What We Know about Nasal Polyposis: The Clinician’s Point of View

Abstract

Nasal polyposis is defined as a Th2-driven chronic inflammation of the nose and sinus with polyps visible in the nasal fossae. It is a prevalent disease with a significant impact on health-related quality of life (HRQL). Allergies, allergic rhinitis, asthma, and aspirin intolerance are frequently associated. The management is individual. The first line of treatment is long-term treatment with intranasal corticosteroids. Oral corticosteroids should be used with caution. When the medical treatment fails, the patient is eligible for sinus surgery, which usually consists of a complete sphenoethmoidectomy. In the case of symptomatic recurrence after both medical and surgical treatment, biologics are currently a very promising treatment effective on all respiratory tracts. Dupilumab is considered in the literature to be the molecule of choice. However, besides the international guidelines published by EPOS and Euforea, the molecule prescribed depends also on its availability in each country and the criteria edited by the health authorities to receive reimbursement. Traditional medical treatment remains necessary as a complement to biologics. At the moment, there is no consensus on when the medical treatment can be stopped.

1. Introduction

Sinonasal polyposis is a distinct form of chronic rhinosinusitis characterized by various phenotypes and endotypes [1,2].

Chronic rhinosinusitis (CRS) is defined as a chronic inflammation of the nose and paranasal sinuses, characterized by two or more symptoms, one of which should be nasal blockage or nasal discharge and/or facial pain or pressure and/or reduction or loss of smell. The diagnosis is confirmed by endoscopic signs (such as nasal polyps/mucopurulent discharge/edema of the middle meatus) or radiologic signs (such as mucosal changes in the sinuses/ostiomeatal complex on CT). In order to comply with the diagnosis of chronic rhinosinusitis, clinical manifestations should last longer than 12 weeks without resolution.

CRS is classified in chronic rhinosinusitis with nasal polyps (CRSwNP) and chronic rhinosinusitis without nasal polyps (CRSsNP) [2]. Patients with nasal polyps count for 10 to 40% of all CRS patients [3,4,5].

In the EPOS guidelines, there is a distinction between primary nasal polyposis and secondary nasal polyposis associated with cystic fibrosis, primary ciliary dyskinesia, and immunodeficiency [1,2].

We focus our topic on primary nasal polyposis.

2. Epidemiology

CRS affects approximately 10–12% of the general population, although there are significant geographical variations all over the world [4,5,6,7,8]. These include Europe 10.9% [3,4], USA 12% [7], France 2% [8], Denmark 7.8% [9], China 8% [10], and Korea 6.9% [11,12].

The exact prevalence of NP (nasal polyposis) in the general population is not clearly known, as epidemiological studies are missing. However, in the literature, we can find some percentages: an overall prevalence of 1% to 4% with great differences between countries ranging from 2.1% in France [8], 7% in Sweden [9], 4.3% in Finland, 1–4.2% in the USA(è), and 1.1–2.2% in China [10].

Nasal polyposis (NP) is more prevalent in men than in women, except in cases of aspirin intolerance. It predominantly affects adults after the age of 40, and its prevalence increases with age [5,13].

Special attention is needed in the case of polyposis diagnosed in children.

3. Etiology and Pathophysiology (Phenotypic and Endotypic Variants of Polyposis)

The pathophysiology of CRSwNP is considered multifactorial as there is not a single molecular pathway explaining the modifications of the mucosa, leading to the formation of polyps [14]. The present conception is that CRS is a chronic inflammation generated by an imbalance of interactions between the host, the commensal flora, different pathogens, and exogen stresses [15]. During the last research period, a superantigen theory was proposed for the pathophysiology of CRSwNP, hypothesizing that the colonization with staphylococcus aureus, which secretes superantigenic enterotoxins, increases eosinophilic inflammation, leading to the formation of the polyps [16].

The categorization of CRSwNP into phenotypes and endotypes is now recommended because it helps understand the underlying mechanisms and influences the modality of the treatment to apply [1,2].

Therefore, NP can be categorized into two variants: neutrophilic and eosinophilic polyposis.

Polyposis with neutrophils is associated with a TH1 inflammatory profile. It is more common in Asian or Chinese adults or in children with conditions such as cystic fibrosis or primary ciliary dyskinesia.

NP with eosinophils is mainly found in Caucasian patients, with or without aspirin intolerance, in allergic fungal sinusitis, or in Churg Strauss syndrome.

