Medical and Surgical Management of Rhinosinusitis

Prologue

Knowing when not to operate is just as important as knowing how to operate, and it is a more difficult skill to acquire

Henry Marsh

This page serves as a way to stay updated on published studies that are advancing the treatment of rhinosinusitis. The primary focus is not on biologics, but rather on determining the optimal medical therapy and the most suitable extent of surgery for patients. While numerous papers have been published addressing the best surgical management, to the best of our knowledge, no national guidelines establishing a surgical standard have been developed.

No more beating the bush: Clear, applicable, key statements for the management of acute- and chronic rhinosinusitis.

This document utilizes a system of random three-letter codes for references rather than sequential numbering. This approach is more suitable for an online guideline that is subject to continuous updates and restructuring, where chronological ordering would be impractical.

Funding: No funding was received for this project.
Conflicts of interest, Mads Guldager: None.

Acute Rhinosinusitis

…

Primary Chronic Rhinosinusitis

A key consideration for physicians treating CRS is to determine when surgical intervention offers a greater advantage than relying solely on medical therapy. Surgical management may be particularly beneficial for patients with specific CRS manifestations, such as fungal balls, CRSwNP with or without bony erosions, or findings like eosinophilic mucin(ref-hmt).

Using biologics as a first-line treatment for uncontrolled CRSwNP, instead of surgery, was, in a research paper, estimated to have an overwhelming budget impact. A budget impact analysis projected that the “less likely” scenario with 90% biologics as first-line treatment would increase costs by 1048%, while a “normal” scenario with 18% adoption would see a 184% rise (ref-qjx).

Surgery for the symptomatology – Biologics for the etiology

But who will benefit sufficiently from surgery alone, mitigating the risk of potentially life-long immunomodulators

Primary, Diffuse CRS

Diagnosis

CRSwNP: Scoring of nasal polyps should be done to monitor the patient’s response to treatment(ref-uer).

Key Action Statements
– Patients with bilateral pathology who fail appropriate medical therapy should undergo a biopsy of the pathology (e.g. polyps). This is to confirm the diagnosis. Histological examination should include assessment of inflammation, specifically quantifying eosinophils per high-power field when evidence of type-II inflammation.

Medical management

Local/topical…

Biologics

Biologics are a cornerstone for managing primary, diffuse chronic rhinosinusitis in patients whose medical and surgical treatments have not achieved sufficient outcomes, or who are not eligible for surgery. Given the estimated annual costs ranging from 44.268 to 66.000 USD, careful patient selection for this treatment is essential(ref-nlb).

We take notice that although many studies report a lower incidence of AEs when treating CRSwNP with biologics another study found a noticeably higher incidence when reporting any AE for Mepolizumab (20%) and Dupilumab (45%) (ref-skc).

Primary, Diffuse, Endotype-II, Eosinophilic Rhinosinusitis

Diagnosis

Histopathology: A correlation exists between higher eosinophil counts per HPF and greater disease severity. For example, tissue eosinophil levels above 5 cells/HPF have been associated with poorer endoscopy scores following ESS (ref-bsm). In cases where counts are higher than 10 cells/HPF, the association is with worse endoscopic and CT scores, as well as diminished improvements in quality of life(ref-dhy)(ref-for).

A study found that a cut-off of 55 eos/HOF had the highest sensitivity and specificity for recurrence in eCRS patients (ref-uuh).

In another study, they described tissue eosinophils as having a moderate accuracy in detecting recurrence, with a count of 70 or more having the highest Youden’s index in detecting recurrence. Likewise the study described that for patients with 10-70 eosinophils in NP-tissue eCRS was a likely diagnosis, potentially involving T2 inflammation, however because of the low recurrence rate for these patient’s they did not consider biologics as necessary (ref-hfj).

Key Action Statements
– Extensive surgery is recommended for generalized mucosa disease.

Surgical management

Surgical management of patients should aim for a personalized approach. While the CT scan reveals bony partitions that might hinder natural drainage pathways, it’s important to remember that any observed opacification offers only a glimpse and may not accurately represent the patient’s continuous status. The surgical extent should be tailored to the patient’s wishes and symptoms. However, we recommend that treating a general inflammatory condition of the mucosa, such as extensive chronic rhinosinusitis (eCRS), should aim to establish drainage pathways and optimize the potential delivery of topical agents.

As a recent paper by Lee et. al. proved — surgeons with a high-volume of operations had lower revision rates. We recommend that ESS is performed at high-volume centres (>30 cases per year)(ref-cmu).

Discussing the surgical extent of ESS in eCRS, we take note that some studies find superiority of dupilumab in managing these patients (ref-che), though we likewise take notice that some studies find an elevated incidence of adverse events than previously reported in phase-III trials for Dupilumab (ref-lfk)(ref-skc).

