To the EditorIn 2022, a group of clinician scientists working in the field of research in chronic rhinosinusitis with nasal polyps (CRSwNP), came together under the auspices of the European Academy of Allergy and Clinical Immunology (EAACI) to achieve greater clarity with respect to scoring of nasal polyp size and published the definitions in a Position Paper (PP)1. Before this initiative, several scoring systems had previously been described. However, the lack of standardisation across their application in research trials and clinical practice prevented comparison and led to inter-rater variability2. Our aim was therefore to propose a unified scoring system with high validity and reproducibility. The system we devised is already being widely utilised in both randomised controlled trials and real-life registries evaluating the effectiveness of CRSwNP treatment3-6.A recent trial investigator meeting highlighted the benefits of this standardised approach, however one area of ambiguity was identified which needs clarification.In the position paper we stated that where the middle turbinate is not visible and no assessment can be made regarding whether nasal polyps are located medial or lateral to it, provided the nasal polyps can be seen to come below the level of upper margin of the inferior turbinate they will be scored 2, unless they reach the lower limit of the inferior turbinate (Nasal Polyp Score (NPS) 3) or the floor (NPS4)1.This was intended to be applied only when anatomical features such as a septal deviation prevent the view of the middle turbinate. (Figure 1)However, in the case that the middle turbinate is not visible due to the presence of a single or multiple nasal polyps completely obstructing visualisation and further passage of the endoscope, such that it is not possible to assess whether nasal polyps are located medial or lateral to the middle turbinate, then this will be scored as 3, provided the lower limit extends below the reference line of the upper margin of the inferior turbinate, or 4 if the nasal polyps reach the floor of the nose. (Figure 1)This requires further clarification, as if the first rule were applied to cases where the view of the middle turbinate was obscured by large nasal polyps which did not reach the lower margin of the inferior turbinate, they would be scored as 2. However, if they reduced in size sufficiently to allow a view of the turbinate such that polyps could be seen both medial and lateral to the middle turbinate, and extending below its inferior margin, paradoxically the NPS might increase to 3 despite the reduction in polyp volume.This was agreed at the original task force discussions, and we had intended that the figures provided in the position paper would provide sufficient guidance. Recent discussions have highlighted that the failure to specify in the text that the first rule above did not apply when the view of the middle turbinate was obscured by polyps has led to confusion, and in some cases may contribute to screening failures and discordance between blinded reviewers. We hope that this addendum will address this accordingly.As a practical consideration in a research setting, every effort should be made to visualise the middle turbinate and its relationship to any nasal polyps that are present to facilitate consistent application of the NPS and reduce inter-rater variability.References1. Gevaert P, De Craemer J, Bachert C, et al. European Academy of Allergy and Clinical Immunology position paper on endoscopic scoring of nasal polyposis. Allergy . Apr 2023;78(4):912-922. doi:10.1111/all.156502. Djupesland PG, Reitsma S, Hopkins C, Sedaghat AR, Peters A, Fokkens WJ. Endoscopic grading systems for nasal polyps: are we comparing apples to oranges? Rhinology . Jun 1 2022;60(3):169-176. doi:10.4193/Rhin21.4013. De Corso E, Porru DP, Corbò M, et al. Comparative real-world outcomes of dupilumab versus endoscopic sinus surgery in the treatment of severe CRSwNP patients. Clin Otolaryngol . Jul 2024;49(4):481-489. doi:10.1111/coa.141724. Huber P, Förster-Ruhrmann U, Olze H, et al. Real-world data show sustained therapeutic effects of dupilumab in chronic rhinosinusitis with nasal polyps (CRSwNP) over 3 years. Allergy . Nov 2024;79(11):3108-3117. doi:10.1111/all.162635. van der Lans RJL, Otten JJ, Adriaensen G, et al. Two-year results of tapered dupilumab for CRSwNP demonstrates enduring efficacy established in the first 6 months. Allergy . Oct 2023;78(10):2684-2697. doi:10.1111/all.157966. Homøe AS, Aanæs K, Tidemandsen JE, et al. Superior Benefits of Combining Mepolizumab With Sinus Surgery Compared to Mepolizumab Alone: Results From a Randomised 6-Month Trial. Int Forum Allergy Rhinol . Jul 2025;15(7):724-733. doi:10.1002/alr.23562AuthorsPhilippe