Endoscopic Sinus Surgery versus Optimized Medical Treatment in Chronic Rhinosinusitis with Nasal Polyps: A Systematic Review

Abstract

Introduction:
Chronic rhinosinusitis with nasal polyps is a chronic inflammatory condition of the sinonasal mucosa that severely affects patients’ quality of life. Management strategies include optimized medical treatment, consisting of intranasal corticosteroids, short courses of systemic corticosteroids, saline irrigations, and more recently biologic therapies, as well as surgical intervention, primarily functional endoscopic sinus surgery. The relative benefits and risks of each approach remain debated.

Objectives:
To systematically review the evidence comparing endoscopic sinus surgery with optimized medical treatment in adult patients with chronic rhinosinusitis with nasal polyps, with a focus on efficacy and safety outcomes.

Data Synthesis:
A systematic search was performed in PubMed, Scopus, Web of Science, Cochrane Library, and SciELO up to May 2025, restricted to English, Spanish, and Portuguese. Randomized controlled trials, prospective cohort studies, and systematic reviews comparing surgery with medical treatment were included. Four key sources were identified: two Cochrane systematic reviews (systemic and intranasal corticosteroids), one randomized controlled trial of intranasal corticosteroids after surgery, and one multicenter randomized trial comparing surgery plus medical therapy with medical therapy alone. Evidence demonstrates that short courses of systemic corticosteroids improve symptoms for 2–3 weeks but lack sustained benefit at 3–6 months, while intranasal corticosteroids provide moderate improvements in nasal obstruction and rhinorrhea with an increased risk of mild epistaxis. Endoscopic sinus surgery consistently improves symptom scores and polyp burden in patients refractory to medical therapy, with recent evidence showing superior outcomes when combined with biologic therapy.

Conclusion:
Optimized medical therapy provides important short-term benefits, whereas surgery offers durable symptom and structural improvements in refractory patients. Combination approaches, including biologic therapies, may enhance outcomes. High-quality randomized trials with long-term follow-up are needed to guide personalized treatment strategies.