A study described 38% of patients experiencing recurrence of NP, though in their study population, more than half did not experience recurrence (ref-hfj).

Surgical Extent for patients with Primary, Diffuse eCRS

Maxillary Antrostomy: This involves a complete uncinectomy, respecting the attachment of the uncinate process. A complete antrostomy should be performed, removing the fontanelle anteriorly to the lacrimal bone, superiorly to the level of the maxillary sinus ceiling, and posteriorly to the vertical plane of the back wall of the maxillary sinus.

In a paper, Jian et. al. describe positive olfactory outcomes (TDI improving > 5.5 score) at 6 months when the MT is also resected during surgery with nasal polyps (ref-kzu).

Anterior and Posterior Ethmoidectomy: This requires the complete removal of the ethmoid bullae and all bony partitions. Care must be taken to respect the slope of the anterior skull base and the superior part of the basal lamella if the anterior ethmoidal artery is dehiscent.

Sphenoid Sinusotomy: A transnasal sphenoidotomy can be combined with a transethmoidal sphenoidotomy, or vice versa. The sphenoidotomy should be a IESSC 2a/2b with an opening exceeding 70% when assessed on the axial plane(ref-wfv)(ref-zkv).

Frontal Recess and Frontal Sinusotomy: A minimum of a Draf-IIb should be performed. Some studies found favorable outcomes performing a Draf-III with resection of the middle turbinates(ref-wfv)(ref-iqa). However, a systematic review found revisions and restenosis to be less frequent utilizing a Draf-IIb, though this was across all indications(ref-lgp).

Primary, Diffuse, Non-Endotype-II CRS

Medical management

A treatment regimen with peroral Roxithromycin 150mg a day for 3 months can be perscribed. It should be kept in mind that there is an increased risk of cardiac arrhythmias and nefro- and hepatotoxicity(ref-pkb). Following paraclinical examinations are recommended(ref-wsj).
Before initiation: ECG + (Liver – and Kidney tests)
Day 28: ECG + Blood samples (Liver- and Kidney tests)

Note: The reference (wsj) only states liver tests should be performed. Kidney is added as the precautions below are mentioned by The Danish Association of the Pharmaceutical Industry and Danish Medicines Information (Dansk Lægemiddel Information A/S og Lægemiddelindustriforeningen – promedicin.dk)

Precautions (promedicin.dk)

• AV block, arrhythmias, or prolonged QT interval.
• Regular monitoring of kidney and liver function as well as blood values for treatment lasting longer than 14 days.

Biologics

Tapering STudies

Studies on tapering treatment with biologics in CRSwNP are currently a major focus. This is driven by a combination of established clinical efficacy, the high cost of treatment, and the urge to develop personalized, long-term management strategies for patients to find the minimum effective dose, maintain control of symptoms, improve cost-effectiveness, and minimize potential side effects.

In a study by D’Ascanio et al. they did not find difference when deescalating 27 “good-to-excellent” responders from receiving Dupilumab every 2 weeks to every 4 weeks at 18- and 24 months (with deescalation initiated at 12 months).

Another study on tapering by van der Lans et al. they found that 74% of moderate-to-excellent responders to treatment with Dupilumab, were able to prolong dosing intervals while maintaining satisfactory treatment response.

Secondary Chronic Rhinosinusitis

…

Surgical Complications

In a study Olsson et al. they did a register study investigating complications following sinus surgery among swedish patients with CRSwNP. In their population they found a complication rate of 6.4% for patient’s having one surgery and 17.8% for revision surgeries. The complications were indexed by diagnostic codes. The three highest incidence of complications Infection (Abscess, T81.4) 1.81%, acute sinusitis (J01.0-9) 1.54%, and epistaxis (R04.0) 1.34% (ref-dae).

Post-operative Care

In a study by Ayoub et al. they did not find nose blowing post-operative had any adverse affect on the frequency or severity of epistaxis, and advocated that “judicious nose blowing” could be permissable immediately after uncomplicated ESS (ref-gyl).

Image Guided Surgery

For sinus and skull base surgery, the intraoperative use of IGS is endorsed in appropriately selected cases to aid surgeons in navigating complex anatomy. This endorsement is backed by expert consensus and a solid body of literature. The decision to use this technology rests with the operating surgeon.

Examples of when IGS might be appropriately utilized include(ref-pjs):

• Pathology involving the frontal, posterior ethmoid, or sphenoid sinuses.
• Distorted sinus anatomy, whether from development, prior operations, or injury.
• Revision cases.
• Skull base defect or CSF rhinorrhea.
• Pathology close to the skull base, eye socket, optic nerve, or carotid artery.
• Extensive sino-nasal polyposis.
• Sino-nasal neoplasms, both benign and malignant.

