ENT Evaluation and Post Transplant Lymphoproliferative Disorder in Pediatric Transplant Patients

Introduction: Adenotonsillar hypertrophy (ATH) can be an early manifestation of post transplant lymphoproliferative disease (PTLD). We aimed to identify factors associated with ENT referral, diagnostic tonsillectomy, and PTLD diagnosis in pediatric solid organ transplant recipients.

Methods: A retrospective chart review was performed of pediatric liver, kidney, heart, and lung transplant recipients with active follow-up in a tertiary pediatric transplant clinic between January 1, 2018, and July 1, 2025. Collected variables included demographics, Epstein–Barr virus (EBV) and cytomegalovirus (CMV) donor/recipient status, viremia and seroconversion, operative findings, and pathology results. Descriptive statistics, chi-square analysis, and univariate and multivariate logistic regression were used to identify factors associated with ENT referral, diagnostic tonsillectomy, and PTLD diagnosis with significance defined as p< 0.05.

Results: A total of 106 patients were included; 39 (36.8%) were referred for otolaryngology evaluation, 16 (15.1%) underwent tonsillectomy, and 10 (9.4%) were diagnosed with PTLD. PTLD was diagnosed via tonsillectomy (n=8), bone marrow biopsy (n=1), and endobronchial biopsy (n=1). The average age at transplant was 9.6 years ±6.9 and 52.8% were female. Liver transplant was the most common (48.1%) followed by kidney (29.2%), heart (19.8%), and lung (2.8%). Patients referred to ENT were younger at transplant than those not referred (p < 0.001).

Among patients referred to ENT, younger age, sleep disordered breathing, ATH, EBV seroconversion, and PTLD symptoms (EBV viremia, fatigue, adenopathy, or fevers) were significantly associated with tonsillectomy (all p< 0.05). Tonsil grade did not differ between patients with and without PTLD (p>0.05). EBV seroconversion and PTLD symptoms were significantly associated with PTLD diagnosis (p < 0.05).

Conclusions: Low tonsil grade should not preclude diagnostic tonsillectomy in pediatric solid organ transplant recipients with clinical concern for PTLD, particularly in younger patients with EBV seroconversion and systemic symptoms.