Incidence and Risk Factors for Toxic Shock Syndrome After Endoscopic Sinus Surgery: A Systematic Review

Objective: Toxic shock syndrome (TSS) is a rare but serious complication after sinonasal surgery and a commonly cited consideration for prescribing antibiotics when nasal packing or stents are placed. Most reports are limited to case reports or small series. The aim of this systematic review was to describe the incidence, risk factors, and clinical course of patients who developed TSS as a complication of endoscopic sinus surgery (ESS) and/or septoplasty. Data Sources: A systematic review was conducted using MEDLINE, EMBASE, CINAHL, Web of Science, and Cochrane Library databases. Review Methods: Eligibility criteria were patients of any age who developed TSS as a complication of ESS and/or septoplasty. Results: Twenty-five studies were included in the final review. Seventy cases were identified over 38 years (1982-2020). The pooled incidence of TSS after sinonasal surgery was 0.0003 (0.0002-0.0004, 95% confidence interval, CI) or 30 per 100,000 persons. Among 33 patients with single-subject data, mean age was 33.8 years (29.73-37.87, 95% CI). Seventeen (51.5%) patients had nasal packing, 3 (9.1%) had stents, 5 (15.2%) had both, 7 (21.2%) had none. Fourteen (42.4%) patients had nonabsorbable packing and 5 (15.2%) had absorbable packing. Sixteen (48%) patients received peri-operative antibiotics. Thirty-two (97%) patients had full recovery. Conclusion: The incidence of TSS after sinonasal surgery is very rare. TSS can occur with and without nasal packing and prophylactic antibiotics were not protective. Outcomes were favorable with appropriate recognition and management. Further study is needed to determine which patients are most at risk for TSS.