This technology is also known as navigation-based sinus surgery, computer-assisted sinus surgery, surgical navigation, or computer-guided imaging systems.

National Recommendations

From Nordic Rhinologic Forum

🇳🇴 : Kriterier og prosedyre for oppstart Dupilumab
(Eng: Criteria and procedure for initiating Dupilumab).

🇸🇪 : Riktlinjer för behandling med biologiska läkemedel vid kronisk rinosinuit med näspolyper (CRSwNP) med typ 2-inflammation
(Eng: Guidelines for biologic treatment of chronic rhinosinusitis with nasal polyps (CRSwNP) with type 2 inflammation).

🇫🇮 : Sivuontelotulehdus
(Eng: Sinusitis)

🇮🇸 :

🇩🇰 : Kronisk Rhinosinuit
(Eng. Brief Clinical Guideline – Chronic Rhinosinusitis)

Globally

Arranged by year published

🇧🇷 :  Romano, F. R. et al. Rhinosinusitis: Evidence and experience – 2024. Brazilian Journal of Otorhinolaryngology 91, 101595 (2025).

🇮🇹 : Lombardi et. al. – ARIA-Italy multidisciplinary consensus on nasal polyposis and biological treatments: Update 2025 (2025)

🇦🇹 : Walla et. al. – Current diagnostic and therapeutic management of chronic rhinosinusitis with nasal polyps in Austria: insights and unmet needs from a nationwide survey (2025)

🇨🇳 : Xian et. al. – Chinese Position Paper on Biologic Therapy for Chronic Rhinosinusitis With Nasal Polyps (2025)

🇩🇪 : Hildenbrand et. al. – The diagnosis and treatment of chronic rhinosinusitis (2024)

🇨🇦 : Ouellette et. al. – Biologics in the Treatment of Chronic Rhinosinusitis with Nasal Polyposis in Canada: Current Trends and Practice Patterns (2024)

🇮🇹 : De Corso et. al. – Biologics for severe uncontrolled chronic rhinosinusitis with nasal polyps: a change management approach. Consensus of the Joint Committee of Italian Society of Otorhinolaryngology on biologics in rhinology (2022)

🇨🇦 : Saydy et. al. – What is the optimal outcome after endoscopic sinus surgery in the treatment of chronic rhinosinusitis? A consultation of Canadian experts (2021)

🇨🇦 : Thamboo et. al. – Canadian Rhinology Working Group consensus statement: Biologic therapies for chronic rhinosinusitis (2021)

🇺🇸 : Shin, J. J. et al. Clinical Practice Guideline: Surgical Management of Chronic Rhinosinusitis. Otolaryngol.–head neck surg. 172, (2025).

🇺🇸 : Payne, S. C. et al. Clinical Practice Guideline: Adult Sinusitis Update. Otolaryngol.–head neck surg. 173, (2025).

Abbreviations

ARS: Acute rhinosinusitis
AE: Adverse events
CRS: Chronic rhinosinusitis
CRSsNP: Chronic rhinosinusitis without nasal polyps
CRSwNP: Chronic rhinosinusitis with nasal polyps
eCRS: Eosinophilic chronic rhinosinusitis
HPF: High-power field
IGS: Image-guided surgery
NP: Nasal polyps
T1: Type-1
T2: Type-2

References

(bsm): Kountakis, S. E., Arango, P., Bradley, D., Wade, Z. K. & Borish, L. Molecular and Cellular Staging for the Severity of Chronic Rhinosinusitis. The Laryngoscope 114, 1895–1905 (2004).

(che): Chen, H. et al. Long-term efficacy and safety of different biologics in treatment of chronic rhinosinusitis with nasal polyps: A network meta-analysis. Brazilian Journal of Otorhinolaryngology 91, 101633 (2025)

(cmu): Lee, D. J. et al. Surgeon Case Volume Impacts Revision Rate of Endoscopic Sinus Surgery. Int Forum Allergy Rhinol (2025) doi:10.1002/alr.23602.

(dae): Olsson, P. et al. Complications and Economic Burden of Surgery in Chronic Rhinosinusitis With Nasal Polyps: An Observational Cohort Study Using Swedish Register Data. Clinical Otolaryngology (2025)

(dhy): Soler, Z. M., Sauer, D., Mace, J. & Smith, T. L. Impact of Mucosal Eosinophilia and Nasal Polyposis on Quality‐of‐Life Outcomes after Sinus Surgery. Otolaryngol.–head neck surg. 142, 64–71 (2010).

