Rewriting the Rules of Rhinosinusitis

Individualized Surgical Planning

The 2025 clinical practice guidelines for the surgical management of CRS underscore the fact that there is “no predefined, one-size-fits-all regimen that is a prerequisite to sinus surgery,” said Jennifer Shin, MD, SM, a surgeon at Mass General Brigham and chair of the surgical guideline development group.

According to the guidelines, otolaryngologists should identify which adult CRS patients are most likely to benefit from surgery and least likely to benefit from continued medical therapy— a group that includes patients with nasal polyps, polyps with bony erosion, eosinophilic mucin, or fungal balls. Surgeons should offer sinus surgery when the anticipated benefits exceed those of nonsurgical management alone—and the patient has a good understanding of both anticipated outcomes and the need for long-term disease management post-surgery (Otol Head Neck Surg. 2025;172(S2):S1–S47). You can find a patient information checklist detailing expectations for sinus surgery on the AAO–HNSF website; the document makes it easy to discuss and clarify likely outcomes (https://tinyurl.com/3emehnew).

The surgical guidelines further state that surgeons should not plan sinus surgery based solely on a single criterion for the degree of mucosal thickening. Instead, “it’s more helpful to really think about your patient’s disease process and how it all fits together within a more holistic picture—what treatments can be of benefit overall, what medicines may or may not have been effective, and whether a recent acute episode might alter a given scan,” Dr. Shin said.

Shared Decisions, Better Outcomes

Imagine, for a moment, how confusing the treatment landscape must be for patients who are uncomfortable and who see and hear commercials for biologic medication and balloon sinus dilation, patients who are looking for relief and keeping an eye on their deductible and out-of-pocket expenses.

“When you increase the options for managing any disease beyond two or three options, it can get really overwhelming for a patient,” Dr. Turner said. Most patients don’t understand the pathophysiology of sinusitis; few know that inflammation is likely the underlying cause of chronic rhinosinusitis. So, although it can be time-consuming, it’s essential for otolaryngologists to educate patients about their condition and treatment options.

The AAO–HNSF website contains patient-focused documents physicians can use to educate patients about the medical and surgical management of sinusitis. Conversation will be required, however, to understand individual patients’ goals, opportunities, and limitations.

When biologic medications are an option, physicians and patients must consider the potential effectiveness of biologics as well as the risk of side effects and cost–benefit ratio. “You have to view the patient as a whole to figure out which particular therapeutic or combination of therapeutics will be most effective for that individual,” Dr. Turner said. “There are some patients with nasal polyps who we recognize as likely to do very well with surgery, with a very low likelihood of needing a revision procedure or long-term medical management. It can be a real disservice to those patients, I think, to put them on a very expensive biologic, a medication for which we don’t yet have a full understanding of what the long-term effects will be, if they could have a good outcome with a well-done surgery.”