Current evaluation and management of patients with chronic rhinosinusitis and nasal polyps

ABSTRACT

Introduction

A clear understanding of the pathophysiology of chronic rhinosinusitis with nasal polyps (CRSwNP) and its close association with other airway pathologies, especially asthma, helps to comprehend the concept of the united airway and the importance of a multidisciplinary approach and the actual roll of biologic therapy.

Areas covered

This expert review is the synthesis of a working group on the current state of the art of the evaluation and management of CRSwNP. A thorough analysis of the literature has been conducted for the latest studies and results, specially the European (EPOS 2020) and American (ICAR-RS 2021) guidelines.

Expert opinion

The roles of optimal medical treatment and indications for surgery are becoming clearer, but much research is still needed regarding the extent and radicality when surgery is indicated. The main objectives of this review were to provide a clear and updated description of treatments, their indication, follow-up, and response criteria. These steps are considering the broad spectrum of inflammation endophenotypes and the biologic therapy available. Understanding the role and limitations of each specialty is key for providing greatest benefit to the patient.

KEYWORDS:

• Chronic rhinosinusitis with nasal polyps
• biologics
• management of nasal polyps
• nasal polyps
• endoscopic sinus surgery

Article highlights

• CRS is defined as inflammation of the nasal mucosa and paranasal sinuses, defined on the presence of sinonasal symptoms (nasal obstruction/congestion/blockage, anterior/posterior rhinorrhoea, facial pain/pressure, and decreased/loss of smell) for more than 12 weeks.

• CRS has two main phenotypes: with (CRSwNP) and without (CRSsNP) nasal polyps.

• The current treatment of CRSwNP is based in three main levels: 1) appropriate medical treatment (AMT), 2) endoscopic sinus surgery, and 3) biologic therapy.

• Surgery is an option after appropriate medical therapy fails, but there still exists a strong debate over the appropriate extent of surgery to be performed.

• Biologic therapy is indicated in CRSwNP patients that meet specific criteria and whose symptoms are severe and not controlled after medical and surgical standard of care treatment, or in patients that meet specific criteria without having undergone surgery.

Abbreviations

AERD Aspirin-exacerbated respiratory disease	=
AFRS Allergic fungal rhinosinusitis	=
CRS Chronic rhinosinusitis	=
CRSsNP Chronic rhinosinusitis without nasal polyps	=
CRSwNP Chronic rhinosinusitis with nasal polyps	=
CT Computed tomography	=
ESS Endoscopic sinus surgery	=
ATM Appropriate medical treatment	=

Acknowledgments

The authors acknowledge Dr. Lynna Marie Kiere, native English speaker and PhD in biological sciences, for the proofread and English revision of this manuscript.

Declaration of interests

Joaquim Mullol is a member of national or international advisory boards and received speaker fees/honoraria or funding for clinical trials and research projects from Allakos, AstraZeneca, Genentech, GSK, Glenmark, Menarini, Mitsubishi-Tanabe, MSD, Viatris/MEDA Pharma, Novartis, Proctor & Gamble, Regeneron Pharmaceuticals, Inc., Sanofi, UCB Pharma, and Uriach/Noucor Group. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.