At one year, surgery was minimally more effective than usual medical therapy. 

Chronic rhinosinusitis with nasal polyps (CRSwNP) is an eosinophilic inflammatory disease that is associated with significantly impaired quality of life due to severe congestion, nasal drainage, facial pain and pressure, and anosmia. It is frustrating for both patients and clinicians, because the lack of effective medical treatment frequently leads to endoscopic sinus surgery, with as many as 30% of surgery patients requiring further revisional surgeries.

In an open-label, pragmatic trial, 238 Dutch patients with CRSwNP were randomised to endoscopic sinus surgery with usual care or to usual medical care alone (typically, chronic nasal corticosteroids with saline rinses and short bursts of oral corticosteroids and antibiotics). After one year, improvement was statistically significantly, but not clinically significantly, better in the surgery group (a five-point difference on a 110-point rhinosinusitis-specific quality-of-life scale). A more robust 15-point difference between groups was noted at three months. A total of 23 patients in the medical group eventually required endoscopic sinus surgery.

Comment: This study confirms what we see in clinical practice: endoscopic sinus surgery gives good short relief of CRSwNP but improvement typically wanes over time. About half of all patients had uncontrolled symptoms after one year, with anosmia being most troublesome. Several monoclonal antibodies are US FDA approved for CRSwNP (anti-interleukin [IL]5, anti-IL4/13 and anti-IgE) but these cost as much as US$40,000 annually and are not disease modifying. In an accompanying editorial, the writer – an ear, nose and throat surgeon – was more impressed than I was, noting that this was the first randomised trial to show effectiveness of endoscopic sinus surgery for CRSwNP but also remarking that there is much room for improvement.
DAVID J. AMROL, MD
Associate Professor of Clinical Internal Medicine, Director of the Division of Allergy and Immunology, University of South Carolina School of Medicine, Columbia, USA.

Lourijsen ES, et al. Endoscopic sinus surgery with medical therapy versus medical therapy for chronic rhinosinusitis with nasal polyps: a multicentre, randomised, controlled trial. Lancet Respir Med 2022; 10: 337-346.
Hopkins C. Surgery and uncontrolled chronic rhinosinusitis. Lancet Respir Med 2022; 10: 315-317.

This summary is taken from the following Journal Watch title: General Medicine.