World scientific research journal
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335
CLINICAL COURSE OF POLYPOUS RHINOSINUSITIS: CLINICAL
ANALYSIS BASED ON INTERNATIONAL CLASSIFICATIONS
Akhmedova Ziyodakhon Anvar qizi
Tashkent Medical Academy
Abstract
Chronic rhinosinusitis with nasal polyps (CRSwNP) is a complex, relapsing
inflammatory condition of the upper airways, substantially affecting patients' quality
of life and respiratory function. This study presents a clinical analysis of 120 adult
patients diagnosed with CRSwNP according to the EPOS 2020 criteria. We explore
demographic characteristics, symptom profiles, endoscopic and imaging findings,
laboratory biomarkers, and treatment outcomes over a 12-month follow-up period.
Emphasis is placed on differentiating disease endotypes and phenotypes to better
predict recurrence and response to therapy, including systemic corticosteroids and
biologics. Our findings support the importance of precision medicine approaches in
managing this heterogeneous disease.
Keywords
: CRSwNP, nasal polyps, type 2 inflammation, biologic therapy,
EPOS 2020, eosinophilic rhinosinusitis, endotyping
Introduction
Chronic rhinosinusitis with nasal polyps (CRSwNP) is a significant subtype of
chronic rhinosinusitis (CRS), characterized by persistent inflammation of the
sinonasal mucosa and the presence of bilateral nasal polyps. Affecting approximately
1–4% of the adult population worldwide, CRSwNP is associated with marked
impairment in quality of life, sleep, olfaction, and general well-being [1].
The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 (EPOS
2020) emphasizes the role of underlying inflammatory mechanisms, classifying CRS
into phenotypes (observable features) and endotypes (molecular pathways), with
CRSwNP commonly linked to a type 2 immune response [2]. This subtype is typically
characterized by eosinophilic inflammation, elevated interleukins (IL-4, IL-5, IL-13),
and high serum IgE levels, particularly in patients with comorbid asthma or NSAID-
exacerbated respiratory disease (N-ERD) [3].
Despite the availability of medical and surgical interventions, CRSwNP
frequently recurs, with relapse rates of up to 60–70% within a few years following
endoscopic sinus surgery (ESS) [4]. The recent introduction of biologic therapies
targeting type 2 inflammatory pathways represents a shift in disease management, but
their optimal use requires accurate patient stratification.
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Epidemiology and Classification
CRSwNP typically emerges in the third to fifth decades of life, with a male-to-
female ratio of approximately 2:1. It is more prevalent in patients with asthma (up to
60%) and in those with N-ERD (15–25%) [5]. The disease is chronic by nature, with
symptoms persisting for more than 12 weeks and often extending over several years.
Classification frameworks
include:
EPOS 2020
: divides CRS into CRSwNP and CRS without nasal polyps
(CRSsNP), and further stratifies based on underlying inflammation.
ICAR-RS
(International Consensus Statement on Allergy and Rhinology –
Rhinosinusitis): emphasizes integration of clinical, radiologic, and endoscopic
findings.
Endotyping
: Eosinophilic vs. neutrophilic vs. mixed-type inflammation.
In our study, we used EPOS 2020 guidelines to confirm CRSwNP diagnosis and
differentiate type 2 (eosinophilic) and non-type 2 (neutrophilic or mixed)
inflammation, incorporating endoscopic scores, histology, and biomarkers.
Materials and Methods
Study Population
The study included 120 adult patients (aged 21–65 years) diagnosed with
bilateral CRSwNP at a tertiary care center between January 2023 and January 2024.
Inclusion criteria were based on EPOS 2020: presence of nasal obstruction, discharge,
hyposmia, and endoscopically confirmed bilateral polyps lasting ≥12 weeks.
Exclusion criteria: unilateral nasal polyps, cystic fibrosis, immunodeficiency, or
history of sinonasal tumors.
Parameters Evaluated
Demographics
: age, sex, smoking status
Comorbidities
: asthma, N-ERD
Symptoms
: severity of obstruction, anosmia, facial pressure (scored on VAS)
Endoscopy
: Lund-Kennedy score (0–12)
Imaging
: CT scan, Lund-Mackay score (0–24)
Biomarkers
: blood eosinophil count, total serum IgE
Histology
: inflammatory cell type in polyp tissue
Treatment
: INCS, short-term oral corticosteroids, ESS, biologics (dupilumab
in 28 patients)
Patients were followed over 12 months post-treatment. Symptom recurrence,
need for revision surgery, and response to biologics were recorded.
