CRS in the Immunosuppressed Patient: A Decision-Making Conundrum

PROGRAM DESCRIPTION: There is an established relationship between recalcitrant chronic rhinosinusitis (CRS) and immunodeficiency. In fact, some studies have reported an incidence of immunodeficiency in up to 54% of recalcitrant CRS patients. Most of these studies have focused on primary immunodeficiency and its related treatment options and outcomes. However, the incidence of secondary immunodeficiency in patients with chronic rhinosinusitis is less studied and the condition may not be considered by providers during the workup of CRS. There is likely a rising number of patients with secondary immunodeficiency and recalcitrant CRS due to the increased use of therapies that target the immune response in malignancy, rheumatologic and hematologic disease as well as other conditions. Understanding the impact of this immune dysfunction on CRS is very important. This session uses cased base scenarios to highlight causes of secondary immunodeficiencies and there association with CRS. Treatment options, extent of surgery and timing of surgery in this complex group is controversial and guidelines are lacking. We will discuss the evidence for medical and surgical interventions in these patients. This lecture will address the challenge of deciding when and if to initiate treatment with prophylactic antibiotics, topical antibiotics, antibiotics for acute exacerbations and immunoglobulin replacement therapy. The timing of surgical intervention requires considerable thought and planning as certain medications may increase the risk of surgical failure. This session will review the evidence on TNF alpha inhibitors and other immunomodulators as well as current recommendation for timing of hold medication before and after surgery. Increased numbers of organ transplants are being performed every year. This lecture will review the considerations for elective surgery given the higher risk of injury to the transplanted organ.

OUTCOME OBJECTIVE 1: Discuss the impact of secondary immunosuppression on CRS.

OUTCOME OBJECTIVE 2: Describe the decision-making for early versus delayed surgical intervention for CRS or recurrent acute rhinosinusitis (RARS) in patients with immunosuppression.

OUTCOME OBJECTIVE 3: Discuss potential intraoperative and postoperative complications of surgery in the immunosuppressed patients.

BACKGROUND STATEMENT: A review of the association between secondary immunosuppressive conditions and CRS is needed as this population likely represents an underrecognized yet substantial percentage of recalcitrant CRS. This lecture takes an evidence-based approach to address this potential knowledge gap.

Comprehensive Otolaryngology Track Statement :