Surgery and the role of biologics in chronic rhinosinusitis with nasal polyps: A narrative review.

BACKGROUND: Biologic treatments have helped progress the management of severe chronic rhinosinusitis with nasal polyps (CRSwNP) by targeting the mediators and effectors underlying chronic type 2 inflammation. This review considers the impact of biologics on endoscopic sinus surgery (ESS) in CRSwNP. METHODS: We conducted a comprehensive literature search through March 31, 2025. RESULTS: ESS as part of holistic management with topical anti-inflammatory treatment is very effective at improving symptoms and quality of life in patients with severe CRSwNP. The criteria for eligibility for surgery are not standardized and there is wide variation in surgery rates between regions. Despite regular post-operative topical corticosteroid therapy, in some patients the disease remains active, polyps recur, and repeated surgeries may be required. The introduction of biologics has provided additional treatment options for patients with severe CRSwNP. Most type 2-dominant patients with chronic rhinosinusitis get rapid symptom relief from the initiation of biologics, although non-responders do exist, and some patients may still require ESS to reverse tissue remodeling and restore mucociliary function. The extent and timing of surgery in patients being considered for biologic therapy is an area of active research. There is evidence that recent or concurrent ESS and/or prior completeness of surgery portends greater disease control. CONCLUSIONS: ESS, with topical corticosteroid therapy, remains the standard approach for severe CRSwNP in patients with inadequate response to conventional medical treatments. Emerging evidence is delineating the settings in which biologics may be synergistic, or in certain circumstances an alternative, to surgery.