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C. Hopkins and J.-L. McKenzie
Diagnosis andAssessment
CRSwNP is a diagnosis made through clinical
symptoms and signs corroborated with imaging
and nasendoscopic ndings supportive of a local
inammatory process [7]. Hallmark symptoms
are nasal congestion and hyposmia as well as
nasal discharge, and to a lesser extent, facial pain
and pressure. The symptoms must persist for
more than 12weeks and be supported by nasendoscopy ndings of mucosal inammation, discharge and polypoid changes to the mucosa, and/
or computerised tomography (CT) imaging demonstrating nasal polyps [6, 7].
The clinical history is focused on the duration,
frequency and severity of sinonasal symptoms
and their impact on quality of life and ability to
perform normal daily activities. Nasal obstruction is common, particularly when polyps are
large and may be associated with sleep disturbance. Hyposmia or anosmia is also common.
Nasal discharge anterior or posterior is variably
present. Facial pain and pressure can be present
but are not alone enough to make a clinical diagnosis [7].
Quantication of symptoms using a patientrated outcome measure may facilitate assessment. The SNOT-22 is a widely used clinical
scoring system considering common sinonasal
and associated symptoms [8]. Assessment routinely determines the quality-of-life impact of the
condition and response to interventions and also
can be used to predict likelihood of benet from
interventions including surgery [9].
History needs to consider comorbid conditions such as allergic rhinitis and lower respiratory disease such as asthma and bronchiectasis.
Establishing a respiratory diagnosis and the control of their disease is important in guiding therapy [4]. NSAID-induced wheeze or asthma
exacerbations are an important point of history to
help diagnose NSAID-exacerbated respiratory
disease (N-ERD) for treatment and prognosis
[10]. Patients may also report symptom exacerbation by alcohol.
Prior treatments trialled and the response of
the patient to these can be informative for diagnosis and making management decisions. CRS with
nasal polyps is often responsive to systemic steroids, whereas CRS without nasal polyps is less
steroid responsive. It is important to assess the
duration of response and level of control of the
patients’ symptoms in making treatment decisions. Identifying patients with poor disease control can inform progression to surgery or, after
surgery, the need for revision or to consider other
systemic treatment options such as corticosteroids and biologicals [7, 11]. Many patients may
have already undergone surgery—the extent of
prior surgery is usually apparent on CT imaging;
a short duration of benet is predictive of future
risk of recurrence [9].
Clinical examination is focused on assessing
the nasal airway patency and the presence or
absence of polyps. Anterior rhinoscopy can
establish severe polyposis and any concomitant
anatomical cause of nasal obstruction. Expansion
of the nasal bridge or orbital signs may be present
in very severe CRS with nasal polyposis [12].
Routine Investigations
Nasendoscopy to examine the nasal mucosa is
essential. The presence of pale to translucent
nasal polypoid masses is the hallmark of
CRSwNP, and mucopurulent discharge may also
be present [12]. The degree of polyposis can be
recorded by sites and grading of the polyps in
relation to the middle turbinate and the nasal
oor [7]. The most widely used scoring system is
that described by Lildholdt etal., with each side
of the nose being scores separately and graded
from 0 (no polyps) through to 3 (large polyps
reaching below the lower edge of the inferior turbinate) (Fig.25.1).
Nasal endoscopy is essential in the rhinological examination and can inform of diagnosis as
well response to therapy. It is a simple and welltolerated part of the examination.
25 Clinical Assessment andManagement ofChronic Rhinosinusitis withNasal Polyposis
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considered at an early stage to exclude the rare
occurrence of sinonasal malignancy or more
common benign tumours such as inverted papilloma [12]. Computerised tomography (CT), usually without contrast, is the gold standard
investigation for CRSwNP [7].
CT ndings of importance include extent and
severity of nasal polyps and mucosal changes.
The most used scoring system is the LundMackay which is based on the degree of opacication for the compartments of the sinuses and
the ostiomeatal complex. This scoring system has
been validated in several studies. The disease
subtype can be suggested by CT ndings particularly in allergic fungal disease with bony remod-
Fig. 25.1 Endoscopic image of left nasal cavity showing
grade 2 nasal polyps, reaching below the lower border of
the middle turbinate (solid red line) but not reaching
below lower border of inferior turbinate
elling and double densities. The degree of
osteoneogenesis in CRS indicates long-standing
disease and poorer prognosis of treatment.
Opacication of the olfactory cleft is common in
patients with hyposmia [7, 12] (Fig.25.2).