In the past, these polyps were called allergic polyps.

Endotypes are classified based on pathophysiologic mechanisms and molecular and immunological profiles.

NP in Caucasians is mostly associated with TH2-driven chronic inflammation. Type 2 immune response involves Th2 cells, eosinophils, ECP, and the upregulation of IL 4, IL5, and IL13. There is also a high level of total IgE in the serum and nasal secretion [17,18].

Table 1. Endotyping of CRS, different mediators and their localization.

	Cells: Eosino/Neutron	IgE (Tot or Specific)	Pathogens Staphylo or Other	Cytokines	Other Mediators
Blood	+	+		+	+
Culture Swab			+
Nasal secretion		+	+	+	+
Nasal cytology	+
Tissue	+		+	+	+
Nasal NO	+

shows the endotyping of CRS, the different mediators, and their localization. This is modified from Van Zele et al. 2006 with permission [19].

The type 1 (Th1) endotype is dominated by a type 1 immune response involving Th1 cells, macrophages, and cytokines like TNF α and IFN γ. These patients have persistent polyps with less eosinophilic infiltration and are resistant to corticosteroids.

Recognizing phenotypes and endotypes helps understand the disease and ultimately improves patient management and outcomes.

Th2-driven inflammation responds well to corticosteroids and biologics.

Nasal polyposis is frequently associated with other diseases or comorbidities, such as allergies, allergic rhinitis, asthma, and aspirin intolerance.

Allergic rhinitis is a very prevalent disease in the general population. Its prevalence can be up to 30% in the Belgian population. It is, therefore, logical to suspect a causal etiologic link between allergic rhinitis and CRS with or without polyp [20].

A paper written by Wilson and published in 2014 tried to answer this question [21].

He performed a search in the literature of articles examining the link between allergic rhinitis (AR) and CRS with NP. He found 18 articles. In total, 10 of them showed an association, 7 articles showed no association, and 1 article showed a possible association.

No articles examined the outcomes of CRSsNP or CRSwNP following allergy treatment.

The conclusion was that the role of allergies in CRSwNP and CRSsNP continues to be controversial. Therefore, and because of the high prevalence of allergic rhinitis in the general population, allergy testing and its treatment remain a must in the diagnostic workup of CRSwNP.

In the past, eosinohilic polyps were considered allergic polyps. However, studies did not demonstrate a higher incidence of allergic patients in the population of NP. Nasal polyposis is, therefore, no longer regarded as an allergic process but an inflammatory process that can involve all the respiratory tract [22,23,24].

An interesting direction to be studied in the future would be the link between food allergies and nasal polyps signaled by some authors [25,26].

CRSwNP is frequently associated with asthma [27]. Nasal polyposis is associated with asthma in 40% of cases, thus indicating the fact that it is an inflammatory disease affecting the whole respiratory tract. Lung function testing must be conducted for a complete assessment of nasal polyposis to rule out asthma or bronchial hyperreactivity.

Aspirin intolerance is a condition that is associated with CRSwNP in 36–93% of cases [1,2]. The association between nasal polyps, aspirin intolerance, and asthma is known historically as Widal syndrome or Samter’s triad. Currently, this condition is called aspirin-exacerbated respiratory disease (AERD) or NSAID-exacerbated respiratory disease (NSAIS-ERD) [27]. Compared to the cases of patients tolerant to aspirin, patients with aspirin sensitivity have a more severe evolution in terms of uncontrolled disease, more severe asthma and polyposis, and more frequent recurrences after sinus surgery [28,29].

4. Clinical Manifestations and Diagnostic Methods

The subjective evaluation of CRSwNP was based on its symptoms: nasal obstruction, nasal discharge or postnasal drip, facial pain or pressure, and reduction/loss of smell.

Table 2. Severity of symptoms, radiologic signs, polyp nasal score in CRSsNP, CRSwNP and in cystic fibrosis.

