Rewriting the Rules of Rhinosinusitis

“Subjecting patients to three or four weeks of antibiotics simply to get a scan or surgery is putting patients at risk,” Dr. Payne said. “We wanted to provide physicians with guidelines they can use to defend their decisions.”

To support otolaryngologists in implementing this guideline, the AAO– HNSF has created a template appeal letter (https://tinyurl.com/mt64b56x) that physicians can customize and submit if they receive a denial of approval for a CT scan of the paranasal sinuses for a patient who hasn’t received antibiotics for chronic sinusitis. The letter can be downloaded from the AAO– HNSF website and adapted as needed.

Dr. Payne has already submitted at least one appeal featuring a copy of the 2025 guidelines after receiving a denial for sinus surgery. At press time, he was still awaiting a response.

Biologics in Balance

Biologic medications have been a breakthrough in modern medicine, transforming the treatment of chronic, immune-mediated diseases. The 2015 adult sinusitis clinical practice guidelines did not address biologics, as the U.S. Food and Drug Administration (FDA) did not approve a biologic medication to treat adult CRS until 2019 (AJMC. https://tinyurl.com/j52uexrj).

At present, four biologics— dupilumab, omalizumab, mepolizumab, and tezepelumab—are FDA-approved to treat adult CRS with nasal polyps. The new guidelines state that, in most cases, biologics should only be used in adults with polyps; however, if a patient has multiple inflammation-mediated medical conditions, biologic therapy may be appropriate even in the absence of prior surgery for nasal polyps.

“If somebody comes in with eczema, eosinophilic esophagitis, and sinusitis, instead of treating all three of those organ systems separately, it may make more sense to treat them all with a biologic,” Dr. Payne said.

Right now, biologics are “probably being overused by non-otolaryngologists and underused by otolaryngologists,” Dr. Payne said. “Pulmonologists or allergists who are confronted with a patient with severe sinusitis and severe asthma may be more inclined to start them on a biologic, while an otolaryngologist may be more inclined to offer more surgery or more steroids (oral or topical) instead of a biologic, because that’s a higher level of complicated medical therapy that may be outside the physician’s comfort zone.”

Learning more about the appropriate use of biologic therapy to manage CRS with nasal polyps may help otolaryngologists more effectively treat this population.

But most adults who have CRS with nasal polyps do not need biologics. Most will do well with surgery and topical therapy, Dr. Bleier said. That approach “induces the most rapid improvement in symptoms and is the most cost-effective,” he said. It also precludes the possibility of systemic side effects.