The anatomy revealed on CT sinus imaging
Imaging
reveals essential details for planning safe surgery
including the presence of sphenoethmoidal cells,
Imaging is an important tool in CRS.It may be
used to conrm the diagnosis when endoscopy is
equivocal, assess the severity or extent of disease
and guide treatment decisions. However, in order
to minimise exposure to ionising radiation, it is
usually reserved for patients in whom medical
treatment has failed and when surgical intervention or biological therapies are being considered.
It reveals anatomy and its variants for surgical
planning and may alert to the possible diagnosis
of allergic fungal disease and other diagnoses.
Nasal polyps are usually bilateral– in the setting
of unilateral nasal polyps, imaging should be
location of the optic nerve and anterior ethmoidal
arteries and the position and integrity of the lamina papyracea and cribriform plate. CT is essential for safe and effective sinus surgery, and the
scan should be available in the operating room
[8].
MRI can reveal the presence of sinonasal
inammation. It is most useful in CRSwNP in the
setting of allergic fungal disease or advanced disease with dehiscence of the skull base or orbits.
MRI does not however provide the spatial and
bony denition required for surgical planning [7,
13].
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C. Hopkins and J.-L. McKenzie
Fig. 25.2 Coronal CT demonstrating extensive opacication of all sinus groups in conjunction with nasal polyps
Supplementary Investigations
sionally have a different pathology such as inverting papilloma, sarcoidosis and even malignancy.
Peak nasal inspiratory ow can be measured to
establish severity of nasal congestion and to follow treatment response with an objective measure. It is a low-cost and reliable clinical
measurement [7]. Rhinomanometry is also available and computational methods under investigation. However, these measures do not predict
response to treatment and are largely reserved for
clinical trials.
Standardised testing of olfactory function can
also be useful in the assessment of CRSwNP;
psychophysical testing can assess identication,
discrimination and threshold levels of olfactory
function.
Nasal polyp biopsy performed in clinic or
intraoperatively can help with disease endotyping and potentially informing prognosis and
treatment. Patients with apparent CRSwNP occa-
Polyp biopsy helps avoid mismanagement of this
rare but signicant patient group and should be
considered in the setting of unilateral polyps
[12]. Diagnosing eosinophilic CRS (eCRS)
requires quantication of the numbers of eosinophils, i.e. number/high-powered eld (HPF) [3].
The amount of eosinophilic inltration and the
overall intensity of the inammatory response
were closely related to the prognosis and severity
of disease [14]. With a move to disease endotyping to guide treatment, this may become a more
standard part of patient management and may
help guide treatment decisions (Fig.25.3).
Blood tests are not always required in primary
workup but should be done in patients with
treatment- resistant disease or a suspicion of
underlying inammatory disease such as eosinophilic granulomatous polyangiitis or sarcoidosis.
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yposis of CRSwNP [5]. Skin prick testing or
measurement of specic IgE can help identify
potential targets for immunotherapy. The relationship between inhalant allergies and nasal polyps is less clear in other subtypes, but allergies
may increase the severity of symptoms and therefore should also be controlled [4].
Allergic Fungal Rhinosinusitis
Allergic fungal rhinosinusitis (AFRS) is a form
Fig. 25.3 Histological examination of nasal polyp
removed from patient in Fig.25.2, demonstrating more
than 100 eosinophils per high-powered eld
Patients with high blood eosinophils and IgE tend
to demonstrate more aggressive and resistant disease, and there is a strong correlation between
serum and tissue eosinophilia in CRS patients.
Serum eosinophils are more readily assessed than
tissue eosinophils; however, levels may reect
both upper and lower airway disease and can be
supressed by recent steroid usage [3, 15]. Nasal
nitric oxide measurements have been shown to
aid diagnosis of cystic brosis and primary ciliary dyskinesia and similarly can be of utility in
treatment-resistant or severe disease where these
diagnoses are being considered [7].
of a non-invasive fungal rhinosinusitis with IgEmediated hypersensitivity to fungal hyphae in
eosinophilic mucin. It appears an immunologically distinct subtype of CRS and is characterised
by severe nasal polyposis and recidivist disease.
The diagnosis is based on the criteria proposed
by Bent and Kuhn: (1) production of eosinophilic
mucin without fungal invasion into sinonasal tissue; (2) positive fungal stain of sinus contents;
(3) nasal polyposis; (4) characteristic radiographic ndings (with expansion of sinus cells
and bony remodelling, and heterogenous opacication of the sinuses caused by eosinophilic
mucin; and (5) allergy to fungi [16].
