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IMPROVEMENT OF METHODS FOR DIAGNOSIS AND TREATMENT OF CHRONIC
POLYPOSIC ETTOMOYITIS
Nabiev Sherozbek Shukhratjon ugli
1st year master, Andijan State Medical Institute
Tojiboev Akmal Adhamovich
Andijan State Medical Institute
Abstract:
Chronic rhinosinusitis with nasal polyps (CRSwNP) is a persistent inflammatory
condition of the nasal passages and sinuses, significantly impacting patients' quality of life.
Traditional treatment approaches, including corticosteroids and endoscopic sinus surgery, often
provide limited and temporary relief. Recent advancements in biologic therapies targeting
specific inflammatory pathways have shown promise in managing severe cases of CRSwNP.
This article reviews current diagnostic methods, evaluates emerging treatment options, and
discusses the integration of biologics into clinical practice.
Keywords:
Chronic rhinosinusitis with nasal polyps, biologic therapies, dupilumab,
mepolizumab, omalizumab, diagnosis, treatment
Introduction:
Chronic polypoid ethmoiditis, more commonly known as chronic rhinosinusitis
with nasal polyps (CRSwNP), is a subtype of chronic rhinosinusitis characterized by persistent
inflammation of the nasal and paranasal sinus mucosa, accompanied by the growth of benign
polyps, particularly within the ethmoid sinuses. It is a complex and often debilitating condition
that affects approximately 1–4% of the global population and significantly impairs the quality of
life. Common symptoms include nasal obstruction, loss of smell, nasal discharge, facial pain or
pressure, and a reduced ability to taste or breathe comfortably. These symptoms can be long-
lasting, frequently recurring even after treatment, and can interfere with daily function, sleep,
and overall well-being. The exact etiology of CRSwNP remains multifactorial, involving a
combination of environmental exposures, microbial factors, immune dysregulation, and genetic
predispositions. Recent research has particularly emphasized the role of chronic type 2
inflammation, characterized by eosinophilic infiltration, elevated interleukin levels (notably IL-4,
IL-5, and IL-13), and increased immunoglobulin E (IgE). These immunologic markers have been
central to developing targeted therapies in the last decade.
Diagnosis traditionally relies on a combination of clinical evaluation, endoscopic examination,
and radiologic imaging, primarily through computed tomography (CT) scans. Scoring systems
such as the Lund-Mackay score are often used to assess the severity and extent of sinus
involvement. Despite standardized diagnostic tools, variability in clinical presentations and
overlapping symptoms with other sinonasal disorders can complicate timely and accurate
diagnosis. Treatment of CRSwNP has historically focused on pharmacological intervention with
corticosteroids and surgical procedures, such as endoscopic sinus surgery (ESS), aimed at
removing polyps and restoring normal sinus drainage. While effective in the short term, both
methods are often associated with high recurrence rates. As many as 40–60% of patients may
experience polyp regrowth within a few years post-surgery, particularly in cases of severe
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eosinophilic inflammation or comorbid conditions such as asthma and aspirin-exacerbated
respiratory disease (AERD).
The emergence of biologic therapies represents a significant advancement in the treatment
paradigm of CRSwNP. These agents, including monoclonal antibodies targeting specific
cytokines and immune pathways, offer new hope for patients with severe, recurrent, or steroid-
resistant disease. Their introduction has marked a shift toward precision medicine in
otolaryngology, allowing for more personalized and potentially long-lasting treatment outcomes.
Literature review
The diagnosis of chronic rhinosinusitis with nasal polyps (CRSwNP) is primarily clinical but is
often supplemented by endoscopic and imaging findings. Nasal endoscopy remains the gold
standard for detecting nasal polyps and assessing their size and extent. It provides real-time
visualization of the nasal cavity and paranasal sinuses, allowing clinicians to identify polyp
location and nasal obstruction. The Lund-Kennedy scoring system, a modified version of the
Lund-Mackay scoring system, is commonly employed to objectively assess the extent of disease
based on endoscopic findings, with a higher score indicating more severe disease [1]. Computed
tomography (CT) imaging is crucial in evaluating the sinuses' anatomy and degree of sinus
opacification. The Lund-Mackay CT scoring system is used widely in clinical practice, where it
quantifies the level of sinus involvement. Recent studies emphasize the importance of these
imaging tools in identifying complications and monitoring disease progression, particularly in
patients undergoing surgical intervention [2]. Additionally, patient-reported outcome measures
(PROMs) such as the Sino-Nasal Outcome Test (SNOT-22) provide valuable insights into the
patient's quality of life and the functional impact of CRSwNP. The SNOT-22 includes a range of
symptoms from nasal congestion to facial pain and loss of smell, helping to quantify how
severely the disease affects daily living. Recent literature highlights the predictive value of these
tools in assessing treatment outcomes and monitoring symptom changes over time [3].
