Otolaryngologic manifestations among MPOX patients: A systematic review and meta-analysis

MPOX has numerous otolaryngologic presentations that have been recognized as clinically important, especially with the onset of the 2022 outbreak. However, how these features vary across region and outbreak have yet to be elucidated or supported by meta-analysis. The objective of this study is to identify the otolaryngologic manifestations of MPOX across previous and current outbreaks and among endemic and non-endemic regions.

Data sources of MEDLINE (PubMed), the Cochrane Library, Scopus, Embase, Web of Science, Google Scholar, and OpenGrey were searched through August 2022. All observational studies reporting data on laboratory-confirmed MPOX patients with otolaryngologic symptoms were included. Two authors independently performed the screening process while a third resolved disagreements. Data were extracted into a structured form by two authors independently. We performed a meta-analysis of the prevalence of otorhinolaryngologic symptoms using MetaXL software (version 5.3) under a random-effects model.

38 studies with 5952 patients were included. The four most prevalent manifestations were headache at 31 % (95 % CI [0.16-0.49], I ²  = 99 %), sore throat at 22 % (95 % CI [0.09-0.37], I ²  = 99 %), cough at 16 % (95 % CI [0.05-0.30], I ²  = 99 %), and cervical lymphadenopathy at 10 % (95 % CI [0.01-0.26], I ²  = 100 %). Otolaryngologic features were more prevalent in previous outbreaks as compared to the 2022 outbreak including 37 % prevalence of headache (95 % CI [0.11-0.66], I ²  = 100 %), 33 % prevalence of cough (95 % CI [0.21-0.47], I ²  = 98 %), 27 % prevalence of sore throat (95 % CI [0.07-0.53], I ²  = 99 %), 15 % prevalence of cervical lymphadenopathy (95 % CI [0.00-0.428], I ²  = 100 %), 13 % prevalence of oral ulcers (95 % CI [0.02-0.30], I ²  = 99 %), 6 % prevalence of oral exanthem (95 % CI [0.00-0.17], I ²  = 99 %), 5 % prevalence of dysphagia (95 % CI [0.00-0.18], I ²  = 99 %), and 5 % prevalence of tonsillar signs (95 % CI [0.00-0.13], I ²  = 99 %). Features that were more prevalent in endemic areas versus non-endemic areas include 27 % prevalence of cough (95 % CI [0.14-0.41], I ²  = 99 %), 15 % prevalence of oral ulcers (95 % CI [0.02-0.36], I ²  = 99 %), 6 % prevalence of tonsillar signs (95 % CI [0.00-0.18], I ²  = 99 %), and 19 % prevalence of cervical lymphadenopathy (95 % CI [0.00-0.48], I ²  = 100 %), while the only feature more prevalent in non-endemic areas was headache with a prevalence of 36 % (95 % CI [0.24-0.47], I ²  = 96 %).

In this systematic review and meta-analysis, four symptoms - headache, sore throat, cough, and cervical lymphadenopathy - were found to be the most prevalent otolaryngologic features of MPOX. Otolaryngologic manifestations of MPOX were more pronounced in prior outbreaks and in endemic areas as compared to the 2022 outbreak and non-endemic areas. These findings may aid MPOX recognition in an otolaryngology setting.