Asthma
313
Assessment ofComorbidities
andSubgroups ofCRSwNP
There are some distinct pathological subgroups
of nasal polyps which can be observed in a group
of related but distinct conditions, and which
should be considered during assessment.
Central Compartment Allergic
Disease
In the patient with allergic rhinitis, a central compartment allergic polyposis (CCAP) affecting the
septum and middle turbinate is observed. This
centralised anatomical pattern of nasal polyps is
observed in those with inhaled allergen sensitivities and is distinct from wider sinus cavity pol-
Up to 60% of patients with CRSwNP have
comorbid asthma; late-onset asthma is strongly
suggestive of a type 2 inammatory prole [1].
Asthma may be overlooked if cough is attributed
to post-nasal drip. Uncontrolled nasal polyps
may be associated with frequents asthma exacerbations; close co-management with respiratory
specialists is important to optimise outcomes
[17].
NSAID-Exacerbated Respiratory
Disease
Non-steroidal anti-inammatory drugexacerbated respiratory disease (N-ERD) is characterised by the triad of CRS with severe
eosinophilic nasal polyps, asthma and respiratory
reactions triggered by the ingestion of substances
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C. Hopkins and J.-L. McKenzie
that inhibits cyclooxygenase [10]. The disease
usually begins in the third decade of life with
NSAID-induced reactions generally developing
later and including an acute worsening of respiratory symptoms and nasal congestion. The disease
in this patient group is usually severe and more
rapidly recurrent after intervention [10]. The
prevalence of N-ERD increases in patients with
multiple surgeries [18].
A diagnosis of N-ERD can be made with a
history of two clear reactions to NSAIDS, but
many patients with asthma are told to routinely
avoid such medications. When the diagnosis is
uncertain, the patient could be considered for an
aspirin provocation test which is done in an outpatient setting under medical supervision with
capacity for resuscitation [10].
Immunodeciency andMucociliary
Dysfunction
The testing of immune function in all patients
presenting with CRSwNP is unlikely to be sufciently informative to justify routine use.
Cystic brosis is commonly associated with
polyps, and primary ciliary dyskinesia may also
be encountered and should be considered in
recalcitrant cases [7, 12].
Treatment ofCRSwNP
Medical Management
Intranasal Treatments
Irrigation with nasal saline is a simple and central
treatment recommendation for CRS. Despite a
lack of high-quality trials, clinical experience
suggests symptomatic benet. It is low risk and
therefore widely used and recommended [7, 19].
Topical steroids have robust evidence for
improvement of symptoms in CRSwNP. The
improvements are demonstrated as quality-of-life
improvements as well as endoscopic assessment
[20]. They deliver improvement in obstruction,
rhinorrhoea, hyposmia and reduce polyp size.
They are very well tolerated although can cause
nasal irritation and epistaxis. Their long-term
safety is well established [20]. New-generation
corticosteroids such as mometasone and uticasone have low systemic bioavailability and have
high-quality safety data for long-term use [7].
Patients with high tissue eosinophilia have been
demonstrated as the most responsive [14]. For
moderately or severely symptomatic nasal polyps, clinical experience suggests that intranasal
delivery of glucocorticoids may be improved
using topical drops or, in patients who have had
previous sinus surgery with open cavities, by
high-volume irrigations [20].
The effectiveness of topical glucocorticoids is
believed to be enhanced after surgery, likely
owing to improved access. The delivery of glucocorticoids with high-volume nasal irrigation has
been shown as more effective in reducing endoscopic evidence of recurrence than delivery of an
equivalent dose by means of nasal spray after
sinus surgery [21]. Other modes of delivery, such
as breath activated exhalation delivery devices,
may also enhance effectiveness [12]. Nasal steroid formulations are widely underutilised with a
database study showing only 20% of CRS
patients regularly use a nasal steroid [7]. Patients
should be educated regarding appropriate delivery techniques and the need for long-term adherence to therapy.
Steroid-eluting stents have been developed for
use before and after sinus surgery, with the aim of
delivering higher local concentrations of steroids
than other delivery methods and overcoming
compliance issues. They have been in research
and development without a signicant uptake to
date in clinical practice. In support of these stents,
one trial showed signicant reductions in polyp
score and need for surgery following placement
of a mometasone-eluting implant in patients with
CRSwNP who were considered candidates for
surgery, while other trials have shown no change
in progression to requiring ESS [7]. Their use has
been investigated postoperatively where improvement has been demonstrated in endoscopic and
imaging scores but not in terms of symptoms of
quality of life [20].