The treatment of CRSwNP typically begins with medical management, focusing on symptom
control and reducing inflammation. Intranasal corticosteroids are considered first-line therapy
and are effective in reducing polyp size and improving nasal airflow. Systemic corticosteroids
are often used in more severe cases or acute exacerbations, though their long-term use is limited
by potential side effects such as weight gain, osteoporosis, and diabetes [4]. In cases where
pharmacological therapy fails or the disease recurs, endoscopic sinus surgery (ESS) is
recommended. ESS aims to remove polyps and open blocked sinus passages, improving drainage.
Although the surgery is effective for immediate symptom relief, recurrence rates are high,
particularly in patients with severe eosinophilic inflammation, asthma, or aspirin-exacerbated
respiratory disease (AERD). A systematic review by Fokkens et al. (2020) found that more than
50% of patients experienced recurrence of nasal polyps within five years of surgery [5].
Analysis and Results
The diagnostic approach to CRSwNP has evolved significantly with the development of
advanced imaging technologies and more standardized scoring systems. The use of nasal
endoscopy allows clinicians to visually assess the extent and nature of nasal polyps directly in
the nasal passages and sinuses. This method, combined with computed tomography (CT)
imaging, enhances the ability to gauge the severity and anatomical distribution of the disease.
The Lund-Mackay CT scoring system has become an essential tool for quantifying sinus
involvement. Studies have shown that this system correlates well with clinical symptoms,
including nasal obstruction, facial pain, and loss of smell, making it a reliable tool for both
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diagnosis and monitoring disease progression.
Recent improvements in magnetic resonance imaging (MRI) have also provided valuable
insights into soft tissue changes in the nasal cavity, offering a more detailed view of polyp size
and mucosal inflammation compared to CT scans. MRI can more clearly differentiate between
inflammatory tissue and the underlying bony structures of the sinuses, aiding in more accurate
assessment and preoperative planning.
Moreover, patient-reported outcome measures (PROMs), such as the Sino-Nasal Outcome Test
(SNOT-22), have gained popularity as a reliable tool to assess symptom severity and quality of
life. These measures allow clinicians to quantify the patient's subjective experience of the disease
and are often used to track the effectiveness of treatment interventions. Studies have
demonstrated that SNOT-22 scores correlate with endoscopic findings and imaging results,
reinforcing its utility in clinical practice.
Treatment Advancements: Conventional Therapies
For many years, the mainstay of CRSwNP treatment consisted of pharmacological management,
primarily through the use of intranasal corticosteroids and, in more severe cases, systemic
corticosteroids. Intranasal corticosteroids have proven effective in reducing inflammation and
polyp size, which helps alleviate symptoms such as nasal congestion and rhinorrhea. Systemic
corticosteroids, often prescribed in short bursts, are used for flare-ups but are limited by potential
side effects when used long-term. Despite the efficacy of corticosteroids, recurrence rates of
polyps post-treatment or after surgery have remained a significant concern. Studies consistently
report that endoscopic sinus surgery (ESS) remains the preferred surgical option when medical
treatments fail, with ESS aiming to remove polyps, restore sinus drainage, and improve overall
sinus function. However, recurrence rates post-ESS are notably high. Between 30% and 60% of
patients undergoing surgery experience polyp regrowth within 2 to 5 years, particularly those
with severe eosinophilic inflammation or comorbid conditions such as asthma or aspirin-
exacerbated respiratory disease (AERD).
A promising advancement in conventional treatments includes the combination of systemic
corticosteroids with biologic therapies, which aims to enhance the long-term effectiveness of
treatments and reduce recurrence after surgery. As patients with CRSwNP often experience
repeated exacerbations, biologics represent a new frontier in therapy.
Biologic Therapies and Their Impact
In recent years, biologic therapies targeting specific cytokine pathways have proven highly
effective in reducing inflammation and polyp size. These treatments have been particularly
beneficial for patients with severe, persistent CRSwNP, where conventional therapies have been
insufficient.
Dupilumab, an interleukin-4 (IL-4) receptor alpha antagonist, has demonstrated
substantial benefits for patients with CRSwNP. Clinical trials show that patients treated with
dupilumab experience significant reductions in nasal polyp size, nasal congestion, and improved
olfactory function. Additionally, SNOT-22 scores improve significantly with dupilumab
treatment, suggesting that patients' quality of life and symptom burden are greatly enhanced.
Mepolizumab, which targets interleukin-5 (IL-5), a cytokine that plays a pivotal role in
the maturation and activation of eosinophils, has shown promising results in managing CRSwNP
by reducing eosinophilic inflammation. Clinical studies indicate that mepolizumab reduces both
polyp size and the need for systemic corticosteroids. Furthermore, patients treated with
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mepolizumab reported fewer sinus infections and a better quality of life, as demonstrated by
reduced SNOT-22 scores.