	Controls	Chronic Sinusitis	Nasal Polyps	Cystic Fibrosis: Nasal Polyps	One-Way Anova Fisher’s Test
N	10	10	14	14	14
CT score/Lund & Mackay	0.75 (0–2)	6 (2–11)	16.3 (7–24)	14.5 (5–20)	<0.0001
Polyp score (Davos)	0	0	4.8 (2–6)	2.9 (0–6)	<0.0001
Total symptom score	4(3–5)	6.6 (4–10)	9.6 (3–14)	4.3 (0–9)	<0.0001
Nasal congestion	1.1 (0–3)	1.0 (0–3)	2.6 (0–3)	2.8 (2–3)	0.001
Sneezing	0	0.1 (0–1)	0.2 (0–2)	0.6 (0–2)	0.761
Rhinorea	0.3 (0–2)	1.6 (0–3)	1.6 (0–3)	1.0 (0–3)	0.19
Loss of smell	0	0	2.3 (0–3)	1.0 (0–3)	<0.0001
Postnasal drip	0	1.4 (0–2)	1.3 (0–3)	0.6 (0–2)	0.001
Headache	0.9 (0–2)	2.5 (1–3)	1.6 (0–3)	1.2 (0–3)	0.003
				Van Zele et al. Allergy 2006

shows the severity of the symptoms, the radiologic signs, and the polyp nasal score for the case of CRSsNP, CRSwNP, and in cystic fibrosis. It is adapted from Van Zele et al. with permission [19].

Obviously, nasal obstruction is a typical symptom more severe in the case of NP, while cephalalgia is less frequent in CRSwNP compared to CRSsNP, except for patients with a surgical history. Nasal obstruction can be evaluated using rhinomanometry, acous0tic rhinometry, a simple PNIF test, or a visual analogic scale (VAS).

The smell disorders encountered in CRSwNP are more common than in CRSsNP. Olfactory dysfunction is frequent in patients with CRSwNP (90%) and does not depend on the degree of nasal obstruction. Smell dysfunctions can vary significantly among patients with nasal polyps. Assessing smell with olfactometry is important because the patient has difficulty evaluating their own smell; currently, olfactometry can be easily conducted using either a sniffing test [30] or a UPSIT test [31].

Sleep apnea syndrome can be associated with nasal polyposis and is quite frequent [32]. Patients with CRSwNP with important polyposis should be assessed in order to detect sleep disturbances [32,33,34].

Anterior rhinoscopy is used to assess the patient with polyposis, but fiberoptic endoscopy is preferable because it allows a better visualization of the interior of the nasal fossae for the diagnoses of polyposis in the nasal meatus [35].

Figure 1 shows grade IV at the anterior rhinoscopy.

Figure 2 shows a nasal fiberoscopy showing nasal polyps in the middle and superior meatus on both sides. It also enables the size of the nasal polyps to be scored. Many scoring systems have been used over the years to quantify the dimensions of nasal polyps [35,36].

One of the most used scoring systems for grading nasal polyps is the Meltzer clinical scoring system [37]. This scoring categorizes polyps into four grades.

• 0 = no polyps;
• 1 = polyps confined to the middle meatus;
• 2 = multiple polyps occupying the middle meatus;
• 3 = polyps extending beyond the middle meatus;
• 4 = polyps completely obstructing the nasal cavity.

In 2023, Gevaert et al. [38] proposed a new scoring system for nasal polyps that also involved four grades as follows:

• 0 = no polyps;
• 1 = small polyps in the middle meatus not reaching the inferior border of the middle meatus;
• 2 = nasal polyps reaching below the lower border of the middle meatus;
• 3 = large polyps reaching the lower border of the inferior turbinate or polyps medial to the middle turbinate;
• 4 = large nasal polyps causing complete obstruction of the inferior nasal cavity.

CT scans are the radiological investigation of choice for the diagnosis of CRSwNP [39]. CT scans are useful in confirming the type of polyposis, including either a diffuse type involving the ethmoidal sinuses allergic and the other paranasal cavities bilaterally or a central localization, called CCDA (central compartment atopic disease) [40]. The central compartment type is frequently associated with allergies.

As the concern for radiation exposure increases, cone-beam technology might be an alternative to classic CT scans [41].

The classic radiologic staging used in nasal polyposis is the one proposed by Lund-Makay in 1993 [42]. When reading a CT scan of the paranasal sinuses, the reader assigns each sinus a score:

• No abnormality = 0 points;
• Partial opacification = 1 point;
• Complete opacification = 2 points.

For the ostiomeatal complex, the score is different:

• No opacification = 0 points;
• Opacification = 2 points.

The sinuses are grouped into frontal sinus, anterior ethmoidal sinus, posterior ethmoidal sinus, maxillary sinus, sphenoid sinus, and ostiomeatal complex. Each side is scored separately. A maximum of 24 points is possible. Despite its simplicity, it correlates well with the severity of the disease, the extent of surgery, treatment response, and complication rates [32,43].

