Rhinosinusitis in transplant patients

Evaluation of ear, nose, and throat-screening in liver transplantation candidates: A retrospective cohort study

BACKGROUND

Patients with end-stage liver disease can be treated with a liver transplantation (LT). Before listing, candidates are subjected to a screening procedure according to the EASL Clinical Practice Guidelines for LT. In our hospital, this includes an ear, nose, and throat (ENT) examination, directed towards the identification of (asymptomatic) infections and head and neck malignancies.

METHODS

We retrospectively reviewed all ENT screening examinations in LT candidates from 2007 to 2022. The screening consisted of a visit to the ENT outpatient clinic combined with sinus radiography.

RESULTS

ENT screening was performed in 1099 patients. Sixty-one cases were identified, either diagnosed with an infection (n = 58, almost exclusively sinusitis) or a neoplasm (n = 3, of which two malignancies). With binary logistic regression, we could not identify significant risk factors for diagnosing sinusitis. 711 patients underwent LT. After LT, two patients developed a novel malignancy of the head and neck area, while 14 patients were diagnosed with sinusitis, two of the latter already showed opacification on sinus radiography during screening. Despite immunosuppressive drugs, no complicated sinusitis was observed.

CONCLUSION

Sinusitis or a neoplasm was diagnosed in almost 6% in a large cohort of LT candidates. Although almost a third of sinusitis patients were not treated accordingly, we did not observe any complicated sinusitis after LT. A more conservative approach to sinusitis may therefore be justified in LT candidates, especially in asymptomatic cases. At our institution, we aim to refer only those patients with specific ENT complaints .

Evaluation of Routine Ear, Nose, and Throat Screening in Heart Transplant Candidates: A Retrospective Cohort Study

BACKGROUND

Patients with end-stage heart failure refractory to medication can be treated with a heart transplant (HTx). These patients are subjected to a preoperative screening procedure according to International Society for Heart and Lung Transplantation guidelines. Additionally, in our hospital, a routine ear, nose, and throat (ENT) screening is performed, directed toward the identification of asymptomatic infections and head and neck neoplasms. There are no studies demonstrating that this screening has additional value in these patients.

METHODS

To investigate the yield of protocolled ENT screening in candidates for HTx, we retrospectively reviewed the medical records of patients who were subjected to the screening procedure between 2012 and 2020.

RESULTS

The study population consisted of 251 patients of whom 177 (70.5%) were male with a median age of 52 years (IQR, 45-59 years). Ten patients (4.0%) were diagnosed with an infection (sinus) or a neoplasm, resulting in a number needed to screen of 25. In all cases, ENT consultation or sinus radiography did not influence the decision to list patients for HTx. Furthermore, no major ENT infections or occurrence of de novo head and neck malignant neoplasm were observed during follow-up after HTx.

CONCLUSIONS

The clinically relevant yield of protocolled ENT screening in candidates for HTx is low. Based on these findings, we believe that only patients with abnormal findings on a routine sinus computed tomography scan and/or specific ENT complaints should be referred to an otorhinolaryngologist.

Incidence and Treatment Outcome of Rhinosinusitis before Kidney Transplantation: A Retrospective Cohort Study

BACKGROUND

The use of immunosuppressants after transplantation can aggravate sinus infections. Although kidney transplantation (KT) recipients are administered strong immunosuppressant therapy, there is few consensus or reports on incidence and treatment of rhinosinusitis before KT. This study was undertaken to analyze the results of a cohort of KT recipients that underwent sinonasal evaluation before KT.

METHODS

Observational retrospective cohort data were analyzed from adults who underwent a KT between January 2015 and December 2018. In total, 966 patients were screened by clinical history, nasal endoscopy, and plain X-ray before KT.

RESULTS

A total of 86 patients (8.9%) were diagnosed with rhinosinusitis. Twenty-three of the eighty-six patients (26.7%) who underwent plain X-ray on second follow up were successfully treated with primary and secondary antibiotics, saline irrigation, and INS. From the remaining 63 patients who underwent additional CT on second follow up, 43 patients were treated with primary or secondary antibiotics and 20 patients (10 with chronic rhinosinusitis and 10 with fungal ball) were treated with endoscopic sinus surgery. There were no serious complications affecting patient mortality after KT.

CONCLUSION

We report that 8.9% of patients showed abnormal findings in sinonasal evaluation before KT. Although most patients did not require surgery, surgery is recommended for active rhinosinusitis, which does not respond to medication, and for fungal rhinosinusitis to prevent postoperative sinonasal infection.