Gevaert1, Elke Vandewalle1, Isam Alobid2, Claus Bachert3, Adam M Chaker4, Cemal Cingi5, Eugenio De Corso6, Joaquim Mullol7, Joseph K Han8, Peter W Hellings9, Valerie Hox10, Wytske J Fokkens11, Ludger Klimek12, Stella E Lee13, Valerie J Lund14, Ralph Mösges15, Oliver Pfaar16, Sietze Reitsma11, Glenis K Scadding14, Thibaut Van Zele1, Stephan Vlaminck17, Martin Wagenmann18, Sanna Toppila-Salmi19, Claire Hopkins201 Upper Airways Research Laboratory, Department of Head and Skin, Ghent University, Ghent, Belgium.2 Rhinology and Skull Base Unit. ENT Department, Hospital Clinic de Barcelona. IDIBAPS, CIBERES, Universitat de Barcelona, Barcelona, Spain.3 Department of Otorhinolaryngology Head and Neck Surgery, University Hospital of Münster, Münster, Germany. International Airway Research Center, First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China.4 Department of Otolaryngology and Center for Allergy and Environment, Technical University of Munich, TUM School of Medicine, Klinikum rechts der Isar, Munich, Germany.5 Department of Otorhinolaryngology, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir.Department of Otorhinolaryngology, Faculty of Medicine, Biruni University, Istanbul, Turkey.6 Otorhinolaryngology Unit, A. Gemelli University Hospital Foundation IRCCS, Rome, Italy.7 Rhinology Unit & Smell Clinic, ENT Department, Hospital Clínic Barcelona, FRCB-IDIBAPS, Universitat de Barcelona, CIBERES, Barcelona, Catalonia, Spain.8 Department of Otolaryngology Head and Neck Surgery, Eastern Virginia Medical School, Norfolk, Virginia, USA.9 Allergy and Clinical Immunology Research Unit, Department of Microbiology and Immunology, Catholic University of Leuven, Leuven, Belgium.Clinical Department of Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium.10 Department of Otorhinolaryngology, Head and Neck Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium.11 Amsterdam Rhinology Team (ART), Department of Otorhinolaryngology and Head/Neck Surgery, Amsterdam University Medical Centre (UMC), University of Amsterdam, Amsterdam, the Netherlands.12 Department of Otolaryngology, Head and Neck Surgery, Universitätsmedizin Mainz, Mainz, GermanyCenter for Rhinology and Allergology, Wiesbaden, Germany.13 Division of Otolaryngology - Head and Neck Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA.14 Royal National Ear, Nose, Throat and Eastman Dental Hospital, University College London, UCLH, London, United Kingdom.15 IMSB, Medical Faculty University at Cologne, Cologne, Germany.ClinCompetence Cologne GmbH, Cologne, Germany.16 Department of Otorhinolaryngology, Head and Neck Surgery, Section of Rhinology and Allergy, University Hospital Marburg, Philipps-Universität Marburg, Marburg, Germany.17 Department of Otorhinolaryngology, Centre Hospitalier de Mouscron, Mouscron, Belgium.18 Department of Otorhinolaryngology, Universitätsklinikum Düsseldorf, Dusseldorf, Germany.19 Department of Otorhinolaryngology, University of Eastern Finland and the North Savo Wellbeing Services County, Kuopio, Finland.Department of Allergy, Skin and Allergy Hospital, Inflammation Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.20 ENT Department, Guys and St Thomas’s Hospital, London, United Kingdom.King’s College, London, United Kingdom.Funding sourcesEuropean Academy of Allergy and Clinical Immunology:EAACI task force on nasal polyp scoringFigure legendsFigure 1. Visual representations of the nasal polyp score (NPS).NPS 0 = No nasal polyps.NPS 1 = Small nasal polyps in the middle meatus not reaching below the lower border of the middle turbinate.NPS 2 = Nasal polyps reaching below the lower border of the middle turbinate*.*The scoring is modified to accommodate patients who have had a middle turbinectomy, such that the nasal polyp must reach the top of the inferior turbinate to be scored 2. When anatomical features such as septal deviation prevent the view of the middle turbinate, nasal polyps seen to come below the level of the upper margin of the inferior turbinate are scored 2, unless they reach the lower limit of the inferior turbinate (NPS 3) or the floor (NPS 4).NPS 3 = Large nasal polyps reaching the lower border of the inferior turbinate or (large) nasal polyps medial to the middle turbinate**.**Large nasal polyps which score 2 plus additional polyps medial and beyond the borders of the middle turbinate. When a single or multiple nasal polyps completely obstruct visualisation of the middle turbinate, nasal polyps reaching below the reference line of the upper margin of the inferior turbinate are scored 3, unless they reach the floor (NPS 4).NPS 4 = Large nasal polyps causing complete obstruction of the inferior nasal cavity***. ***Large nasal polyps touching the floor of the nose.

