Medical Treatment of CRS Before Escalation to Endoscopic Sinus Surgery or Biologics: A Critical Scoping Review

Abstract

Chronic rhinosinusitis (CRS) is a heterogeneous inflammatory disease in which medical treatment should be tailored to endotype, disease severity, and patient-specific factors. This review examines the evidence supporting medical therapy before escalation to endoscopic sinus surgery or biologics. Intranasal corticosteroids and saline irrigations remain the foundation of treatment. Short courses of systemic corticosteroids may provide temporary benefit in CRS with nasal polyps, but repeated exposure should be limited because of severe cumulative adverse effects. Evidence for prolonged systemic antibiotic therapy in CRS is inconsistent, and specifically long-term macrolides should not be considered a universal prerequisite before treatment escalation, particularly in type 2 inflammatory disease. Topical antibiotics may be useful in selected postoperative patients, while antihistamines and allergen immunotherapy should be reserved for patients with clinically relevant allergic disease rather than sensitization alone. Appropriate medical therapy should therefore reflect treatments with demonstrated benefit for the individual patient's endotype and characteristics, rather than require sequential failure of all available options. In patients with persistent uncontrolled disease, escalation to surgery or biologics should be guided by disease characteristics, comorbidities, prior treatment, treatment burden, and patient preference.

The authors' abstract, as published at the source. The Journal of Allergy and Clinical Immunology In Practice, 2026 · DOI ↗