Presentation and outcomes of chronic rhinosinusitis following liver and kidney transplant

Objective

This study aims to describe presenting characteristics of patients diagnosed with non-invasive chronic rhinosinusitis (CRS) following liver or kidney transplant and determine factors associated with disease-related complications, selection of endoscopic sinus surgery (ESS), and disease resolution in this population.

Study design

Retrospective chart review.

Setting

An academic tertiary care center (Mayo Clinic, Rochester, Minnesota).

Subjects and methods

Liver and kidney transplant recipients evaluated by Mayo Clinic otolaryngologists for CRS between 1998 and 2018 were identified. Univariate and multivariate logistic regression analyses were used to determine patient factors and treatment modalities associated with developing complications, selection of ESS, and disease resolution.

Results

Fifty-seven patients met inclusion criteria. No patients developed intraorbital or intracranial complications of their CRS. Multivariate modeling demonstrated that the presence of polyps (P = 0.036) was associated with undergoing ESS within one year of presentation. A higher Lund–Mackay (LM) computed tomography score (P = 0.023) and older age (P = 0.018) were significantly associated with decreased disease resolution. No other factors were significantly associated with the use of endoscopic sinus surgery within one year of otolaryngology presentation or resolution of CRS in this cohort.

Conclusion

The risk of developing CRS-related intraorbital or intracranial complications in this immunecompromised patient cohort may be lower than originally thought. For liver- and kidney-recipients stable on immunosuppressive medication for many years, prognostic factors for CRS may mirror those for immunocompetent patients.

Respiratory Tract Infections: Sinusitis, Bronchitis, and Pneumonia

Solid organ and hematopoietic stem cell transplant recipients are at increased risk of upper and lower respiratory tract infections. While these infections are frequently encountered in the general population, the spectrum of their clinical presentation including morbidity and mortality is increased in patients undergoing transplantation procedures. Impaired innate and adaptive immunity, potential anatomical abnormalities resulting from extensive surgical procedures, presences of indwelling medical devices, and increased healthcare exposure put transplant recipients at particularly high risk for respiratory tract disease. Infections of the respiratory tract can be divided into those affecting the paranasal sinuses, the upper airways such as bronchitis and tracheobronchitis, and the lower airways like pneumonia. Each of these clinical syndromes can further be classified based on their chronicity, acute vs. chronic; their setting, community vs. nosocomial; and the etiology such as bacteria, viruses, fungi, and rarely parasites. It is also important to realize that such immunologically vulnerable patients are at risk for polymicrobial infection that may present concurrently or in a sequential, consecutive fashion. This chapter reviews the common respiratory tract infections affecting transplant recipients with particular attention directed toward epidemiological risk factors, clinical presentations, diagnostic strategies, and common pathogens. Specific causes of opportunistic pneumonias are also reviewed.

Rhinosinusitis in Solid Organ Transplant Recipients: Analysis of 4562 Transplanted Patients

INTRODUCTION

Survival rates of solid organ transplant recipients are steadily increasing. Chronic immunosuppression is a key to sustain the transplanted organ. Thus, these patients are at a higher risk for fulminant disease and severe complications of rhinosinusitis (RS). Surprisingly, this has been scarcely discussed in the literature.

OBJECTIVE

To analyze the characteristics and disease course of RS in solid organ transplant recipients.

MATERIALS AND METHODS

Retrospective study. Medical records of all solid organ transplant recipients with a diagnosis RS treated at a national transplant center between the years 2001 and 2016 were reviewed.

RESULTS

Of 4562 solid organ transplant recipients, a documented diagnosis of RS was identified only in 61 (1.3%) patients. Sixty-four patients presented with posttransplantation RS; of them, 54.5% had chronic RS (CRS) and the remaining 45.5% patients were diagnosed with acute RS. Microbial cultures grew almost exclusively bacterial pathogens. A documented invasive fungal infection was noted in only 2 patients. A total of 24 (40%) patients underwent endoscopic sinus surgery, the majority (22) for CRS. On subgroup analysis, surgical intervention was more frequent in lung transplant recipients ( P = .005). Neither specific disease nor surgical complications were found.

CONCLUSIONS

Interestingly, acute fulminant infection or sinusitis complications in solid organ transplant patients were much lower than expected. CRS in this patient group was less frequent than expected as well. Whether chronic immunosuppression minimizes the likelihood for CRS deserves further investigation. A more surgically oriented approach in CRS patients may be favored early in the management course of medically refractory patients in light of patients excellent outcomes.

Sinusitis in patients undergoing allogeneic bone marrow transplantation - a review

Introduction

Sinusitis is a common morbidity in general population, however little is known about its occurrence in severely immunocompromised patients undergoing allogeneic hematopoietic stem cell transplantation.

Objective

The aim of the study was to analyze the literature concerning sinusitis in patients undergoing allogeneic bone marrow transplantation.

