Biologics vs Endoscopic Sinus Surgery in Primary Severe Uncontrolled CRSwNP: Distinct Mechanisms, Complementary Roles

Endoscopic sinus surgery (ESS) and biologic therapies are both effective treatments for chronic rhinosinusitis with nasal polyps (CRSwNP), yet they differ fundamentally in mechanism. Understanding these therapies as mechanistically distinct rather than interchangeable is essential for optimal patient selection and long-term disease control. ESS acts as a local, tissue-level intervention that removes inflammatory burden and enables epithelial recovery, whereas biologics provide systemic suppression of type 2 inflammation. Both ESS and biologic therapy are safe and well tolerated and represent good treatment options for CRSwNP. Despite effectiveness of both therapies in managing CRSwNP, current evidence supports ESS as a cost-effective first-line intervention following failure of intranasal topical corticosteroid therapy, with biologics reserved for refractory disease or selected high-risk phenotypes.