Matteo Gelardi
Dear Editor,We read with great interest the article by Zhang and Li [1], recently published in International Archives of Allergy and Immunology, describing the development and validation of a nomogram integrating clinical characteristics, radiological findings, and serum inflammatory biomarkers to predict postoperative recurrence in patients with chronic rhinosinusitis with nasal polyps (CRSwNP). The proposed model addresses a clinically relevant issue, namely, the early identification of patients at higher risk of recurrence after endoscopic sinus surgery, and confirms the role of well-established risk factors such as asthma, revision surgery, disease extent on imaging, and systemic type 2 inflammatory biomarkers, including periostin and eotaxin-1.However, we believe that an important conceptual aspect deserves consideration in order to further strengthen predictive strategies in CRSwNP, specifically the lack of a direct assessment of local inflammatory heterogeneity. Although clinical variables and circulating biomarkers provide valuable indirect information, they do not fully capture the complexity of mucosal inflammation, which is increasingly recognized as a major determinant of surgical outcomes and disease recurrence. In this context, nasal cytology allows a direct, noninvasive, and repeatable evaluation of the local inflammatory endotype.Importantly, nasal cytology is now a standardized technique, as recently established by an expert-based Delphi consensus promoted by the Italian Academy of Nasal Cytology (AICNA), which defined shared criteria for sampling, interpretation, and reporting, thereby improving reproducibility and clinical applicability [2]. This consensus addresses one of the main historical limitations attributed to nasal cytology and supports its integration into diagnostic and prognostic pathways.In particular, clinical-cytological grading, which integrates the assessment of major systemic comorbidities (asthma, aspirin sensitivity, and allergy) with the characterization of the predominant cellular pattern identified by nasal cytology, enables a biologically grounded stratification of disease severity and recurrence risk. This approach has been shown to effectively guide the nonsurgical management of CRSwNP within a precision medicine framework [3].Among the different inflammatory phenotypes, the eosinophil-mast cell intraepithelial pattern has been associated with the most severe forms of CRSwNP, a higher risk of postoperative recurrence, and an increased likelihood of requiring advanced therapies, including biologics [4]. Unlike serum biomarkers, nasal cytology reflects the actual cellular microenvironment driving disease persistence and progression.An additional strength of clinical-cytological grading lies in its dynamic nature. Being a simple, minimally invasive, and repeatable technique, it can be applied not only in the preoperative setting but also during follow-up, allowing longitudinal risk stratification and treatment adjustment over time. This feature is particularly relevant in the current era of precision medicine, in which therapeutic decisions increasingly rely on continuous disease monitoring rather than static baseline assessments.From this perspective, predictive nomograms based on clinical and serological parameters and clinical-cytological grading should not be considered alternative tools, but rather complementary components of an integrated prognostic framework. The inclusion of a standardized evaluation of local inflammation may enhance the biological robustness and clinical applicability of predictive models, bringing them closer to truly personalized management of CRSwNP. We believe that future predictive strategies combining systemic biomarkers with standardized tissue-level inflammatory characterization may represent a decisive step toward refining recurrence prediction and optimizing genuinely patient-tailored therapeutic pathways.The author declares no conflicts of interest.This study was not supported by any sponsor or funder.Conceptualization, and writing – original draft preparation, review, and editing: M.G.Edited by: H.-U. Simon, Bern.