Algorithm for the management of Primary Diffuse Chronic RhinosinusitisW.J. Fokkens1, , E. de Corso2 , P.W.Hellings3,4, R. J. Harvey5,6, C. Hopkins7, S. Reitsma11 Amsterdam UMC, University of Amsterdam, Department of Otorhinolarynogology, Amsterdam2. Unit of Otorhinolaryngology and Head-Neck Surgery, ”A. Gemelli” University Hospital Foundation IRCCS, 00168 Rome, Italy.3. University of Leuven, Department of Otorhinolaryngology, Leuven,4.The European Forum for Research and Education in Allergy and Airway Diseases Scientific Expert Team Members, Brussels, Belgium.5. Rhinology and Skull Base Research Group, St Vincent’s Centre for Applied Medical Research, University of New South Wales, Sydney, Australia.6. Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.7. King’s College London, London, UK.

Following the European Forum for Research and Education in Allergy and Airway Diseases (EUFOREA) treatment algorithm for chronic rhinosinusitis (CRS) with nasal polyps (CRSwNP), patients suffering from severe uncontrolled CRSwNP are recommended to receive oral corticosteroids, (revision) sinus surgery, systemic biologicals, and/or aspirin treatment after desensitization (ATAD). Given the major differences in indications, outcomes, practical considerations, risks and costs of these key pillars of treatment, there is a growing need to define criteria for each treatment option and list the clinically relevant and major considerations for them. This EUFOREA document therefore provides an expert panel overview of the expected outcomes, specific considerations and (contra)indications of the five major treatment arms of severe uncontrolled CRSwNP: oral corticosteroids, primary and revision sinus surgery, biological treatment, and ATAD. This overview of treatment considerations is needed to allow physicians and patients to consider the different options in the context of providing optimal and personalized care for severe uncontrolled CRSwNP. In conclusion, the five major treatment options for severe uncontrolled CRSwNP have intrinsic advantages, specific indications, and considerations that are of importance to the patient, the physician, and the society. This EUFOREA statement supports the unmet need to define criteria for the indication of every treatment pillar of CRSwNP.

Objective: To investigate the association between laryngopharyngeal reflux (LPR), gastroesophageal reflux disease (GERD) and recalcitrant chronic rhinosinusitis (CRS). Data sources: PubMed, Cochrane Library, and Scopus. Review methods: Three investigators search database for studies investigating the relationship between LPR, GERD and recalcitrant CRS with or without polyposis. The following outcomes were investigated with PRISMA criteria: age; gender; reflux and CRS diagnosis; association outcomes and potential treatment outcomes. Authors performed a bias analysis of papers and provided recommendations for future studies. Results: A total of 17 studies investigated the association between reflux and recalcitrant CRS. According to pharyngeal pH monitoring, 54% of patients with recalcitrant CRS reported hypo or nasopharyngeal acid reflux events. The numbers of hypo- and nasopharyngeal acid reflux events were significantly higher in patients compared to healthy individuals in 4 and 2 studies, respectively. Only one report did not find group differences. The proportion of GERD was significantly higher in CRS patients compared to controls, with a prevalence ranging from 32% to 91% of cases. No author considered nonacid reflux events. There was an important heterogeneity in the inclusion criteria; definition of reflux and association outcomes, limiting the draw of clear conclusion. Pepsin was found in sinonasal secretions more frequently in CRS patients than controls. Conclusion: Laryngopharyngeal reflux and GERD may be a contributing factors of CRS therapeutic resistance, but future studies are still needed to confirm the association considering nonacid reflux event.