(for): Aslan, F., Altun, E., Paksoy, S. & Turan, G. Could Eosinophilia predict clinical severity in nasal polyps? Multidiscip Respir Med 12, (2017).

(gyl): Ayoub, N., Chitsuthipakorn, W., Nayak, J. V., Patel, Z. M. & Hwang, P. H. Nose blowing after endoscopic sinus surgery does not adversely affect outcomes. The Laryngoscope 128, 1268–1273 (2017).

(hdu):  Payne, S. C. et al. Clinical Practice Guideline: Adult Sinusitis Update. Otolaryngol.–head neck surg. 173, (2025).

(hfj): Kumai, T. et al. Combined European and Japanese criteria to diagnose eosinophilic chronic rhinosinusitis. 63, (2025).

(hmt): Shin, J. J. et al. Clinical Practice Guideline: Surgical Management of Chronic Rhinosinusitis. Otolaryngol.–head neck surg. 172, (2025).

(iqa): Noller, M., Fischer, J. L., Gudis, D. A. & Riley, C. A. The Draf III procedure: A review of indications and techniques. World j. otorhinolaryngol.-head neck surg. 8, 1–7 (2022).

(kzu): Jian, F., Lao, J., Ge, R., Yang, Q. & Wu, S. A prospective cohort study comparing the effects of different middle turbinate treatments on olfactory function recovery in CRSwNP patients after FESS. Rhin 0, 0–0 (2025).

(lfk): Wang, A. J. et al. Adverse Effects of Dupilumab for Chronic Rhinosinusitis With Nasal Polyposis: Real‐World Single Institution Experience. The Laryngoscope (2025)

(lgp): Hirayama, Y. et al. Comparison of outcomes for Draf IIB vs Draf III in endoscopic frontal sinus surgery: a comprehensive systematic review and meta-analysis. Rhin 0, 0–0 (2025).

(lzf): Grayson, J. W., Hopkins, C., Mori, E., Senior, B. & Harvey, R. J. Contemporary Classification of Chronic Rhinosinusitis Beyond Polyps vs No Polyps. JAMA Otolaryngol Head Neck Surg 146, 831 (2020).

(nlb): Luk, H. G., Janz, T. A., Siddiqui, F. N. & Hardison, S. A. Considerations for the Use of Biologics in Chronic Rhinosinusitis With Nasal Polyps. Ear Nose Throat J (2025)

(pjs): American Academy of Otolaryngology – Head and Neck Surgery. Position Statement: Intra-Operative Use of Computer Aided Surgery [Internet]. American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS). 2021 [Accessed June 5th 2025] at https://www.entnet.org/resource/position-statement-intra-operative-use-of-computer-aided-surgery/

(pkb): Albert, R. K. & Schuller, J. L. Macrolide Antibiotics and the Risk of Cardiac Arrhythmias. Am J Respir Crit Care Med 189, 1173–1180 (2014).

(qjx): Fieux, M. et al. The extra cost of biologics as first-line treatment in uncontrolled chronic rhinosinusitis with nasal polyps with no previous sinus surgery is overwhelming: a budget impact analysis. 63, (2025).

(skc): Dorling, M. et al. Real‐World Adverse Events After Type 2 Biologic use in Chronic Rhinosinusitis with Nasal Polyps. The Laryngoscope 134, 3054–3059 (2024).

(wfv) Workman, A. D. et al. Assessing adequacy of surgical extent in CRSwNP: The Completion of Surgery Index. Int Forum Allergy Rhinol 15, 9–17 (2024).

(wsj) Smith, D. BTS guideline on long-term macrolides in adults with respiratory disease: not quite a panacea. Thorax 75, 405–406 (2020).

(slq) D’Ascanio, L. et al. De-escalation of dupilumab for chronic rhinosinusitis with nasal polyps: analysis of outcomes after modified dosing regimen. Rhin 0, 0–0 (2025).

(uer) Gevaert, P. et al. European Academy of Allergy and Clinical Immunology position paper on endoscopic scoring of nasal polyposis. Allergy 78, 912–922 (2023).

(ufz) van der Lans, R. J. L. et al. Two‐year results of tapered dupilumab for CRSwNP demonstrates enduring efficacy established in the first 6 months. Allergy 78, 2684–2697 (2023).

(uuh) McHugh, T., Snidvongs, K., Xie, M., Banglawala, S. & Sommer, D. High tissue eosinophilia as a marker to predict recurrence for eosinophilic chronic rhinosinusitis: a systematic review and meta‐analysis. Int Forum Allergy Rhinol 8, 1421–1429 (2018).

(zkv) Albaharna, H. et al. A Novel International Endoscopic Sphenoid Surgery Classification (IESSC): A Delphi Consensus. Int Forum Allergy Rhinol (2025)