Expert Consensus on Surgical Management of Primary Diffuse Type 2-Dominant Chronic Rhinosinusitis

Manon Blauwblomme¹, Christos Georgalas^{2

3}, Shahzada Ahmed⁴, Isam Alobid⁵, Paolo Battaglia^{6

7}, Paolo Castelnuovo^{8

7}, Jannis Constantinidis⁹, Iacopo Dallan^{7

10}, Anne-Sophie Eeckels¹, Marco Ferrari¹¹, Philippe Gevaert¹, Jessica Grayson¹², Richard Harvey^{13

14}, Philippe Herman¹⁵, Iordanis Konstantinidis⁹, Darlene Lubbe¹⁶, Cem Meco^{17

18

19

20}, James Palmer²¹, Zara M Patel²², Agnieszka Strzembosz²³, Benjamin Verillaud¹⁵, Bradford A Woodworth¹², Thibaut Van Zele¹

Affiliations

¹ Department of Otorhinolaryngology, Ghent University Hospital, Ghent, Belgium.
² Department of Otorhinolaryngology Head and Neck Surgery, University of Nicosia Medical School, Nicosia, Cyprus.
³ Endoscopic Skull Base Centre Athens, Hygeia Hospital, Athens, Greece.
⁴ Department of ENT and Skull Base Surgery, Birmingham Hospital, Birmingham, UK.
⁵ ENT Department, Rhinology and Skull Base Unit, Hospital Clínic de Barcelona, Universitat de Barcelona, August Pi i Sunyer Biomedical Research Institute, CIBERES, Barcelona, Spain.
⁶ Department of Otolaryngology Head and Neck Surgery, Department of Biotechnology and Life Sciences, ASST Lariana, Ospedale Sant'Anna, University of Insubria, Varese, Italy.
⁷ Head and Neck Surgery and Forensic Dissection Research Center (HNS&FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy.
⁸ Department of Otorhinolaryngology Head and Neck Surgery, Department of Biotechnology and Life Sciences, Ospedale di Circolo e Fondazione Macchi, ASST Sette Laghi, University of Insubria, Varese, Italy.
⁹ Department of Otorhinolaryngology Head and Neck Surgery Department, Aristotle University of Thessaloniki, Papageorgiou Hospital, Thessaloniki, Greece.
¹⁰ Skull Base and Rhino-Orbital Surgery Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy.
¹¹ Section of Otorhinolaryngology Head and Neck Surgery, Department of Neurosciences, University of Padua, Padua, Italy.
¹² Department of Otolaryngology, University of Alabama Birmingham, Birmingham, Alabama, USA.
¹³ Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia.
¹⁴ Department of Otolaryngology, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.
¹⁵ Department of Head and Neck Surgery, Université Paris Cité, Lariboisière Hospital, Paris, France.
¹⁶ Division of Otolaryngology, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa.
¹⁷ Department of Otolaryngology Head and Neck Surgery, Ankara University Medical School, Ankara, Turkey.
¹⁸ Department of Otolaryngology Head and Neck Surgery, Salzburg Paracelsus Medical University, Salzburg, Austria.
¹⁹ Department of Otolaryngology Head and Neck Surgery, Weill Cornell Medical College, Cornell University, New York, New York, USA.
²⁰ Department of Clinical Anatomy, Institute of Health Sciences, Ankara University, Ankara, Turkey.
²¹ Department of Otolaryngology Head and Neck Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
²² Department of Otolaryngology Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, USA.
²³ Otorhinolaryngology Division, Department of Surgery, Medicover Hospital, Warsaw, Poland.

PMID: 39927867
PMCID: PMC11872782
DOI: 10.1002/alr.23538

Review

Expert Consensus on Surgical Management of Primary Diffuse Type 2-Dominant Chronic Rhinosinusitis

Manon Blauwblomme et al. Int Forum Allergy Rhinol. 2025 Mar.

. 2025 Mar;15(3):303-316.

doi: 10.1002/alr.23538. Epub 2025 Feb 10.

Authors

Affiliations

¹ Department of Otorhinolaryngology, Ghent University Hospital, Ghent, Belgium.
² Department of Otorhinolaryngology Head and Neck Surgery, University of Nicosia Medical School, Nicosia, Cyprus.
³ Endoscopic Skull Base Centre Athens, Hygeia Hospital, Athens, Greece.
⁴ Department of ENT and Skull Base Surgery, Birmingham Hospital, Birmingham, UK.
⁵ ENT Department, Rhinology and Skull Base Unit, Hospital Clínic de Barcelona, Universitat de Barcelona, August Pi i Sunyer Biomedical Research Institute, CIBERES, Barcelona, Spain.
⁶ Department of Otolaryngology Head and Neck Surgery, Department of Biotechnology and Life Sciences, ASST Lariana, Ospedale Sant'Anna, University of Insubria, Varese, Italy.
⁷ Head and Neck Surgery and Forensic Dissection Research Center (HNS&FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy.
⁸ Department of Otorhinolaryngology Head and Neck Surgery, Department of Biotechnology and Life Sciences, Ospedale di Circolo e Fondazione Macchi, ASST Sette Laghi, University of Insubria, Varese, Italy.
⁹ Department of Otorhinolaryngology Head and Neck Surgery Department, Aristotle University of Thessaloniki, Papageorgiou Hospital, Thessaloniki, Greece.
¹⁰ Skull Base and Rhino-Orbital Surgery Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy.
¹¹ Section of Otorhinolaryngology Head and Neck Surgery, Department of Neurosciences, University of Padua, Padua, Italy.
¹² Department of Otolaryngology, University of Alabama Birmingham, Birmingham, Alabama, USA.
¹³ Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia.
¹⁴ Department of Otolaryngology, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.
¹⁵ Department of Head and Neck Surgery, Université Paris Cité, Lariboisière Hospital, Paris, France.
¹⁶ Division of Otolaryngology, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa.
¹⁷ Department of Otolaryngology Head and Neck Surgery, Ankara University Medical School, Ankara, Turkey.
¹⁸ Department of Otolaryngology Head and Neck Surgery, Salzburg Paracelsus Medical University, Salzburg, Austria.
¹⁹ Department of Otolaryngology Head and Neck Surgery, Weill Cornell Medical College, Cornell University, New York, New York, USA.
²⁰ Department of Clinical Anatomy, Institute of Health Sciences, Ankara University, Ankara, Turkey.
²¹ Department of Otolaryngology Head and Neck Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
²² Department of Otolaryngology Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, USA.
²³ Otorhinolaryngology Division, Department of Surgery, Medicover Hospital, Warsaw, Poland.

