007;121(3):289-92.

13. Duchemann B, Lavol\selectlanguage{ngerman}é A, Naccache J-M, Nunes H, Benzakin S, Lefevre M,
et al. Laryngeal sarcoidosis: a case-control study. Sarcoidosis,
vasculitis, and diffuse lung diseases: official journal of WASOG.
2014;31(3):227.

14. Neel III HB, McDonald TJ. Laryngeal sarcoidosis: report of 13
patients. Annals of Otology, Rhinology \& Laryngology.
1982;91(4):359-62.

15. Mayerhoff RM, Pitman MJ. Atypical and disparate presentations of
laryngeal sarcoidosis. Annals of Otology, Rhinology \& Laryngology.
2010;119(10):667-71.

16. Colvin I. Audiovestibular manifestations of sarcoidosis: a review of
the literature. The Laryngoscope. 2006;116(1):75-82.

17. Baughman RP. Pulmonary sarcoidosis. Clinics in chest medicine.
2004;25(3):521-30, vi.

18. Callejas-Rubio JL, López-Pérez L, Ortego-Centeno N. Tumor necrosis
factor-alpha inhibitor treatment for sarcoidosis. Therapeutics and
Clinical Risk Management. 2008;4(6):1305.

19. Roberts SD, Wilkes DS, Burgett RA, Knox KS. Refractory sarcoidosis
responding to infliximab. Chest. 2003;124(5):2028-31.

20. Ryu C, Herzog EL, Pan H, Homer R, Gulati M. Upper Airway Obstruction
Requiring Emergent Tracheostomy Secondary to Laryngeal Sarcoidosis: A
Case Report. Am J Case Rep. 2017;18:157-9.

21. Butler CR, Nouraei SR, Mace AD, Khalil S, Sandhu SK, Sandhu GS.
Endoscopic airway management of laryngeal sarcoidosis. Archives of
Otolaryngology--Head \& Neck Surgery. 2010;136(3):251-5.

22. Gurkov R, Berghaus A. Nasal reconstruction in advanced sinunasal
sarcoidosis. Rhinology. 2009;47(3):327.

23. Arsovic N, Babic B, Dimitrijevic M, Bukurov B, Vucinic V. Otitis
media and facial paralysis as presenting symptoms of a primary middle
ear sarcoidosis. Otol Neurotol. 2013;34(8):e121-2.

24. Vorselaars A, Keijsers R, Grutters J. Earlobe sarcoidosis.
Sarcoidosis Vasculitis and Diffuse Lung Diseases. 2012;29(1):55.

25. Krespi YP, Kuriloff DB, Aner M. Sarcoidosis of the Sinonasal Tract:
A New Staging System. Otolaryngology--Head and Neck Surgery.
1995;112(2):221-7.

\textbf{Tables}

Table 1. Staging of sinonasal sarcoidosis, as proposed by Krepsi et al.
(25):\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
Stage 1 & Mild, reversible disease without paranasal sinus
involvement\tabularnewline
Stage 2 & Moderate, potentially reversible disease without sinus
involvement\tabularnewline
Stage 3 & Moderate, potentially reversible disease with sinus
involvement\tabularnewline
\bottomrule
\end{longtable}

\textbf{Figure Legends}

Figure 1. Endoscopic appearance of laryngeal sarcoidosis with pale
oedematous supraglottic swelling and deformity affecting the epiglottis
with arytenoids and aryepiglottic folds involved to a lesser extent.

\textbf{Key Points}

\begin{itemize}
\tightlist
\item
  Sarcoidosis is a multisystemic inflammatory disease with ENT
  manifestations present in 10-15\% of patients, often as a presenting
  feature.
\item
  Diagnosis typically requires evidence of non-caseating granulomata and
  prognosis is favourable with treatment.
\item
  `Turban-shaped' epiglottis and restricted glottic mobility is observed
  on endoscopic examination of laryngeal sarcoidosis, where treatments
  include Speech and Language Therapy (SLT), intralesional injection,
  dilatation and tissue reduction surgery.
\item
  Sinonasal sarcoidosis is staged according to location and severity of
  disease, which guides treatment options, including intranasal,
  intralesional and systemic treatments, separately or in combination
  with topical, nasal and intralesional corticosteroid, and endoscopic
  sinus surgery.
\item
  Otologic sarcoidosis is difficult to diagnose but responds well to
  oral or intralesional corticosteroid therapy.
\end{itemize}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Image-001/Image-001}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

