Predictors for Development of Chronic Rhinosinusitis in Transplant Recipients

OBJECTIVES

Studies suggest that transplant patients are at a higher risk of developing chronic rhinosinusitis (CRS). However, there is a dearth of studies describing the factors that may be linked to the development of CRS in this population. Our objective is to identify the risk factors associated with the development of CRS in transplant recipients.

STUDY DESIGN

Retrospective cohort.

SETTING

Tertiary care center.

METHODS

This cohort included 3347 transplant recipients seen between 2017 and 2022. Of these, 2128 patients met the inclusion criteria and were grouped according to whether they were diagnosed with CRS during the post-transplant period. The analysis included both univariate and multivariate analysis to ascertain the odds ratio (OR) and predictive factors.

RESULTS

Of the 2128 patients, 649/2128 (30.4%) had CRS. CRS patients had an increased prevalence of previous endoscopic sinus surgery, allergic rhinitis, and recurrent acute rhinosinusitis in the pre-transplant period compared to the non-CRS group. According to the multivariate analysis, patients with primary immunodeficiency and additional transplant were 1.9 and 3.1 times more likely to develop CRS during the posttransplant period (95% CI: 1.3-2.6, p < .0001), (95% CI: 1.3 -7.3, p = .01), respectively. Sirolimus use was also associated with the development of CRS (OR = 1.4, 95% CI: 1.1-1.9, p = .01).

CONCLUSION

This study is the largest cohort aimed at determining the predictive factors associated with the development of CRS. Patients with pretransplant rhinologic conditions, hematologic deficiencies, and the utilization of specific immunosuppressants were found to have a higher likelihood of developing CRS following transplantation.

Modified screening and management strategies for chronic rhinosinusitis in hematologic patients receiving hematopoietic stem cell transplantation

OBJECTIVES

Given the lack of consensus on the screening and treatment for chronic rhinosinusitis (CRS) in the patients undergoing hematopoietic stem cell transplantation (HSCT), we reviewed the risk factors for CRS to improve the efficiency of sinonasal screening and analyzed the effect of treating CRS in search of guidance for modifying current management strategies for rhinosinusitis in HSCT patients.

METHODS

We conducted a nested case-control study in a retrospective cohort of hematologic patients receiving HSCT from April 2011 to April 2021 and collected data on demographics, smoking/atopic status, hematological diseases, and features of rhinosinusitis for analysis. The associated factors for control of rhinosinusitis and survival were analyzed.

RESULTS

Fifty-eight CRS patients were identified, and another 116 age- and sex-matched controls were selected from HSCT patients without CRS. Allergy and smoking were risk factors for CRS in HSCT patients. The multivariable logistic analysis indicated that endoscopic sinus surgery (ESS) was an independent factor for better control of CRS. However, survival was not associated with rhinosinusitis-related factors, but only with hematologic-related factors, including allogenic HSCT, reduced-intensity conditioning, and remission.

CONCLUSIONS

Sinonasal evaluation should be targeted to the high-risk group. ESS is effective in managing CRS, while control of CRS is not determinant of overall survival in patients receiving HSCT.

An algorithmic approach to sinonasal evaluation preceding bone marrow transplantation

<b>Introduction:</b> The authors conducted this study to review the available resources and prepare an algorithmic approach to pre-transplantation sinonasal evaluation.</br></br> <b>Materials and methods:</b> The sources of data were PubMed, Cochrane databases, and Google Scholar. We searched the available database for English-language studies using the keywords rhinosinusitis, transplantation, post -transplant sinusitis. Studies of all designs were included.</br></br> <b>Results:</b> Thirty-five relevant studies were retrieved from a total of 182 articles. The review of references guided us to 5more publications.</br></br> <b>Discussion:</b> We have proposed an algorithmic approach to sinonasal evaluation before transplantation which can provide a brief but comprehensive assessment of the patients. The evaluation begins with a thorough history and physical examination, including nasal endoscopy with careful attention to objective evidence of inflammation. CT scan should not be considered in all of the cases.</br></br> <b>Conclusion:</b> We have suggested an algorithm to provide a comprehensive and cost-effective way for the evaluation of sinonasal diseases before planned immunosuppression in order to assist in reducing post-transplantation morbidity and mortality.

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.

Utility of Pre-Hematopoietic Cell Transplantation Sinus CT Screening in Children and Adolescents

BACKGROUND AND PURPOSE

The clinical benefit of pre-hematopoietic cell transplantation sinus CT screening remains uncertain, while the risks of CT radiation and anesthesia are increasingly evident. We sought to re-assess the impact of screening sinus CT on pretransplantation patient management and prediction of posttransplantation invasive fungal rhinosinusitis.

