Biologics and Surgery in Chronic Rhinosinusitis With Nasal Polyps: A Comparative Outcomes Analysis

Objective: Chronic rhinosinusitis with nasal polyps (CRSwNP) presents with nasal obstruction, facial pressure, smell alterations, and post-nasal drainage. Endoscopic sinus surgery (ESS) is indicated when medical treatments fail, however some patients' nasal polyps can recur. Biologic therapies targeting type-2 inflammation have been shown to improve sinonasal symptoms in CRSwNP. Few studies compare ESS to biologic outcomes longitudinally. To review and compare the efficacy of ESS to biologics in managing CRSwNP using standardized outcome measures longitudinally. Data Sources: We searched electronic databases, including MEDLINE, EMBASE, Cochrane Library, Web of Science, and ClinicalTrials.gov from inception through August 2024. Review Methods: Primary outcome included changes in symptom scores (SNOT-22). Secondary analyses included change in nasal polyp score (NPS) and olfactory function scores. The mean differences and 95% CI were synthesized using a random-effects meta-analysis with heterogeneity assessed using I² statistics. Results: Although there was significant heterogeneity between and within groups, we performed a meta-analysis of SNOT-22 outcomes from both biologic and ESS studies (n = 27). SNOT-22 significantly improved at 6/12 months in biologic and ESS studies with no differences between groups. Secondary analysis of NPS and olfactory function were limited by the small number of studies. Both treatments improved outcomes from baseline, with biologics showing improved olfaction at 6 months compared to ESS. Conclusion: Significant heterogeneity in patient selection, testing methods, and longitudinal data collection was identified. Future comparative studies should incorporate individual complete data with consistent follow-up to reduce heterogeneity and synthesize the best evidence comparing biologic to ESS outcomes in CRSwNP.