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315
Systemic Therapy
Glucocorticoids
Glucocorticoids have a long history of use in airway inammation; oral steroids have a body of
strong evidence in this setting. They are effective
in the management of CRSwNP reducing symptoms at least in the short term [22]. However, the
immediate benets of systemic glucocorticoid
therapy need to be balanced with the long-term
potential adverse effects which are signicant.
Therefore, systemic steroids should not be considered as a rst line of treatment for CRSwNP
(23)s. They can be used in a short course during
2–3 weeks as a last resort of treatment when
combinations of other medications are ineffective
[7].
The potential for adverse effects of glucocorticoids is well established. Severe outcomes
include suppression of hypothalamic pituitary
axis, hyperglycaemia, diabetes and Cushing’s
syndrome [23]. There are data to assess specic
adverse effects in sinonasal patients. Multiple
studies have shown injection of steroid or
repeated courses to cause osteopenia. The effect
of bone loss is well demonstrated in asthma literature. A recent consensus document has
considered the wider range of potential side
effects for OCS but still concluded that a clear
assessment of the risks associated with oral steroid use in upper airway disease cannot be made.
However, there is growing evidence from studies
in asthma that patients receiving >2.5 short
courses of OCS per year suffered signicantly
higher loss in bone density and a dose-dependent
increase in all adverse effects, with as little as
four courses over a lifetime being associated with
harm [23].
Perioperative use of glucocorticoids has been
explored and has mixed data. Some studies have
shown benet to reduce perioperative bleeding
and improve surgical conditions for the surgeon
during endoscopic sinus surgery; however, the
reduction of blood loss is limited, and the risk of
repeated systemic steroid use needs to be carefully considered; topical vasoconstriction and
modern anaesthetic techniques usually mean pre-
operative treatment is of limited additional value.
Only one of ve studies on this topic found a conclusive benet. This application is therefore to be
considered with caution, given the growing evidence of cumulative risk of harm [7].
Antibiotics
The practice of using short-term antibiotics in
CRSwNP is widespread in primary care despite a
lack of evidence. Short-term doxycycline has
demonstrated a small but statistically signicant
reduction in nasal polyp endoscopic scores and
rhinorrhoea in one study. Long-term (>4weeks)
antibiotic use has been investigated and has limited utility in this disease group. Macrolides have
not been demonstrated to improve symptom
scores in CRswNP patients [24].
Anti-leukotrienes
Anti-leukotriene medications target the inammatory pathway driven by leukotrienes. They
have been investigated in CRSwNP and appear to
have little added benet in terms of symptom
improvement when used as an add-on to intranasal corticosteroids [7]. There are described neuropsychiatric adverse effects, and so their use is
not currently recommended. Some may have a
role in N-ERD but have not been formerly evaluated in RCTs [10].
Biological Therapy inCRSwNP
Biologic therapy using monoclonal antibodies
(Mabs) that block the action of interleukins (IL)
or other targets central to type 2 inammation
now plays an important role in the management
of difcult-to-treat asthma. Many of these treatments have also been shown to be useful in the
management of severe CRSwNP [25]. Their
placement in the therapeutic pathway for
CRSwNP is in evolution as experience with the
medications evolves. Consensus guidelines are
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C. Hopkins and J.-L. McKenzie
available and suggest they should be considered
for patients with at least moderate symptoms or
a moderate Lund-MacKay score who fail conventional medical and surgical treatment [26].
Their role in specic subsets of CRSwNP, such
as AFRS and N-ERD, is yet to be clearly
dened.
IL4/IL13 pathway activation is targeted by
dupilumab, an IL4 receptor subunit Mab. It has
been shown to improve symptom scores, nasal
polyp scores, olfaction and imaging scores. The
most common reported adverse events (nasopharyngitis, worsening nasal polyps and asthma,
headache, epistaxis, injection-site erythema)
were more frequent with placebo. The agent
seems well tolerated in available trials [25].
Anti-IgE therapy with omalizumab has shown
improvements in nasal polyp burden and symptoms scores. Associated adverse effects have
been reported as anaphylaxis, arterial and venous
thromboembolic events and an increase in common colds [26].
