We report the first case.

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We report the first case, to our knowledge, of sarcoidosis affecting the middle ear.

Sarcoidosis affects head and neck constitutions in 9 percent of cases.[1] The following is, to our knowledge, the first reported case of sarcoidosis involving the middle ear.[2]

CASE REPORT

A 48-year-old black woman neared with a 6-month history of left-sided tinnitus, hearing los left ear "plugging," and ear pain. Three years earlier, investigation of cough and dyspnea revealed bilateral hilar and paratracheal lymphadenopathy forward chest radiography. She was treated briefly with prednisone. brace years before, she was treated for bilateral iritis. There was a history of hyperthyroidism. She mentioned having reduc have an odor and taste, and pain in the right knee

forward examination, there was left tympanic membrane hyperemia and immobility, a flat left tympanogram, submandibular, cervical, and inguinal lymphadenopathy, and reduc hearing onward the left with the Weber touchstone (512 Hz) lateralizing to the left

A undivided blood cell count, differential white descendants cell count, sickling test, routine chemistry, arterial kin gases, urinalysis, and ECG were normal. The VDRL was nonreactive. Gamma globulins were elevated at 22 g/L (7 to 15) as was angiotensin-converting enzyme at 115 U/L ([les than] 75) A chest radiograph showed bilateral hilar enlargement. Paranasal sinus radiographs showed mild left maxillary antrum mucosal thickening. A radiograph and bone scan of the right knee revealed lateral femoral condylar subarticular lucency and increased activity respectively.

There were foci of increased activity upon gallium scan in the mediastinum, hila, left supraclaivcular region, and groins. eventuates of pulmonary function tests were normal. Borderline mitral valve prolapse was seen forward echocardiogram and cardiac color Doppler study

An audiogram disclosed mild conductive hearing los in succession the left. Brain-stem auditory evok answers were normal. A comput tomographic scan of the head demonstrated a soft-tissue density in the left middle ear mysterious to the tympanum and without bony erosion. The left mastoid air small cavitys were opacified (Fig 1).

At left tympanotomy, a pale, pink granular mass could be seen filling the posterior portion of the tympanum and extending into the aditus and toward the sinus tympani. Portions were remov Histopathologic examination showed noncaseating granuloma with collections of epithelioid enclosed spaces surrounded by a rim of lymphocyte There were occasional multinucleate giant solitary abode; squalids and no acid-fast bacilli (Fig 2)

A left nasal septal polypectomy 1 month later also showed noncaseating granulomata. After several month forward prednisone therapy, 40 mg daily, the hearing improved while the tinnitus remained. The postoperative audiogram showed slight conductive hearing los in succession the left.

DISCUSSION

Sarcoidosis of the nose, nasopharynx, paranasal sinuses, larynx, pharynx, salivary glands, and cervical lymph nodes has been described.[2] Middle ear involvement in sarcoidosis has hitherto been indirect, to be paid to otitis media secondary to nasopharyngeal disease.[3] Hearing los has been of sensorineural impressed sign with various mechanisms proposed.[4] Eighth hardihood sarcoid involvement is commonly associated with other cranial neuropathies or uveitis.[5] Auditory theory sarcoidosis has also included the external ear.[6] The initial presentation of sarcoidosis may be a head and neck manifestation.

In our case, systemic sarcoidosis was established according to physical examination, blood tests (eg angiotensin-converting enzyme) and imaging. Pathologic confirmation came via the left middle ear mass and the nasal polyp

We are unaware of explanation for the rarity of middle ear involvement on sarcoidosis. The mucosa, relations supply, and oxygen tension are not significantly different from other regions of the upper respiratory tract. Ossicular vibration and a relatively small surface area to use are unsubstantiated, speculative possibilities.

REFERENCES

[1] McCaffrey TV McDonald TJ Sarcoidosis of the nose and paranasal sinuses. Laryngoscope 1983; 93:128-84

[2] Ellison DE McDonald TJ Sarcoidosis of the head and neck Clin Dermatol 1986; 4:136-42

[3] Fishman s Canalis RF. Sarcoidosis of the head and neck Ear Nose Throat J 1979; 58:147-49

[4] Gristwood RE force deafness associated with sarcoidosis. J Laryngol Otol 1958; 72:479-91

[5] Souliere CR Kara CR Barrs DM Bell AF. abrupt hearing loss as the solitary manifestation of neurosarcoidosis. Otolaryngol Head Neck Surg 1991; 105:376-81

[6] Nora s Sarcoidosis of the ear. Ear Nose Throat J 1981; 60:387-88

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