Non-invasive Fungal Sinusitis as a Complication of a Steroid-Eluting Stent Following Endoscopic Sinus Surgery: A Case Report

Abstract

Objective: Steroid eluting stents have proven to be a highly useful adjunctive therapy for chronic rhinosinusitis (CRS) and play an important role in the treatment of many inflammatory diseases of the sinuses. Few reports of adverse events were reported in clinical trials and are described in the literature. However, we describe the first known case of an immunocompetent patient developing non-invasive fungal tissue infection as a sequelae of stent-related tissue necrosis requiring surgical debridement. Methods: A 69-year-old immunocompetent male with CRS had Propel™ stents placed in the bilateral frontal sinus outflow tracts during revision endoscopic sinus surgery. He presented 2 weeks post-operatively with severe facial pain without vision changes, fevers, mental status changes, or evidence of cranial neuropathies. On rigid nasal endoscopy, necrotic tissue and gross fungal elements were visualized in the left frontal sinus outflow tract at the area of previous steroid stent position. Results: The patient was taken for urgent endoscopic sinus surgery and debridement given significant symptoms and concern for invasive fungal infection. A revision left maxillectomy, ethmoidectomy, and draf 2b frontal sinus drillout were performed, with healthy bleeding tissue encountered beneath necrotic tissue. Pathology revealed tissue necrosis, exudative lumenal debris, and extensive fungal elements with no evidence of tissue invasion, and cultures yielded growth of aspergillus niger. The patient’s symptoms improved significantly on post-operative day 1, he had normal post-operative changes at 2 weeks following debridement, and had no recurrence of fungal infection with complete healing at 4 months. Conclusion: While likely rare, steroid-eluting stents may pose a risk of saprophytic tissue infection as a result of tissue necrosis and local immunosuppression. Caution should be taken in using these devices in immunocompromised patients.

Short‐term postoperative efficacy of steroid‐eluting stents for eosinophilic chronic rhinosinusitis with nasal polyps: A randomized clinical trial

“…Serum cortisol levels of patients were stable and fell within the normal range after treatment, which is consistent with previous reports 21,40 . Although reports in the literature suggest that patients may present with sinus infection, obvious crusting, granulation tissue formation, and even fungal sinusitis after stent implantation, 36,41 none of these implant‐related adverse reactions were observed in our study. This could be due to the use of corticosteroid nasal spray and nasal irrigation postsurgery.…”

Clinical Characteristics of Bloodstream Infection in Immunosuppressed Patients: A 5-Year Retrospective Cohort Study

“…Generally, typical immunosuppressive status includes patients with hematological diseases, tumor, oral immunosuppressive medications, solid-organ transplant, stem cell transplant, or bone marrow transplant, and atypical immunosuppressive status includes patients with diabetes mellitus, liver cirrhosis, and burns ( Mylotte and Tayara, 2000 ; Li et al., 2021 ; Willis et al., 2021 ). Studies revealed that immunosuppression could result from critical surgery as well ( Si et al., 2021 ), and sometimes postoperative patients are susceptible to infections caused by opportunistic pathogens ( Mada et al., 2020 ; Shipman et al., 2021 ). IS patients with infections may present with atypical signs and symptoms.…”

The next generation of sinus stents for chronic rhinosinusitis: A systematic review

“…In addition, a retrospective study investigating adverse events (AEs) of corticosteroid-eluting stents has been published recently based on a national database (the U.S. FDA's Manufacturer and User Facility Device Experience [MAUDE]) [24,25]. The reported AEs were postoperative infection, periorbital cellulitis, and fungal infection [25].…”

“…In addition, a retrospective study investigating adverse events (AEs) of corticosteroid-eluting stents has been published recently based on a national database (the U.S. FDA's Manufacturer and User Facility Device Experience [MAUDE]) [24,25]. The reported AEs were postoperative infection, periorbital cellulitis, and fungal infection [25]. Based on our unpublished in-house experience, the topical steroid has been related to fatal invasive fungal sinusitis in those patients with and without immunocompromised status.…”