Functional endoscopic sinus surgery (FESS) has long been the standard for patients with severe or refractory chronic rhinosinusitis with nasal polyps (CRSwNP).1 While often effective in the short term, polyp recurrence following surgery remains a major challenge, especially in patients with comorbid asthma, aspirin-exacerbated respiratory disease (AERD), or elevated eosinophilic inflammation.2
New treatment strategies are emerging that integrate biologic therapies with traditional surgical approaches to improve long-term outcomes. Interleukin (IL)-4 receptor alpha antagonists have demonstrated strong efficacy in patients with persistent disease post-FESS, as well as in those who are surgical candidates but seek to delay or avoid additional procedures.2-4 By targeting the alpha chain of IL-4Ra, a receptor for IL-4 and IL-13, this therapy addresses the root drivers of mucosal edema, epithelial dysfunction, and polyp regrowth present with type 2 inflammation.4
Initiating biologic treatment preoperatively may reduce mucosal inflammation, optimize the surgical field, and potentially minimize disease burden at the time of intervention.5 Postoperative use can help maintain remission, especially in patients with a history of rapid recurrence. Importantly, the integration of biologics does not replace surgery but complements it in appropriate cases, particularly for patients with a history of multiple prior procedures or corticosteroid dependence.5
As newer agents enter clinical trials targeting IL-5, thymic stromal lymphopoietin (TSLP), and other pathways, the timing, selection, and sequencing of therapy will become increasingly nuanced. Tools like diagnostic algorithms, biomarker panels, and shared decision-making protocols can support clinicians in determining when and how to escalate care. Specifically, the contextual use of three assessment tools (nasal polyp score (NPS), sinonasal outcome test (SNOT-22), and clinical-cytological grading (CCG)) has been found to be more effective than using only one assessment.4
Given the chronic and relapsing nature of CRSwNP, a comprehensive, multimodal approach is essential.4 Otolaryngologists and their care teams are uniquely positioned to lead this shift, using surgery where needed, while incorporating emerging immunomodulatory therapies to achieve sustained symptom control and improved patient quality of life.
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