Isolated areas of the scanner do not allow the differentiation between meatal polyposis and chronic sinusitis without polyps.

Endoscopy remains the complementary examination of choice.

An MRI is not typically part of the assessment except for previously operated patients with the suspicion of mucocele or neoplasia. MRI has a better capacity to describe soft tissue and does not have a radiation risk. By better defining soft tissue, it can differentiate different masses of retained secretions.

The analysis of the nasal secretions proposed by ST Vlaminck can be a valuable diagnostic tool in the diagnosis and monitoring of eosinophilic polyposis. The secretions can be collected by simple blowing or preferably by aspiration under endoscopic control. The collected material is then examined for eosinophils, Charcot–Leyden crystals, allergic mucin, and fungal hyphae [44,45,46].

5. Impact on the Quality of Life

CRS has a remarkable impact on health-related quality of life [47,48] and is associated with important healthcare costs [49,50,51]. The quality of life of the patient with nasal polyposis can be severely impaired, and it should be assessed by questionnaires meant to analyze the impact of the pathology on daily life. The SNOT 22 test is an effective tool for this purpose [52,53,54,55].

The test has 22 questions as presented in Figure 3 with scores ranging from 0 to 5 for each question.

Studies have described the following stratifications:

• Mild: 8–20;
• Moderate: >20–50;
• Severe: >50.

The visual analog scale is also another method to quantify the severity of symptoms.

6. Management and Treatment Approaches

The management of nasal polyposis remains individual [56].

The usual medical treatment of CRSwNP polyps is based on nasal lavages associated with long-term intranasal corticosteroids [57,58].

These corticosteroids reduce rhinitis symptoms, improve nasal breathing, reduce the size of polyps, and prevent, in part, their recurrence, but this treatment has minimal effect on the sense of smell [57]. The effect of corticosteroids is based on their ability to diminish eosinophilic infiltration by reducing their viability and activation.

Intranasal corticosteroids can be administered via spray or in lavages, and the literature regarding their use is quite rich and favors nasal steroids. The topical corticosteroids usually used are fluticasone propionate, mometasone furoat, betamethasone, and beclomethasone dipropionate. Budesonide in nasal rinses is commonly used, though it is off-label [59,60,61]. The side effects of nasal steroids are epistaxis, dry nose, and local irritation, but usually, they are well tolerated.

Oral corticosteroids (OCs) should be reserved for obvious polyps associated with severe symptoms. Despite their effectiveness, OC should be used for the short term (less than 7 days and a maximum of 3 courses per year), given its important side effects (such as osteoporosis, diabetes melitus, necrosis of the head of the hip, and glaucoma). The anti-inflammatory effect cannot be separated from the metabolic effect. There is a need for special attention for patients with diabetes mellitus or severe glaucoma.

The mean annual cumulative dose of oral corticosteroids over the year should be monitored and should not exceed 1ooo mg of prednisolone [32].

Short-term or long-term antibiotic treatments with macrolides or doxycycline have been reported by some studies to have a moderately positive effect on the size of polyps and the patient’s symptoms [62,63]. Nevertheless, the danger of antimicrobial resistance should be considered.

Patients not responding after a trial of the maximum medical treatment (intranasal steroids for at least 8 weeks, at least 2 courses of OC over the year, and symptomatic recurrence) are eligible for surgery [2,32,64].

Surgical options include primary surgery, a simple polypectomy, a polypectomy associated with skeletonization of the different meatuses, or a functional ethmoidectomy. In fact, there is no definitive consensus. Simple polypectomy improves nasal blockage but is associated with an early and high recurrence rate [65].

Therefore, most rhinologists recommend conducting a complete ethmoidectomy, sparing the sinus mucosa [66,67].

In the case of revision surgery for massive symptomatic recurrence of polyposis, the surgery is usually more extended, more aggressive, and the attitude towards the mucosa is less conservative.

The surgical options are, therefore, a nasalization, a Draf procedure, or a reboot procedure with complete resection of the mucosa of all the paranasal sinus cavities in the case of major symptomatic recurrences nonrespondent to current treatments [68,69].

Even if it is an aggressive and extended surgery, the health-related quality of life is preserved [70].

Surgery has its advantages but also its inconveniences and obvious risks. There are anesthetic risks as well as neurological, vascular, and orbital complications. There are also risks of late complications, such as synechiae, mucoceles, and colonization with staphylococcus aureus. In

Table 3. Comparison of the benefits and weaknesses of oral corticosteroids and sinus surgery.

