Biologics vs endoscopic surgery in the management of chronic rhinosinusitis with nasal polyps

Chronic rhinosinusitis with nasal polyposis is a heterogeneous inflammatory condition typically characterized by type 2 inflammatory responses. Patients who fail medical therapy (ie, nasal saline irrigation and topical steroids) have historically been managed with functional endoscopic sinus surgery (FESS), but the availability of biologic therapies has upended this paradigm. This presents an important decision for the allergist in managing refractory disease. FESS is a minimally invasive procedure to dissect the paranasal sinuses, allowing for medication access and debridement of retained secretions. This procedure alone does not modify the underlying inflammation but instead augments the delivery of medical therapy. This combination improves both objective and subjective outcomes. As such, patients who are unable or unwilling to continue topical medical therapies may not benefit from this approach. Currently, there are 4 biologics approved by the US Food and Drug Administration to treat chronic rhinosinusitis with nasal polyposis-dupilumab, omalizumab, mepolizumab, and tezepelumab. Each has been found to also improve objective and subjective outcomes. However, dupilumab is seemingly most effective at improving patient-reported outcomes and sense of smell (though tezepelumab has not been included in comparative studies). These therapies may be most appropriate for patients with comorbid atopic diseases. In addition, cost comparison analyses in the United States reveal that biologic therapy is less cost-effective than FESS, even in the setting of revision surgery. Ultimately, there are some patients who will benefit from the combination of both FESS and biologic therapies. Additional evidence is needed to evaluate the head-to-head outcomes of these 2 important management pathways.