Background: As elective surgical services recover from the COVID-19 pandemic a movement towards day-case surgery may reduce waiting lists. However, evidence is needed to show that day-case surgery is safe for many ENT operations including endoscopic sinus surgery (ESS). We aimed to investigate the safety of ESS in England. Methods: This was an observational, secondary analysis of administrative data. Participants were all patients in England undergoing elective ESS procedure aged ≥ 17 years during for the five years from 1st April 2014 to 31st March 2019. The exposure variable was day-case or overnight stay. The primary outcome was emergency readmission within 30 days post-discharge. Results: Data were available for 49,223 patients operated on across 129 NHS hospital trusts. In trusts operating on more than 50 patients in the study period, rates of day-case surgery varied from 100% to 20.6%. Rates of day-case surgery increased from 64.0% in 2014/15 to 78.7% in 2018/19. Day-case patients had lower rates of 30-day emergency readmission (odds ratio 0.71, 95% confidence interval 0.62 to 0.81). For secondary outcomes measures, there was no evidence of poorer outcomes for day-case patients. Outcomes for patients operated on in trusts with ≥80% day-case rates compared to patients operated on in trusts with <50% rates of day-case surgery were similar. Conclusions: ESS can safely be performed as day-case surgery at current rates. There is a potential to increase rates of day-case ESS in England, especially in departments that currently have low rates of day-case ESS.

• Telephone interviews were conducted with 19 MACRO trial participants from 5 ENT sites across the UK. • Trial participants experienced mixed levels of communication during the COVID period and some felt uninformed about the trial status and their clinical situation. • Participants were most concerned about getting COVID through interactions with other patients in hospital settings. Conversely, there was a high level of trust in healthcare professionals. • Pre-visit COVID-safety information, minimising contact with other patients, and strict waiting room management can facilitate the restart of the MACRO trial from the patient perspective. • Patient confidence in trial participation is likely to continue improving with COVID vaccination roll out.

Objectives We set out to create Consensus Guidelines, based on current evidence and relative risks of adverse effects and the costs of different treatments, that reflect the views of the British Rhinological Society (BRS) Council on where the use of biologics should be positioned within treatment pathways for CRSwNP, specifically in the setting of the National Health Service (NHS). Methods An expert panel of 16 members was assembled. A review of the literature and evidence synthesis was undertaken and circulated to the panel We used the RAND/UCLA methodology with a multi-step process to make recommendations on the use of biologics. Setting and participants N/A Results Recommendations were made, based on underlying disease severity, prior treatments and co-morbidities. A group of patients for whom biologics were considered an appropriate treatment option for CRSwNP was defined. Conclusions Although biologics are not currently available for the treatment of CRSwNP, the BRS Council have defined a group of patients who have higher rates of ‘failure’ with current treatment pathways, higher resource use and are more likely to suffer with uncontrolled symptoms. We would urge NICE to consider approval of biologics for such indications without applying further restrictions on use.

