Page 18 - Portuguese Journal - SPORL - Vol 61. Nº2

surgery (ESS) should be considered in patients optimized pharmacological treatment fails, an
with CRS with:
• Lund-Mackay score ≥ 1 and
• At least eight weeks of treatment with nasal
topical corticosteroid and
o Short course of systemic corticosteroid or
o Short course of systemic broad-spectrum
antibiotic after culture or
o Long course of a low-dose systemic
antibiotic with anti-inflammatory action.
• Total SNOT-22 score ≥ 20 despite
pharmacological treatment.
It should be emphasized that CRS is a chronic
disease and that ESS is a therapeutic modality
that aims to create the ideal anatomic conditions
for topical corticosteroids to act. According
to the literature, in chronic type-2 bilateral
diffuse rhinosinusitis, the surgical approach
may vary from simple polypectomy (removal
of polyps from the nasal cavity) to the opening
of the paranasal sinuses (maxillary approach
and complete frontosphenoethmoidectomy),
often called “full-house FESS”. Another type of
surgical approach (more aggressive) includes
the removal of the entire sinus mucosa
(reboot surgery). The choice of the type of
surgical approach depends on the surgeon’s
preference; however, the efficacy in terms
of recurrence is generally higher for more
aggressive procedures 16-18 .
Continuous topical treatment is mandatory
after surgery. If surgery combined with
Figure 2
Indications for endoscopic sinus surgery
160 Portuguese Journal of Otorhinolaryngology - Head and Neck Surgery
alternative treatment should be considered,
namely the use of biologic agents (monoclonal
antibodies). Three biologic drugs are currently
available in Portugal for different diseases with
type 2 inflammation: anti-immunoglobulin
E (IgE): omalizumab; anti-IL-5/IL-5 receptor
(IL-5R): mepolizumab; and anti-interleukin
4 receptor (IL4R): dupilumab. Dupilumab
received marketing authorization (MA) in
2019, supported by the LIBERTY NP SINUS-24
and -52 studies; omalizumab obtained MA
for uncontrolled CRS with polyposis in 2020,
supported by the POLYP 1 and POLYP 2 studies;
and mepolizumab has MA since January 2022,
based on the SYNAPSE study. Clinical trials
have also been conducted with reslizumab
and benralizumab, but they are currently not
approved for this indication. The three biologic
agents indicated for the treatment of CRS with
polyposis were evaluated for their efficacy and
safety in adult patients:
• Omalizumab: anti-IgE monoclonal antibody
approved in the European Union and United
States for the treatment of severe allergic
asthma . Given the high levels of total IgE
19
in nasal secretions, polyps, and serum of
patients with CRS with polyposis, combined
with its relevance in patients with allergic
asthma, omalizumab has been evaluated
as a potential treatment for the subgroup
of patients with CRS with polyposis and
comorbid asthma. In addition, eosinophilia