Parotid gland involvement in sarcoidosis.

To the Editor: Sarcoidosis is a systemic granulomatous disease of unknown cause that may involve virtually any organ, including the parotid gland. Involvement of the parotid gland has been reported in 6 to 30% of patients with systemic sarcoidosis. (1-3) We retrospectively evaluated the general clinical features of 26 patients with sarcoidosis with parotid involvement over a 36-year period.

Five percent of patients with sarcoidosis had parotid gland involvement. Of these subjects, 77% were female and 23% were male. When the patients were assigned a radiologic disease stage, 1 patient had stage 0 disease, 17 patients had stage I, and 8 patients had stage II disease. Extrapulmonary involvement other than the parotid gland was present in 84.6% of the patients. In most patients with parotid involvement (92.3%), there was a painless enlargement of the glands bilaterally. Thirty percent had xerostomia and 19.2% had xerophthalmia. Lacrimal gland involvement was present in 4 of the 5 patients with xerophthalmia.

The frequency of parotid gland involvement has been reported to approach 30% in sarcoidosis. (3) In this study, we diagnosed parotid involvement in 5% of our patients with sarcoidosis over a 36-year period. In a recently reported sarcoidosis series, the frequency of parotid gland involvement was 6%. (1) It is possible that factors such as different diagnostic modalities and differences in the ethnicities and demographic features of the patients led to different frequencies of parotid involvement in the various studies.

Although the mean age of our patients with parotid involvement was no different from patients without parotid involvement, it was greater than 40 years. However, other studies have reported that most of their patients with parotid involvement were 20 to 40 years of age. (1,4) In our patients with sarcoidosis with parotid involvement, the clinical presentation was generally in the form of bilateral, painless swelling of the gland. Different series have reported painless swelling of the gland as the clinical presentation in 83 to 95% of patients. (2,4,5) Xerostomia (34.7%) and xerophthalmia (19.2%) were relatively more frequent in our study. In addition, most of our patients with xerophthalmia also had lacrimal gland involvement. Furthermore, involvement of the lacrimal gland was more frequent in patients with parotid gland involvement than in those with no involvement of the parotids. In three of our patients, parotid enlargement was the initial clinical manifestation of sarcoidosis. In two of them, the only sign was painless swelling of the parotids and the diagnosis of sarcoidosis was reached by parotid biopsy.

Extrapulmonary involvement, other than parotid, was significantly more frequent, at 84.6%, in our patients with sarcoidosis with parotid involvement. In the study performed by Iko et al, (4) extrapulmonary involvement was present in almost 68% of their patients with parotid involvement. We found that most of our patients with parotid gland involvement (69.2%) had stage 0 and stage I disease with no pulmonary parenchymal involvement. Iko et al (4) found that approximately three fourths of their patients with parotid involvement also had involvement of the pulmonary parenchyma. These differences can probably be explained by the fact that quite a high percentage of our patients had stage 0 and stage I disease. On the other hand, we found that 81.8% of our patients without parotid involvement also had no parenchymal involvement. From this, we can conclude that extrapulmonary involvement rather than pulmonary parenchymal involvement was more predictive of parotid gland involvement.

In summary, in patients with sarcoidosis, especially those with extrapulmonary involvement, the presence of painless parotid swelling should remind us of the involvement of the parotid gland by sarcoidosis. Xerostomia is a frequent finding and might point to minor salivary gland involvement. Xerophthalmia was also a relatively frequent finding in our study that accompanied lacrimal gland involvement in most cases. In some rare conditions, parotid enlargement might be the initial manifestation of sarcoidosis.

References

1. James DG, Sharma OP. Parotid gland sarcoidosis. Sarcoidosis Vasc Diffuse Lung Dis 2000; 17:27-32.

2. Som PM, Shugar JMA, Train JS. Biller HF. Manifestations of parotid gland enlargement, radiographic, pathologic, and clinical correlations. Radiology 1981;141:421-426.

3. Hamner JE III, Scofield HH. Cervical lymphadenopathy and parotid gland due to sarcoidosis: a study of 31 cases. J Am Dent Assoc 1967;74:1224-1230.

4. Iko BO, Chinwuba CE, Myers EM, Teal JS. Sarcoidosis of the parotid gland. Br J Radiol 1986;59:547-552.

5. James DG, Sharma OP. Parotid gland sarcoidosis. Sarcoidosis Vasc Diffuse Lung Dis 2000;17:27-32.

Halil Yanardag, MD

Istanbul University

Aksaray, Istanbul, Turkey