Both dupilumab and omalizumab have been
approved by regulatory bodies for use in severe
CRSwNP. Head-to-head comparisons are not
available, but indirect comparison data currently
favours dupilumab [27].
IL5 is targeted by the agents mepolizumab,
benralizumab and reslizumab. Only mepolizumab currently has available evidence for
reduced symptoms and decreased revision surgery in CRSwNP patients. There are no serious
noted adverse effects [25]. More data is becoming available, although these drugs are currently
only approved for use in asthma.
Although biologicals have been shown to
reduce the need for surgical intervention for
CRSwNP, their high costs and the need for longterm treatment mean that this is unlikely to be the
most cost-effective treatment across the whole
population with CRSwNP, even if superior in
terms of long-term symptom control in the
difcult- to-treat groups, such as those with severe
asthma and N-ERD [26].
It is likely that there will be continued developments in this eld, both in terms of the development of new monoclonal antibodies and
understanding of response rates, and where in the
treatment pathway, these should be optimally
placed. In the future, biomarkers may allow us to
personalise patient care by identifying which
endotype would respond best to one monoclonal
therapy over another resulting in substantially
better clinical outcomes with fewer side effects
than present treatment options. At present, biologics are being positioned as an alternative to
repeated surgery, but in the future, they may be
given much earlier in the disease process in an
attempt to alter the natural history, or in combination with surgery, either in the immediate pre- or
post-operative period [25].
Surgery forCRSwNP
Surgery for uncomplicated CRSWNP is usually
restricted to those patients who fail to achieve
adequate symptomatic benet from a trial of adequate medical therapy [17]. What constitutes
failed medical therapy is variable in the literature
but at a minimum requires a sustained trial of
intranasal saline and topical steroid, usually in
conjunction with a trial of systemic corticosteroid [28]. In patients who fail medical treatment,
surgical intervention acts to reduce the volume of
inammatory tissue, remove obstruction and
optimise delivery of topical medication. It can be
conceived as an adjunct to maximise effect of
medical therapy but is not considered curative
[8].
Several studies have shown the positive
impact of surgery on improving symptoms, particularly in those patient groups with high baseline symptom scores [28]. More severe imaging
scores are also associated with greater benet
from surgery [7]. Older patients benet more
with asthmatic and aspirin-sensitive patients
having less improvement [9]. There is some data
that earlier intervention with surgery relative to
when symptoms started leads to better outcomes
with more sustained improvements in symptom
scores [7]. There is also some suggestion that
earlier surgery reduces subsequent development
of asthma [17].
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Nasal congestion, obstruction and less so
smell seem particularly improved by surgery.
However, revision surgery is not uncommonly
required even in tertiary centres. Prospective
cohort studies report revision rates of 11% at
3years and 19% at 5years [9]. Female gender,
older age at rst surgery, the presence of nasal
polyposis, comorbid asthma, allergy and family
history of chronic rhinosinusitis all appear to be
associated with high revision rates [17, 29].
The extent of primary surgery for CRSwNP is
debated. Approaches can be described as minimally invasive, complete and extensive. A functional approach based on the ostial drainage
pathways is well established as benecial [7].
Heterogeneity between studies and lack of large
randomised trials makes assessment difcult, but
there is some evidence for more extensive sinus
surgery especially in revision surgery [13]. Many
series have more complete surgery applied to
more extensive or recurrent disease introducing a
signicant confounder. Lower revision rates and
greater improvements in symptoms have been
demonstrated in complete sinus surgery cohorts
such as those by Masterson and Deconde [9, 30].
Primary frontal sinus drill-out or a modied
endoscopic Lothrop has been shown to decrease
symptom burden and polyp recurrence in revision surgery and has some advocates for the primary setting of CRSwNP in selected cases, such
as those with N-ERD [13, 31]. Most recently,
there has been a proposal for removal of diseased
mucosa, described as a sinonasal mucosal reboot,
as opposed to mucosal sparing techniques, but
further evidence is required to support efcacy
[14]. The balance of extent of surgery must be
discussed with and tailored to each individual
patient.
Surgery carries a risk of potential severe complications including meningitis, intracranial or
intra-orbital bleeding, leading to potential neurological decit or blindness; one study identied
the risk of such severe complications as 0.04%;
however, signicant bleeding or cerebrospinal
uid leak may occur in 0.9% of patients. The UK
sinonasal audit reported the following complication rates; excessive bleeding 5% intraopera-
tively and 1% post-operatively, intra-orbital
complications in 0.2% and CSF leak in 0.06%
[7, 8].