	Benefits	Weakness
Oral corticosteroids	Big improvement in major symptoms Improvement in HRQL: Improvement in the sleep quality, sense of smell, reduction in the facial pain, and reduction in nasal blockage	Frequent and early recurrence of the symptoms Rebound effect Adverse events: weight gain, anxiety, nervosity, and irritability Osteoporosis, diabetes melittus, necrosis of the head and of the hip
Sinus surgery	Improvement in HRQL Good outcome after short and middle-term	Frequent recurrence of the disease Iatrogenicity Need for general anesthesia Possibility of minor and major intraoperative and postoperative complications

we summarize the benefits and the weaknesses of the surgical treatment versus the medical treatment for CRSwNP.

One important item after surgery is the recurrence of nasal polyps. The percentage is highly variable. In EPOS, they reported a percentage of at least 40% recurrence of nasal polyps 3–5 years after FESS before the arrival of biologics [70,71,72].

Vlaminck S found 40% recurrence rates 3 years after FESS and a 62% recurrence rate after 10 years of follow-up [44,46].

Calus et al. found a 78.9% recurrence rate with a follow-up of 12 years. Among them, there is a 36.8% need for revision surgery [73].

7. Biological Treatment and Ongoing Care

Based on these data, it seems necessary to find new molecules as an add-on treatment to intranasal steroids and surgery [74].

In recent years, biological therapies have been developed as an endotype-driven therapy. Indeed, these are monoclonal antibodies acting as antagonists to some specific mediators of the Th2 inflammatory cascade.

Historically, biologics first demonstrated their efficacy for the treatment of moderate or severe asthma when patients were unresponsive to traditional therapies.

Then, they were used to treat uncontrolled nasal polyposis.

Therefore, ENT specialists benefit from the experience of pulmonologists.

Specific criteria have been edited by EPoS and EUFOREA guidelines for the prescription of biologics by an ENT [1,2,74,75,76].

Biological treatment is indicated in the event of the symptomatic recurrence of nasal polyposis after a well-conducted medical treatment, a complete ethmoidectomy, or in the case of a contraindication for anesthesia.

According to EPOS, indications for biological treatment in CRSwNP are as follows:

• Symptomatic uncontrolled nasal polyposis that is unresponsive to traditional medical treatment (medical therapy ± surgery) with the following additional criteria:
• Evidence of type 2 inflammation (tissue eos ≥ 10/hpf, or blood eos ≥ 250, or total IgE ≥ 100);
• The need for systemic corticosteroids or contraindication for systemic corticosteroids (≥2 courses per year, or long term. 3 months low dose steroids);
• Significantly impaired quality of life (SNOT22 ≥ 40);
• Significant loss of smell (anosmic on smell test);
• Diagnosis of comorbid asthma (asthma needing regularly inhaled corticosteroids).

In the absence of surgical history, four criteria are required. A surgical history of three criteria is sufficient.

In 2023, the criteria changed slightly. Blood eosinophilia should be >150 instead of 250 in the initial report [74].

A total of three molecules are currently prescribed by the ENT and are available in Belgium:

Omalizumab, mepolizumab, and dupilumab.

Omalizumab is an anti-IgE monoclonal antibody. It reduces the levels of the total IgE in a dose-dependent way. Very early after its administration, a quick drop in the level of serum IgE from 89 to 90% is observed.

Ph Gevaert published five important studies in 2013 (first study), 2021 (comparison of 2 cohorts of patients: polyp 1 and polyp 2), 2023, and 2024 (long-term results) [75,76,77,78]. He demonstrated that compared to the placebo group, omalizumab reduced the polyp nasal score, the symptomatology, the sense of smell, and the opacity (Lund McKay score) on CT significantly. The efficacy was similar in allergic and non-allergic patients. In patients with concomitant asthma, the lung function also improved.

Mepolizumab is an anti-IL5 monoclonal antibody validated by the FDA.

IL 5 is an interleukin playing a major role in the multiplication, maturation, and survival of eosinophils, which are key cells in the TH2 inflammatory cascade [79].

JK Han published in 2021 a well-known study called the Synapse Study conducted over 52 weeks [80].

This is a phase 3 RCT double-blind study demonstrating the efficacy and safety of mepolizumab for the management of severe bilateral refractory nasal polyposis refractory to conventional treatment, which required, in the past, multiple sinus surgeries. The study was conducted for 52 weeks.