Methods

An electronic database search was performed with the objective of identifying all original trials examining sinusitis in allogeneic hematopoietic stem cell transplant recipients. The search was limited to English-language publications.

Results

Twenty five studies, published between 1985 and 2015 were identified, none of them being a randomized clinical trial. They reported on 31–955 patients, discussing different issues i.e. value of pretransplant sinonasal evaluation and its impact on post-transplant morbidity and mortality, treatment, risk factors analysis.

Conclusion

Results from analyzed studies yielded inconsistent results. Nevertheless, some recommendations for good practice could be made. First, it seems advisable to screen all patients undergoing allogeneic hematopoietic stem cell transplantation with Computed Tomography (CT) prior to procedure. Second, patients with symptoms of sinusitis should be treated before hematopoietic stem cell transplantation (HSCT), preferably with conservative medical approach. Third, patients who have undergone hematopoietic stem cell transplantation should be monitored closely for sinusitis, especially in the early period after transplantation.

Chapter 8: Invasive fungal rhinosinusitis

Invasive fungal rhinosinusitis (IFRS) is a disease of the paranasal sinuses and nasal cavity that typically affects immunocompromised patients in the acute fulminant form. Early symptoms can often mimic rhinosinusitis, while late symptoms can cause significant morbidity and mortality. Swelling and mucosal thickening can quickly progress to pale or necrotic tissue in the nasal cavity and sinuses, and the disease can rapidly spread and invade the palate, orbit, cavernous sinus, cranial nerves, skull base, carotid artery, and brain. IFRS can be life threatening if left undiagnosed or untreated. While the acute fulminant form of IFRS is the most rapidly progressive and destructive, granulomatous and chronic forms also exist. Diagnosis of IFRS often mandates imaging studies in conjunction with clinical, endoscopic, and histopathological examination. Treatment of IFRS consists of reversing the underlying immunosuppression, antifungal therapy, and aggressive surgical debridement. With early diagnosis and treatment, IFRS can be treated and increase patient survival.

Management and Outcomes of Chronic Otitis Media in Patients Who Received Solid Organ Transplantation

Objectives. Control of perioperative infection can increase the success rate of organ transplant. The incidence, clinical features, and optimal management of chronic otitis media (COM) in solid organ transplant recipients have not been adequately evaluated. We therefore assessed the incidence and clinical course of COM in solid-organ transplant recipients.

Design. Case series with chart review.

Setting. Tertiary referral center.

Subjects and Methods. We reviewed the medical records of 3278 patients who underwent solid organ transplantations between February 1995 and December 2007 to identify those diagnosed with COM before and after transplant. We analyzed the long-term clinical course and management of COM in these patients.

Results. Of 3278 solid organ transplant recipients, 65 (2.0%) were diagnosed with pretransplant COM with a perforated ear drum, including 31 liver, 28 renal, and 6 heart transplant recipients. The primary symptom was otorrhea, followed by hearing disturbance, otalgia, and tinnitus. Middle ear swab culture showed bacterial growth in 17 of the 40 patients (42.5%) with suppurative COM. Of these 40 patients, 14 underwent tympanomastoid surgery (operation group) and 26 were prescribed antibiotics (medication group). The remaining 25 patients, with dry perforated ear drums and well-pneumatized mastoids, were observed without treatment (observation group). After transplantation, the incidence of otorrhea was significantly lower in the operation group (11.1%) than in either the medication (26.9%) or observation (26.7%) group ( P = .040, .048, respectively).

Conclusions. Precise diagnosis and proper surgical intervention for COM may reduce the rate of otorrhea and exacerbation of COM in solid organ transplant recipients.

Sinusitis caused by the fungus Xylaria enteroleuca in a lung transplant recipient

We report the 1st case of sinusitis and human infection by Xylaria enteroleuca (anamorph Nodulisporium sp.), a rare fungal endophyte of rain forest trees. The patient was a Brazilian woman who had her lung transplanted. Diagnosis was established by direct microscopic examination, computed tomographic scan, cultures, and sequencing of a ribosomal RNA gene. The in vitro antifungal susceptibility of the isolate is provided.

Contemporary management of rhinosinusitis and cystic fibrosis

Historically, cystic fibrosis has been a devastating disease, with patients rarely living beyond childhood. Recent advances during the last two decades, however, have led to an improved understanding of the disease on a molecular level. Such understanding has in turn led to new treatments, longer life expectancy, as well as new challenges in the management of both pulmonary and extrapulmonary manifestations of cystic fibrosis. The otolaryngologist caring for patients with cystic fibrosis is thus challenged with the medical and surgical management of chronic sinusitis and sinonasal polyposis in these challenging circumstances.