A Focus on Chronic Rhinosinusitis with Nasal Polyposis: Leaving Aside Endoscopic Surgery, a Step towards Biologic Therapies. This is the title of the study published in the Journal of Otolaryngology, which was attended by several specialists of Humanitas, such as Dr. Luca Malvezzi, Dr. Matteo Ferrando, Dr. Francesca Puggioni, Professor Enrico Heffler and Professor Giorgio Walter Canonica.

As Dr. Luca Malvezzi, specialist in Otorhinolaryngology and Facial Cervical Surgery in Humanitas explains: “Chronic rhinosinusitis with and without nasal polyposis is a complex disease. In 2017, the mistake of underestimating recurrent or chronic airway inflammation should no longer be made, by labeling it as a simple cold or seasonal illness when the upper airways are involved, tracheitis or bronchitis when the lower airways are involved.

In particular, chronic rhinosinusitis with or without nasal polyposis, as well as being characterized by a high incidence is frequently related to asthma and allergic rhinitis. In the face of these close correlations between the upper and lower respiratory tract, patients with these diseases suffer from sleep disorders, eye symptoms and fluctuating disturbances of sound perception, referring to the classic ear padding, at a not insignificant rate. These patients therefore have a complex clinical and symptomatological picture, with a significant negative impact on quality of life in terms of absence from the world of work, reduced school performance, reduced attention and concentration (including driving their own vehicles), reduced social activity, including sexual activity. In short, a disease with an impact on the quality of life and social aspects is not irrelevant also in terms of public expenditure”.


The importance of multidisciplinary management

“Rhinosinitis is still an underestimated disease, even in the specialist field, and has insufficient capacity for multidisciplinary management. In fact, if it is relatively simple to diagnose a rhinosinusitis, it is often sufficient to collect a meticulous history and endoscopic clinical examination of the upper pathways, the role of the specialist today must be to phenotype the disease. The specialist must initiate a multidisciplinary study and management process involving an allergist and pulmonologist to clarify the presence of comorbidities such as allergy and asthma, must research the epithelium of the airways for respiratory, biological, and immunological characteristics of the disease, so as to offer the patient the most appropriate medical treatment in relation to the characteristics of the same. We must increasingly personalize medical treatment by applying so-called precision medicine,” Dr. Malvezzi stresses.


The role of surgery

“Today, the gold standard in the surgical treatment of chronic rhinosinitis with and without nasal polyps is represented by rhinosinus endoscopic surgery, which has developed technologically and is becoming more and more widespread worldwide. We can offer patients surgical treatments with extraordinarily advanced technological instruments, but we are not yet able, as regards to rhinosinusitis with nasal polyposis, to guarantee the full recovery from the disease. This is easily understood by the number of visits for nasal polyposis and by the frequent poor control of symptoms.

However, we must not fall into the trap of treating a disease, such as nasal polyposis, without caring for the patient. It is clear that rhinosinusitis surgery will still have a significant place in the future, as these diseases are an indication for surgical treatment. However, the effort we must now aim to make is to define the why, when and how of medical treatment, a treatment that must be preceded by a clinical study that guides the choice of treatment. Identifying the immunological characteristics of rhinosinusitis with or without nasal polyps means having a clear picture of the natural evolutionary history of the disease, even in thermals that tend to relapse. It also means that the surgical procedure can be modulated to suit the biological characteristics of the individual – not just the pathology, which we will treat,” the specialist explains.


Biological medicines

“It is important to be able to offer the patient a therapeutic alternative to surgery. It means offering a different drug treatment from the usual one and often repeated cortisone treatment, which should play an increasingly limited role, particularly in certain age groups and patients at risk.

In the modern era, biological medicines are the new therapeutic frontier. So today thanks to the growing interest in the immunological bases that characterize the remodeling of the mucous membrane of nasal pits, paranasal sinuses and the lower respiratory tract, and thanks to some more knowledge about the pathophysiological mechanisms that regulate inflammation and to the novelties in the pharmacological field, we have a different therapeutic choice, focused on biological therapies (as in the case of monoclonal antibodies) to dominate for example forms of chronic rhinosinitis with more severe nasal polyps, characterized by association with asthma, hypereosinophilia, and intolerance to acetyl salicylic acid. This new therapeutic choice has forced us to reflect on the role of endoscopic rhinosinus surgery, which today needs to be completely re-thinkable.

Monoclonal antibodies are drugs that modulate inflammation and in particular the replication and proliferation of those cells that dominate inflammation by amplifying and reproducing it, for example eosinophils,” the specialist points out.


The role of precision medicine

“Precision medicine must be the only medicine, the recommended medicine to be proposed in 2017 and in the future to each patient because the results show that this is the decisive path for patients who present the reappearance of the disease after treatment or before undergoing surgery,” concludes Dr. Malvezzi.