Results
1. Demographic and Clinical Characteristics
Out of 120 patients:
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Mean age
: 46.2 ± 10.1 years
Male:female ratio
: 1.8:1
Comorbid asthma
: 72 patients (60%)
N-ERD
: 20 patients (16.7%)
Active smokers
: 18 patients (15%)
Table 1. Clinical Profile of Patients with CRSwNP
Parameter
Value (n=120)
Mean age (years)
46.2 ± 10.1
Male sex
78 (65%)
Comorbid asthma
72 (60%)
N-ERD
20 (16.7%)
Elevated eosinophils (>0.3 × 10⁹/L)
88 (73%)
Elevated IgE (>100 IU/mL)
76 (63%)
Type 2 inflammation (histologically confirmed)
83 (69%)
2. Symptom Severity and Endoscopy Scores
Nasal obstruction
: reported as severe (VAS > 7) in 85% of patients
Olfactory loss (anosmia)
: reported in 92 patients (76.7%)
Mean Lund-Kennedy endoscopy score
: 6.8 ± 1.9
Mean Lund-Mackay CT score
: 17.3 ± 3.2
3. Treatment Modalities and Outcomes
Conventional Treatment (All Patients)
Intranasal corticosteroids (INCS)
: all 120 patients
Systemic corticosteroids
(short-term): 102 patients (85%)
o
Mean improvement in symptoms: 2.4 points on VAS
o
Duration of effect: ~6–8 weeks
Endoscopic Sinus Surgery (ESS)
Performed in 76 patients (63%)
Mean time to symptom recurrence:
9.5 months
Revision surgery required in 22 patients (29% of ESS group)
Biologic Therapy
Administered to 28 patients with uncontrolled, type 2 CRSwNP
Mean baseline eosinophils: 0.59 × 10⁹/L
Mean reduction in polyp score: 58% by week 24
Significant improvements in smell, congestion, and quality of life (SNOT-22)
Discussion
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The clinical course of CRSwNP in this cohort confirms the chronic, relapsing
nature of the disease, with a strong association with
type 2 inflammation
, asthma,
and N-ERD. The majority of patients (69%) exhibited eosinophilic endotype, in line
with global data suggesting a high prevalence of type 2 CRSwNP in Western and
Middle Eastern populations [6].
Predictors of Recurrence
Patients with:
Asthma
Elevated eosinophils
Higher initial polyp score
were significantly more likely to experience early recurrence following ESS,
indicating the need for adjunctive or alternative treatment strategies.
Efficacy of Biologics
Our analysis supports existing evidence that
dupilumab
is highly effective in
reducing symptom burden and polyp size in patients with type 2 inflammation. These
patients also had improved olfaction and quality of life, reinforcing the EPOS 2020
recommendation of biologics for severe, recurrent CRSwNP not controlled with
corticosteroids and surgery [2, 7].
Conclusion
This clinical study reinforces the importance of endotype-based diagnosis and
treatment in CRSwNP. While conventional therapy and surgery remain cornerstones
of management, a substantial subset of patients—particularly those with type 2
inflammation—benefit from targeted biologic therapies.
The use of international classification systems such as
EPOS 2020
, combined
with objective biomarkers (eosinophils, IgE) and imaging, enables a
personalized
medicine approach
, reducing the likelihood of recurrence and improving long-term
outcomes.
References
1.
Bachert C, Marple B, Schlosser RJ, et al. Adult chronic rhinosinusitis. Nat Rev
Dis Primers. 2020.
2.
Fokkens WJ, Lund VJ, Hopkins C, et al. EPOS 2020: European Position Paper
on Rhinosinusitis and Nasal Polyps. Rhinology. 2020.
3.
Stevens WW, Lee RJ, Schleimer RP, Cohen NA. Chronic rhinosinusitis
pathogenesis. J Allergy Clin Immunol. 2015.
4.
DeConde AS, Mace JC, Alt JA, et al. Predictors of revision sinus surgery. Int
Forum Allergy Rhinol. 2017.
5.
Laidlaw TM, Mullol J, Woessner KM, Amin N, Mannent LP. Biologics for nasal
polyps. J Allergy Clin Immunol Pract. 2021.
6.
Tomassen P, Vandeplas G, Van Zele T, et al. Inflammatory endotypes of
CRSwNP. J Allergy Clin Immunol. 2016.
7.
Han JK, Bachert C, Fokkens WJ, et al. Dupilumab in nasal polyposis. Lancet.
2019.