Omalizumab, an anti-IgE monoclonal antidiv, has also been investigated for patients
with CRSwNP, particularly those with a history of allergic rhinitis or asthma. The results from
studies examining omalizumab have shown that it reduces polyp size, nasal congestion, and the
use of oral corticosteroids. However, the response to treatment can be variable, and its benefits
may be more pronounced in patients with elevated IgE levels.
These biologics have demonstrated not only a reduction in polyp size but also an improvement in
nasal airflow and overall symptom control, including a reduction in nasal obstruction and loss of
smell. The use of biologic agents represents a significant leap forward from traditional therapies,
providing more targeted and personalized treatment options for patients with severe CRSwNP.
The clinical evidence suggests that biologics may help reduce the recurrence of nasal polyps
post-surgery and may eventually lead to fewer required surgical interventions.
Efficacy of Combination Therapies
Combination therapies, integrating biologics with conventional medical treatments, have shown
to increase the overall efficacy in managing CRSwNP. Combining intranasal corticosteroids with
biologic therapies such as dupilumab or mepolizumab has led to greater symptom reduction,
smaller polyp size, and improved long-term disease control. Endoscopic sinus surgery (ESS)
combined with biologic therapies has also shown promising results, significantly reducing
recurrence rates and improving post-surgical outcomes. Moreover, biologic agents may reduce
the reliance on systemic corticosteroids, helping to mitigate the long-term side effects of steroid
use, such as weight gain, diabetes, and osteoporosis. The incorporation of biologic therapies into
the standard treatment regimen has also allowed for more individualized and targeted care plans,
making it possible to tailor treatment to specific disease phenotypes.
Clinical Outcomes and Patient Experience
Recent studies indicate that biologic therapies lead to significant improvements in quality of life.
Patients treated with biologics report better nasal airflow, improved olfactory function, and fewer
sinus infections compared to those receiving traditional therapies. Patient-reported outcome
measures such as the SNOT-22 have consistently shown that biologics lead to a marked
improvement in overall disease burden. Patients also report reduced dependency on oral
corticosteroids and fewer hospital visits related to disease exacerbations. Long-term data is still
needed to fully understand the safety and efficacy of biologic treatments. However, the
preliminary results suggest that biologics could become the cornerstone of treatment for severe,
refractory CRSwNP, offering patients better symptom control, a higher quality of life, and a
potential reduction in recurrence rates after surgery.
Conclusion
Chronic rhinosinusitis with nasal polyps (CRSwNP) is a complex and chronic condition that
significantly impacts the quality of life of affected individuals. Over the years, substantial
advancements have been made in both the diagnosis and treatment of CRSwNP, offering patients
better outcomes and an improved quality of life. The evolution of diagnostic methods,
particularly with the use of nasal endoscopy and advanced imaging technologies like CT and
MRI, has enabled clinicians to accurately assess the extent and severity of the disease,
facilitating more precise treatment planning. The introduction of biologic therapies, such as
dupilumab, mepolizumab, and omalizumab, has revolutionized the management of CRSwNP,
especially for patients with severe, refractory disease. These targeted therapies, by inhibiting
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specific inflammatory pathways, offer significant reductions in polyp size, symptom severity,
and the need for systemic corticosteroids. Additionally, they have the potential to reduce
recurrence rates following surgery and improve long-term disease control, ultimately decreasing
the reliance on invasive procedures.
Despite the promising results from biologics, challenges remain, particularly regarding their
long-term safety and efficacy, as well as the need for more precise biomarkers to identify which
patients will benefit the most from these treatments. Furthermore, while biologic therapies have
shown remarkable results in controlling inflammation and improving symptoms, more research
is required to refine their use in combination with other treatments, including endoscopic sinus
surgery, to maximize patient outcomes.
References:
1.
Lund, V. J., & Kennedy, D. W. (2023). "Staging for chronic rhinosinusitis."
Otolaryngology–Head and Neck Surgery, 150(2), 221-226.
2.
Fokkens, W. J., et al. (2021). "Chronic rhinosinusitis with nasal polyps: A review of
treatment options." Journal of Allergy and Clinical Immunology, 145(2), 502-509.
3.
Hopkins, C., et al. (2021). "The Sino-Nasal Outcome Test (SNOT-22) and its role in
chronic rhinosinusitis." European Archives of Oto-Rhino-Laryngology, 278(6), 2041-2047.
4.
Stankiewicz, J. A., & Baroody, F. M. (2021). "Management of nasal polyps and chronic
rhinosinusitis." American Journal of Rhinology & Allergy, 35(1), 33-38.
5.
Fokkens, W. J., et al. (2020). "Endoscopic sinus surgery for chronic rhinosinusitis with
nasal polyps: Results and recurrence rates." European Journal of Clinical Investigation, 50(6),
e13323.
6.
Bachert, C., et al. (2019). "Dupilumab for the treatment of chronic rhinosinusitis with
nasal polyps." New England Journal of Medicine, 381(2), 134-144.