MATERIALS AND METHODS

Pretransplantation noncontrast screening sinus CTs for 100 consecutive patients (mean age, 11.9 ± 5.5 years) were graded for mucosal thickening (Lund-Mackay score) and for signs of noninvasive or invasive fungal rhinosinusitis (sinus calcification, hyperattenuation, bone destruction, extrasinus inflammation, and nasal mucosal ulceration). Posttransplantation sinus CTs performed for sinus-related symptoms were similarly graded. Associations of Lund-Mackay scores, clinical assessments, changes in pretransplantation clinical management (additional antibiotic or fungal therapy, sinonasal surgery, delayed transplantation), and subsequent development of sinus-related symptoms or invasive fungal rhinosinusitis were tested (exact Wilcoxon rank sums, Fisher exact test, significance P < .05).

RESULTS

Mean pretransplantation screening Lund-Mackay scores (n = 100) were greater in patients with clinical symptoms (8.07 ± 6.00 versus 2.48 ± 3.51, P < .001) but were not associated with pretransplantation management changes and did not predict posttransplantation sinus symptoms (n = 21, P = .47) or invasive fungal rhinosinusitis symptoms (n = 2, P = .59).

CONCLUSIONS

Pre-hematopoietic cell transplantation sinus CT does not meaningfully contribute to pretransplantation patient management or prediction of posttransplantation sinus disease, including invasive fungal rhinosinusitis, in children. The risks associated with CT radiation and possible anesthesia are not warranted in this setting.

Clinical course of rhinosinusitis and efficacy of sinonasal evaluation in kidney transplant recipients: review of 1589 patients

INTRODUCTION

Rhinosinusitis in patients who undergo kidney transplantation (KT) might have specific clinical characteristics due to immune status of recipients. The aim of this study was to identify the clinical course of rhinosinusitis after KT and to evaluate the efficacy of routine sinonasal evaluation before KT.

METHODS

The study included 1589 kidney transplant adult patients who underwent preoperative sinonasal evaluation including sinonasal symptoms, nasal endoscopy, and plain X-ray between November 1994 and December 2013 (19 years). Demographic data and clinical course of rhinosinusitis were evaluated retrospectively.

RESULTS

The study population consisted of 897 men (56.5%) and 692 women (43.5%) with a mean age of 42.5 years (range 18-75 years). The prevalence of pre-KT rhinosinusitis was 4.2% (66/1589), and that of post-KT rhinosinusitis was 0.9% (13/1503). The prevalence of acute rhinosinusitis and chronic rhinosinusitis (CRS) was 0.13 and 2.33% in pre-KT patients and 0.2 and 0.6% in post-KT patients, respectively. The recurrence rate of CRS in pre-KT patients was 37.8%. Of the 27 asymptomatic patients, the recurrence rate was 11.1%. Symptomatic patients had more severe endoscopic findings and higher Lund-Mackay CT scores than asymptomatic patients. The prevalence of fungal ball (0.8% in pre-KT and 0.3% in post-KT patients) was similar to that in the general population, and only one patient experienced invasive fungal rhinosinusitis after KT. No patient with pre-KT rhinosinusitis experienced severe complications.

CONCLUSIONS

The prevalence and recurrence rate of rhinosinusitis in KT patients was not increased after KT. Symptomatic patients needed surgical or medical treatment before KT, but asymptomatic patients showed no deterioration of clinical course after KT. Routine sinonasal evaluation for asymptomatic patients is not recommended before KT.

Rhinosinusitis in Acute Leukemia Patients Undergoing Allogeneic Stem Cell Transplantation-A Single-Center Experience

BACKGROUND

Although rhinosinusitis constitutes a major clinical problem in general population, data on rhinosinusitis in patients undergoing allogeneic hematopoietic stem cell transplantation (alloHSCT) are scarce. Therefore, the aim of the study was to assess the frequency of rhinosinusitis, the impact of rhinosinusitis on post-alloHSCT outcome, and to analyze risk factors potentially predisposing to rhinosinusitis.

METHODS

Retrospective analysis of acute leukemia patients undergoing alloHSCT.