PMID: 39927867
PMCID: PMC11872782
DOI: 10.1002/alr.23538

Abstract

Background: Chronic rhinosinusitis (CRS) poses significant challenges in surgical management due to the lack of clear guidelines, particularly in type 2 CRS. This review focuses on surgical approaches for primary diffuse type 2-dominant CRS, emphasizing preoperative and intraoperative strategies.

Methods: A consensus group, comprising experts from Europe, United Kingdom, Australia, South Africa, North and South America, was assembled. Using a modified Delphi method, 67 statements were formulated following a literature review, with an additional statement added in the second iteration. Final recommendations were discussed during a consensus meeting in Santorini, Greece, in October 2023.

Results: Out of the 68 proposed statements, consensus was achieved on 45. Most (34) statements received a median score of 7 (strongly agree), and 11 had a median score of 6 (agree). The finalized recommendations cover the indications, timing, extent of surgery, and intraoperative management for both primary and revision surgery in primary diffuse type 2-dominant CRS. A key focus is on complete sinus surgery, which involves creating a neo-sinus cavity by removing bone partitions in the ethmoid and opening the frontal and sphenoidal sinuses as needed. Adequate primary and revision surgery includes clearing all nasal polyps and diseased mucosa while ensuring ideal conditions for topical therapy. Additionally, there was consensus on performing complete sinus surgery before considering monoclonal antibody therapies, unless contraindicated.

Conclusion: These 45 consensus statements, derived from both current evidence and expert opinion, provide valuable guidance for clinicians in the surgical management of primary diffuse type 2-dominant CRS.

Keywords: Delphi method; consensus statements; endoscopic sinus surgery; extent of surgery; nasal polyps; revision surgery.

PubMed Disclaimer

Conflict of interest statement

M. Blauwblomme has received research grants/support from GSK and Sanofi. C. Georgalas has received honoraria for consultancy and conferences from GSK, Olympus, and Medtronic. I. Alobid has received honoraria for consultancy and conferences from AstraZeneca, Viatris, Roche, Sanofi, GSK, MSD, Menarini, Storz, Olympus, Metronic, Salvat, and Novartis. J. Constantinidis has received honoraria for consultancy from GSK. I. Konstantinidis has served as a speaker and received grant/research support from GSKB. Verillaud has received personal fees as an invited speaker from Amplifon, Collin, GSK, Medtronic, Mylan, and Sanofi Genzyme. P. Gevaert has served as an advisor or speaker and received grant/research support from ALK, GSK, Lilly, Novartis, Regeneron, Roche, Sanofi, and Stallergenes‐Greer. Z. M. Patel has served as an advisor/consultant for Medtronic, Optinose, Dianosic, Wyndly, and Mediflix, and holds equity in Olfera Therapeutics and SoundHealth. T. Van Zele has received honoraria for consultancy from Medtronic. The other authors have no conflicts of interest.

Figures

**FIGURE 1**
Flowchart depicting the iterative process of consensus development. The first two iteration reflects the formulation of 67 initial statements, followed by a second iteration where an additional statement was added. The third iteration represents the consensus meeting held in Santorini, Greece, in October 2023. The fourth iteration represents the final round, where 45 statements achieved consensus. The approved statements from each iteration are highlighted, illustrating the progression toward achieving expert agreement.

See this image and copyright information in PMC

References

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1. Grayson J. W., Hopkins C., Mori E., Senior B., and Harvey R. J., “Contemporary Classification of Chronic Rhinosinusitis Beyond Polyps vs No Polyps: A Review,” JAMA Otolaryngology – Head & Neck Surgery 146, no. 9 (2020): 831–838, 10.1001/jamaoto.2020.1453. - DOI - PubMed
1. Bachert C., Marple B., Schlosser R. J., et al. “Adult Chronic Rhinosinusitis.” Nature Reviews Disease Primers 2020;6(1):86. 10.1038/s41572-020-00218-1. - DOI - PubMed
1. Fokkens W. J., Viskens A. S., Backer V., et al., “EPOS/EUFOREA Update on Indication and Evaluation of Biologics in Chronic Rhinosinusitis With Nasal Polyps 2023,” Rhinology 61, no. 3 (2023): 194–202, 10.4193/Rhin22.489. - DOI - PubMed
1. Orlandi R. R., Kingdom T. T., Smith T. L., et al., “International Consensus Statement on Allergy and Rhinology: Rhinosinusitis 2021,” International Forum of Allergy & Rhinology 11, no. 3 (2021): 213–739, 10.1002/alr.22741. - DOI - PubMed

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Expert Consensus on Surgical Management of Primary Diffuse Type 2-Dominant Chronic Rhinosinusitis

Affiliations

Expert Consensus on Surgical Management of Primary Diffuse Type 2-Dominant Chronic Rhinosinusitis

Authors

Affiliations

Abstract

Conflict of interest statement

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References

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Medical