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).