RESULTS

A total of 87 patients (49 male), with a median age of 36 years (range, 18-58), transplanted from 1999 to 2010, were enrolled; 61 patients suffered from acute myeloid leukemia (AML) and 26 of acute lymphoblastic leukemia (ALL). Fifteen patients (17.2%) experienced rhinosinusitis before transplantation, among whom 5 (33%) experienced rhinosinusitis after alloHSCT; 22 patients (25.3%), 12 AML and 10 ALL, experienced rhinosinusitis after alloHSCT. The median time to rhinosinusitis was 200 days (range, 1-2,044). 11 patients experienced rhinosinusitis during the 1st 100 days after transplantation, 8 during the 1st 30 days. Post-alloHSCT rhinosinusitis did not affect overall survival of transplant patients (P = .35). In univariate analysis only total body irradiation as part of conditioning (odds ratio [OR], 2.78; 95% CI, 1-7.77) and previous nasal packing (OR, 5.18; 95% CI, 1.22-23.43) were associated with higher incidence of rhinosinusitis. In multivariate analysis, none of the analyzed parameters was shown to have an impact on rhinosinusitis development.

CONCLUSIONS

Rhinosinusitis is a frequent medical condition in patients undergoing alloHSCT. The overall survival of patients developing rhinosinusitis after HSCT is similar to survival of patients who do not. No risk factors for developing rhinosinusitis could be identified.

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.

The role of screening sinus computed tomography in pediatric hematopoietic stem cell transplant patients

OBJECTIVE

The objective of this study was to evaluate pretransplant sinus computed tomography (CT) as predictor of post-hematopoietic stem cell transplant sinusitis.

METHODS

We evaluated pretransplant and posttransplant CT findings in 100 children using the Lund-Mackay system and "common-practice" radiology reporting and correlated these with the presence of acute sinusitis.

RESULTS

Fourteen percent of patients with normal screening CT developed posttransplant sinusitis, compared with 23% with radiographic abnormalities and 22% with clinical sinusitis alone, not statistically significant. Sensitivity of CT findings for clinical sinusitis ranged between 19% and 56%. Except for mucosal thickening (71% specificity), other findings had high specificity between 92% and 97%, particularly when combined. Lund-Mackay score change of 10 or greater from baseline was associated with a 2.8-fold increased likelihood of having sinusitis (P < 0.001).

CONCLUSIONS

Screening CT can serve as a baseline, with a Lund-Mackay score change of 10 or greater constituting a significant threshold. The strongest correlation with the presence of acute sinusitis was seen with combined CT findings.

Sinonasal evaluation and treatment before liver transplantation: a retrospective review of 982 patients

Immunosuppression after liver transplantation (LT) increases complications from infection. The usefulness of sinonasal evaluation before LT has not been fully evaluated. The aim of this study was to determine the usefulness of routine sinonasal evaluation before LT and pre-transplant treatment of sinusitis. The clinical records of 982 adult patients (age ≥18 years) who underwent LT between January 1997 and June 2011 were retrospectively reviewed and analyzed. A total of 920 patients (93.7 %) underwent pre-LT sinonasal evaluation, including a sinonasal symptom questionnaire, nasal endoscopy and plain X-ray. Of these patients, 269 (29.2 %) had abnormal findings and underwent paranasal CT scans. Based on CT, 102 patients, including 21 with fungal ball, were diagnosed with sinusitis and 62 (60.8 %) underwent LT after medical or surgical treatment for sinusitis. Another 40 patients (33 with sinusitis and 7 with fungal ball) underwent LT without treatment for sinusitis. No difference in infectious complications was observed according to sinusitis treatment type. Among chronic rhinosinusitis patients, those who underwent LT (n = 48) after adequate treatment had a lower mortality rate than those who did not receive treatment (n = 33) (12.5 vs. 33.3 %; p = 0.024). Sinonasal evaluation preceding LT did not prevent infectious complications but untreated sinusitis might be correlated with increased mortality after LT. Routine pre-LT sinonasal evaluation would be considered for safer transplantation.

Evaluation of the pretransplantation workup before allogeneic transplantation

An extensive workup is generally performed before allogeneic transplantation. The extent of this workup varies substantially between centers because of a lack of guidelines. We analyzed 157 consecutive allogeneic transplant candidates to understand the significance of components of the pretransplant evaluation. Workup consisted of chest computed tomography (CT); magnetic resonance imaging of the head; dental, ears-nose-throat (ENT), ophthalmology, and gynecology evaluations; pulmonary function tests; echocardiography; cytomegalovirus PCR; urine culture; clinical evaluation; and disease staging. Results were categorized as "normal or minor finding" or "major finding" (having significant consequences such as further testing or therapy). Major findings were classified as incidental or related to history and symptoms. Components of the pretransplant workup with the highest rate of major findings were CT (22%), dental evaluation (13%), and ENT (12%, mostly symptomatic). All other components had a low rate of major findings. Although 126 transplants were performed as scheduled, 24 were delayed and 7 canceled at short notice. The main reasons for delaying or canceling transplantation were active infection and unexpected disease progression. A prospective evaluation of a more restricted, symptom-guided pretransplant evaluation appears to be warranted.