Post-operative Care
Post-operative care of patients with CRSwNP
undergoing endoscopic sinus procedures is
important for optimisation of outcomes. Nasal
saline irrigation 24–48 h after surgery has low
risk and a good evidence base for improving
postoperative symptoms and medium-term
symptomatic outcomes [7]. Budesonide added to
the postoperative irrigation has an increasing evidence base to support its use [21]. Post-operative
debridement has shown to reduce synechiae formation but increases postoperative pain.
Debridement improves post-operative endoscopic examination, reducing granulation and
potential restenosis. This is especially true in
patients with signicant mucosa and bone
removal with extended approaches. It is unclear
if it has any long-term positive effects on symptoms or disease severity. Post-operative antibiotics have not demonstrated a benet, and oral
steroids have shown improved polyp scores but
not symptom scores to date [7].
Management of specic subgroups requires a
tailored approach. Those with a specic diagnosis such as granulomatous disorders, cystic brosis and ciliary dyskinesia require a
multidisciplinary systemic treatment paradigm.
Allergic fungal rhinosinusitis requires early and
extensive surgical treatment to the affected compartments. There is no role for topical or systemic
antifungals. Clearing the allergic mucin and
releasing obstruction for irrigation topicalisation
is the mainstay of treatment [16]. The need for
more extensive and revision surgery is common.
There is uncertainty around the role of medical
management in this group, but oral as well as
topical steroids can be an adjunct to postoperative treatment [7].
In the N-ERD group, there is some support for
the use of adjunctive treatments such as aspirin
desensitisation and leukotriene modiers [10].
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C. Hopkins and J.-L. McKenzie
N-ERD patients suffer from poorer surgical outcomes compared to their non-N-ERD CRS counterparts, with shorter time to revision and a greater
number of revision sinus surgeries in the N-ERD
population. There are advocates for more extensive primary surgery including a modied Lothrop
approach in N-ERD [31]. Surgery may be followed by aspirin desensitisation to reduce recurrence rates and improve symptom control [18].
Controversies: Current Pathways
andPosition ofNovel Treatments
There is more data needed to guide optimal treatment of CRSwNP particularly with regard to the
role and timing of surgery and new agents such as
biologicals.
Better intranasal delivery of medication may
further reduce the need for both surgery and systemic treatments; devices and drug-eluting stents
continue to evolve. Long-lasting stents may overcome poor patient compliance that limits the
effectiveness of such treatments.
There is a growing awareness of the risks of
repeated use of systemic glucocorticoids which
means that these cannot usually give more than
occasional, temporary relief.
Surgery is effective in relieving symptoms in
the short term and has a disease-modifying effect
in that it may achieve better long-term control of
disease by facilitating better delivery of topical
steroids, particularly with more extensive surgery. Surgery therefore should be considered in
patients who remain uncontrolled on INCS and
in whom systemic glucocorticoids provide only
short-term benet.
Due to the costs, the need for ongoing treatment and unknown long-term side effects, at the
current time, it seems reasonable to consider biologic therapy only in those patients with recurrent
nasal polyps after surgery and adequate postoperative medical treatment; in those unt for
surgery; or where it may be predicted that surgery
is unlikely to achieve adequate control. However,
patient preference is an essential component to
shared decision-making, and the risks and benets of all options should be discussed.
There is some evidence to suggest that early
surgery may achieve better long-term symptomatic improvements; similar analysis is required to
assess the ideal time to introduce a biologic.
Disease endotyping and developing reliable
biomarkers to guide treatment are further evolving as ways to create precision medicine to benet patients suffering this common condition. It
is likely that in the future, surgery will play only
a limited role in the management of CRSwNP as
we better learn how to address the underlying
inammatory disease.
Key Learning Points
• CRS is a common disease, and those patients
with polyposis commonly have a type 2
inammatory pattern with more difcult to
treat disease.
• Diagnosis is formed based on history and
examination revealing nasal polyps.
• Disease endotyping characterising the type of
inammation may guide treatment and prog-
nosis of CRSwNP.Specic subgroups can be
dened and receive tailored management
strategies.
• The mainstay of medical therapy is intranasal
corticosteroids. Oral steroids provide short-
term benet but have attendant risks.
• Biological drugs are emerging as effective if
expensive agents in the management of dif-
cult treat CRSwNP.
• Surgery is effective in CRSwNP and is gener-
ally reserved for patients with persistent
symptoms despite medical management.
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