This study demonstrated a significant reduction in the level of the blood eosinophilia, an improvement in the nasal polyp score, an improvement in SNOT 22 after 8 weeks, which persisted for the duration of the study, a significant reduction in the VAS for nasal blockage of at least three points in 60% of the patients, a reduction in the rescue medication by oral steroids, and a reduction in and delay for revision surgeries for 57% of patients. All these parameters were significantly improved compared to the placebo group [81]. The safety profile was similar to that observed with the placebo.

Dupilumab is an anti-IL4 and -IL13 monoclonal antibody also validated by the FDA.

A significant study called Liberty NP sinus 24 and Liberty NP sinus 52 was published by Bachert et al. in 2019 in The Lancet [82].

This was a multicentric RCT double-blind control study with two different timings: the first was conducted over 24 weeks, and the other over 52 weeks.

During these studies, they observed a significant reduction in the nasal polyp score and nasal congestion, which became statistically significant after 8 weeks of treatment compared to the placebo.

The time to use oral glucocorticoid or to conduct revision surgery was longer in the group that received dupilumab.

However, the symptoms recurred if dupilumab was stopped after 24 weeks of treatment. In the other group, the efficacy of dupilumab persisted for the 52 weeks of the study.

The following question now needs to be answered by clinicians: which is the best biologic to prescribe to treat severe uncontrolled nasal polyposis?

Based on some meta-analysis and recent real-life studies, dupilumab seems to be the most effective biologic compared to mepolizumab or omalizumab [83,84,85,86], with a good safety profile.

However, dupilumab can be associated with transitory hypereosinophilia, whose meaning is unclear [86].

However, the prescription of one drug instead of another also depends on its availability, costs, and the criteria elaborated in each country to obtain reimbursement.

These molecules must be used for a long period of time. In any case, we must wait for a minimum of 2 months of treatment to observe significant effects, and there are rapid responders and slow responders. This was perfectly well demonstrated in the Synapse Study and the Liberty NP study 24 and 52. Patients stopping their treatment after 24 weeks experienced a recurrence of their symptoms and polyps; patients treated for 52 weeks without interruption remained improved during the entire duration of the study [82].

An important factor for the future is the cost and the criteria given by the authorities to provide reimbursement compared to the cost of the most classical management.

The response to the biologic is evaluated based on the history, the SN0T 22, the presence of polyps at the nasal endoscopy, or the scanner.

According to the most recent guidelines published by EPOS and EUFOREA, they recommend the evaluation of the response to biological treatment in CRSwNP based on five criteria:

• Reduced nasal polyp size;
• Reduced need for systemic oral corticosteroids;
• Improved quality of life;
• Improved sense of smell;
• Reduced impact of comorbidities.

The response is evaluated at 6 months and 1 year after the initiation of the treatment.

If the treatment is effective, it should be continued for several years with regular checks every 6 months. In any case, the patient should not discontinue the intranasal corticoids or the bronchodilator.

If there is no response to any of the criteria, the treatment should be discontinued or a switched to another drug.

At the moment, there is no deadline to stop the treatment.

Some real-life studies have been recently published with longer follow-up confirming the tolerability and efficacy of the biologics after 4 to 5 years [87,88].

However, real-life studies with long-term follow-up (5 or 10 years) are still necessary to confirm the long-term tolerability, efficacy, which molecule is the best to use, and which is the best interval between the injections, taking into account the cost of these products and the adverse events.

8. Conclusions

Nasal polyposis is defined by a Th2-driven chronic inflammation of the nose and sinus with polyps visible in the nasal fossae.

It is a prevalent disease with a significant impact on HRQL.

Allergy, allergic rhinitis, asthma, and aspirin intolerance are frequently associated.

Its management is individual.

The first line of treatment is long-term treatment with intranasal corticosteroids. Oral corticosteroids should be used with caution.

When the medical treatment fails, the patient is eligible for sinus surgery.

In case of symptomatic recurrence after both medical treatment and full-house ethmoidectomy, biologics are currently a very promising treatment and are effective on the respiratory tract. Dupilumab seems, in the literature, the molecule of choice.

However, besides the international guidelines published by EPOS and Euforea, the molecule prescribed depends also on the availability of it in each country and the criteria given by the health authorities to receive reimbursement.

Long-term treatment is mandatory. Traditional medical treatment is necessary as a complement to biologics.