Dupilumab Improves Facial Pain and Reduces Rescue Treatments in Patients with CRSwNP and Recalcitrant Frontal Sinusitis

Abstract

Recalcitrant frontal sinusitis in patients with chronic rhinosinusitis and nasal polyps (CRSwNP) has a negative impact on their quality of life due to frontal pain and a high risk of sinus occlusion, thus necessitating antibiotics, systemic corticosteroids, and multiple surgeries. The aim of this study was to assess the efficacy of dupilumab in reducing frontal pain and the need for rescue treatments for recalcitrant frontal sinusitis in patients with CRSwNP. We enrolled a cohort of 10 patients with severe uncontrolled CRSwNP and concomitant recurrent frontal sinusitis associated with severe facial pain measured by MIDAS score who were treated with dupilumab 300 mg every 2 weeks and followed for at least 12 months. The mean MIDAS score decreased from 45.6 ± 10.7 at baseline to 1.3 ± 2.3 at 6 months (p < 0.05). VAS craniofacial pain decreased from 7.3 ± 1.6 at baseline to 1.2 ± 1.5 at 6 months (p < 0.05). No patient needed oral corticosteroids during treatment with dupilumab (p < 0.05), and the use of analgesics decreased from 9.6 ± 3.1 NSAID pills/week in the last 2 months at baseline to 0.6 ± 1.3 at 1 year of follow-up (p < 0.05). Our results demonstrated that use of subcutaneous dupilumab can improve symptom control, including recurrent severe cranio-facial pain, and reduce the need for rescue medical treatments (systemic steroids and NSAID) in patients with severe uncontrolled CRSwNP and concomitant recurrent frontal sinusitis.

Keywords: biologics; chronic rhinosinusitis; endoscopic sinus surgery; frontal sinusitis; headache; nasal polyps; oral corticosteroids.

Figure 1

A 56-year-old man with 2 previous endoscopic sinus surgeries (1 ESS in 2016 and ESS + Draft 3 in 2019). One major complication during the last surgery (skull base CSF leak in ethmoid that was intraoperatively repaired). Recurrence of NP diagnosed in March 2022 with re-stenosis of the left frontal sinus with severe facial pain. Complete disappearance of polyps after three months of dupilumab administration with resolution of facial pain after 3 months. (A) Endoscopic view of the left osteomeatal complex with preserved middle turbinate. (B) Endoscopic view after 1 month of treatment. (C) Left frontal recess after 2 months of treatment. (D) Left frontal recess after 3 months of treatment. (E) Residual right middle turbinate. (F) Right frontal recess after 1 month of treatment. (G) Right frontal recess after 2 months of treatment. (H) Right frontal recess after 3 months of treatment.

Figure 2

A 53-year-old man with medical history of multiple long-lasting cycles of oral corticosteroid in the last few years (>60 cumulative days/year) and previous treatment with mepolizumab. The patient had undergone six previous surgeries including a bilateral Draft 2b. In April 2022, recurrence of NP associated with severe facial pain was diagnosed. Complete resolution of pain and disappearance of polyps after 6 months of treatment with dupilumab. (A) Recurrence of nasal polyps in left frontal recess. (B) Left frontal recess view after 3 months of treatment. (C) Left frontal recess view after 6 months of treatment. (D) Left frontal recess view after 12 months of treatment. (E) Recurrence of nasal polyps in right frontal recess. (F) Right frontal recess view after 3 months of treatment. (G) Right frontal recess view after 6 months of treatment. (H) Right frontal recess view after 12 months of treatment.

Figure 3

A 62-year-old woman with NSAID-ERD and medical history of multiple brief cycles of OCS in the last few years (>52 cumulative days/year). The patient had recalcitrant frontal sinusitis associated with invalidating frontal pain. Two previous surgeries including an external bicoronal approach to the frontal sinus and reconstruction with custom-made prosthesis. Diagnosis of recurrence of nasal polyps and mucocele was made in January 2023. After 12 months of dupilumab, the mucocele and nasal polyps had resolved. Herein we report the results after 12 months of treatment. (A1–A3) Pre-treatment CT-SCAN, complete opacification of the frontal sinuses ((A1) Sagittal view. (A2) Axial view. (A3) Coronal view). (B1–B3) Pre-treatment MRI showing recurrence of the nasal polyposis and frontal mucocele ((B1) Coronal view. (B2) Axial view. (B3) Sagittal view). (C1,C2) Post-treatment CT showing pneumatization of the frontal sinuses ((C1) Axial view. (C2) Sagittal view). (D) Pre-treatment endoscopic view. (E) Post-treatment endoscopic view.