“A Focus on Chronic Rhinosinusitis with Nasal Polyposis: Leaving Aside Endoscopic Surgery, a Step towards Biologic Therapies”. This is the title of a study that was published on the Journal of Otolaryngology, written by Doctor Luca Malvezzi, Doctor Matteo Ferrando, Doctor Francesca Puggioni, Professor Enrico Heffler, Professor Giorgio Walter Canonica and other specialists of Humanitas.

As Doctor Luca Malvezzi, otolaryngologist and head-and-neck surgeon at Humanitas, explains, “Chronic rhinosinusitis, with or without sinus polyps, is a complex disease. We should not make again the mistake of underestimating recurrent or chronic inflammations of the airway, labeling them as a simple cold or seasonal sickness (upper airway), or bronchitis (lower airway).

Chronic rhinosinusitis in particular, with or without sinus polyps, is both characterized by a high incidence and frequently correlated to asthma and allergic rhinitis. Due to these close links between upper and lower airway, patients who suffer from these common diseases also have sleep disorders, ocular symptoms and recurrent hearing disorders (they report hearing muffled sounds). Thus, these patients have complex symptoms and issues that impact negatively on their quality of life. They can’t do many jobs, perform poorly at school, have issues in concentrating (for instance, also when driving their cars), have a limited social and sexual life. In sum, this is a severe disease in terms of personal and social life, and it also affects the national public expenditure to a great extent”.

The importance of a multidisciplinary management

“Rhinosinusitis is still an underestimated disease (also among specialists), and it is rarely treated in a multidisciplinary way. In fact, it’s relatively easy to diagnose a rhinosinusitis (the patient’s entire medical history and the endoscopic clinical exam of the upper airway are enough). However specialists should phenotype diseases. Moreover, specialists should start a study and multidisciplinary treatment course involving allergy experts and pneumologists in order to ascertain the presence of asthma or allergies. They should also look for the biological and immunological characteristics of the disease in the skin of the airway in order to personalize the medical treatment according to the needs of each patient. We should personalize our medical approach by applying the so-called precision medicine”, Doctor Malvezzi points out.

The role of surgery

“Nowadays the gold standard for the surgical treatment of chronic rhinosinusitis with or without sinus polyps is set by rhinosinusal endoscopic surgery. It is technologically advanced and well-known all over the world. We can offer surgical treatments with extraordinarily advanced technological tools to our patients, but we are still unable to make sure they will completely recover from rhinosinusitis with sinus polyps. In fact, the great number of patients who require another surgery for their polyps, and the lack of strict control over the symptoms, makes it easy to believe.

However, we should not make the mistake of treating a disease (sinus polyps) without caring for patients themselves. It’s obvious that, in the future, rhinosinusitis surgery will still play a big role. These diseases are particularly suitable for surgery. However, we should strive to define why, when and how patients require medical attention. In order to point therapies in the right direction, a clinical study path should precede treatments. Pinpointing the immunological characteristics of rhinosinusitis (with or without sinus polyps) means knowing in advance the natural evolution of the disease and its tendency to come back again. Thus, it also determines the possibility of modulating the surgical approach, customizing it according to the biological characteristics of the single patient – not just the disease’s ones”, the specialist points out.

Biological medications

“It’s important to give patients a therapeutic alternative to surgery. It means offering a pharmacologic treatment that is different from the old, typical cortisone treatment, whose use should be limited (especially in some age ranges and for patients at risk).

Nowadays, the new therapeutic frontier is the use of biological medications. Thus, thanks to the growing curiosity for the immunological basis of the remodeling of the mucous membrane found inside the nose, sinuses and the lower airway, thanks to progresses in the knowledge about the mechanisms that regulate inflammations, and also thanks to pharmacological developments, we are able to choose among different therapies and to perform biological therapies (for example, monoclonal antibodies). For instance, we can now treat the most severe cases of chronic rhinosinusitis with sinus polyps, associated with asthma, hypereosinophilia and intolerance to acetylsalicylic acid. This new therapeutic choice forced us to think about the new role of rhinosinusal endoscopic surgery.

Monoclonal antibodies are medications that modulate the inflammation and, in particular, the replication and proliferation of those cells (for example, eosinophils) that amplify and reproduce the inflammation”, the specialist points out.

The role of precision medicine

“Precision medicine should be the only medicine to be performed from now on. The results have shown that this choice is the ultimate one for patients that suffer again from the disease after the treatment or before undergoing surgery”, Doctor Malvezzi says.