Rhinosinusitis in Adults Receiving Tumor Necrosis Factor Alpha Inhibitors and Anti‐CD20 Therapy: A Scoping Review

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INTRODUCTION: Immunomodulatory therapies, including tumor necrosis factor alpha (TNF-α) inhibitors and anti-CD20 agents, are often used for autoimmune, inflammatory, and neoplastic disorders. While infection risk is well recognized, their association with rhinosinusitis remains poorly characterized. GOAL: To map the existing literature on TNF-α and anti-CD20 agents and rhinosinusitis and to identify emerging clinical patterns. METHODS: A scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. A systematic search of PubMed, Scopus, Web of Science, and Cochrane databases was performed. Studies that reported sinonasal outcomes in patients receiving TNF-α inhibitors or anti-CD20 agents were included. RESULTS: A total of 33 studies were included. The literature was limited and predominantly comprised of case reports and retrospective cohorts. Distinct patterns emerged between drug classes. TNF-α inhibitors were primarily associated with new-onset or severe rhinosinusitis, including opportunistic and invasive fungal infections, often without documented hypogammaglobulinemia. In contrast, anti-CD20 therapy was consistently linked to recurrent bacterial rhinosinusitis within a broader sinopulmonary infection phenotype, frequently accompanied by secondary hypogammaglobulinemia. Several studies reported improvement in infection burden following immunoglobulin replacement therapy. Definitions of rhinosinusitis and outcome reporting were highly heterogeneous across studies. CONCLUSION: Immunomodulator-associated rhinosinusitis appears to manifest as two distinct phenotypes: a TNF-α inhibitor related opportunistic infection pattern and an anti-CD20 associated antibody-deficiency phenotype. Prospective studies are needed to define incidence, risk stratification, and optimal screening and management strategies for sinonasal disease in this patient population.

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