This systematic review evaluates the efficacy and safety of biologicals for chronic rhinosinusitis with nasal polyps (CRSwNP) compared to the standard of care. Pubmed, EMBASE and Cochrane Library were searched for RCTs. Critical and important CRSwNP-related outcomes were considered. The risk of bias and the certainty of the evidence were assessed using GRADE. RCTs evaluated (dupilumab-2, omalizumab-4, mepolizumab-2, reslizumab-1) included 1236 adults, with follow-up 20-64 weeks. Dupilumab reduces the need for surgery (NFS) and oral corticosteroid (OCS) use (RR 0.28; 95%CI 0.20-0.39, moderate certainty) and improves with high certainty smell (mean difference (MD) +10.54; 95%CI +9.24 to +11.84) and quality of life (QoL) (MD -19.14; 95%CI 95%CI -22.80 to -15.47), with fewer treatment-related adverse events (TAEs) (RR 0.95; 95%CI 0.89-1.02, moderate certainty). Omalizumab reduces NFS (RR 0.85; 95%CI 0.78 to 0.92, high certainty), decreases OCS use (RR 0.38; 95%CI 0.10-1.38, moderate certainty), improves with high certainty smell (MD +3.84; 95%CI +3.64 to +4.04) and QoL (MD -15.65; 95%CI -16.16 to -15.13), with increased TAE (RR 1.73; 95%CI 0.60-5.03, moderate certainty). There is low certainty for mepolizumab reducing NFS (RR 0.78; 95%CI 0.64 to 0.94) and improving QoL (MD -13.3; 95% CI -23.93 to -2.67) and smell (MD +0.7; 95%CI -0.48 to +1.88), with increased TAEs (RR 1.64; 95%CI 0.41-6.50). The evidence for reslizumab is very uncertain.

Background: Chronic rhinosinusitis (CRS) is a heterogenous group of inflammatory sinonasal disorders with key defining symptoms, but traditionally separated into phenotypes by clinical/endoscopic findings. It is not known if the two phenotypes have differing socioeconomic, co-morbidity and lifestyle differences. Objective: This analysis of the Chronic Rhinosinusitis Epidemiology Study (CRES) database sought to analyse any key differences in the socioeconomic variables between those with CRS with nasal polyps (CRSwNPs) and those without nasal polyps (CRSsNP). We also sought to analyse differences in comorbidities, lifestyle and quality of life. Methods: Patients with a confirmed diagnosis of CRS in secondary and tertiary care outpatient settings were invited to participate in a questionnaire based case-control study. Variables included demographics, comorbidities, socioeconomic factors, lifestyle factors and health related quality of life. Results: A total of 1204 patients’ data were analysed; 553 CRSsNP and 651 CRSwNP participants. The key socioeconomic variables did not demonstrate any notable differences, nor did lifestyle variables other than alcohol consumption being higher in those with CRSwNP (p=0.032). Aside from confirmation of asthma being more common in CRSwNP, it was notable that this group complained less of URTIs and CRSsNP participants showed evidence of lower HRQoL scores in respect of body pain (p=0.001). Conclusions: Patients with CRSwNP experience higher rates of asthma and lower rates of URTIs but otherwise do not demonstrate significant socioeconomic, comorbidity, lifestyle or quality of life issues other than for body pain and alcohol consumption.

Aims 1. To systematically review the currently available evidence investigating the association between olfactory dysfunction (OD) and the novel coronavirus (COVID-19). 2. To analyse the prevalence of OD in patients who have tested positive on Polymerase Chain Reaction (PCR) for COVID-19. 2. To perform a meta-analysis of patients presenting with olfactory dysfunction, during the pandemic, and to investigate the Positive Predictive Value for a COOVID-19 positive result in this population. 3. To assess if olfactory dysfunction could be used as a diagnostic marker for COVID-19 positivity and aid public health approaches in tackling the current outbreak. Methods We systematically searched MedLine (PubMed), Embase, Health Management Information Consortium (HMIC), Medrxiv, the Cochrane Library, the Cochrane COVID-19 Study Register, NIHR Dissemination centre, Clinical Evidence, National Health Service Evidence and the National Institute of Clinical Excellence to identify the current published evidence which associates coronaviridae or similar RNA viruses with anosmia. The initial search identified 157 articles. 145 papers were excluded following application of our exclusion criteria. The 12 remaining articles, that presented evidence on the association between COVID-19 and olfactory dysfunction, were critically analysed. Results OD has been shown to be the strongest predictor of COVID-19 positivity when compared to other symptoms in logistic regression analysis. In patients who had tested positive for COVID-19 there was a prevalence of 62% of OD. In populations of patients who are currently reporting OD there is a positive predictive value of 61% for a positive COVID-19 result. Conclusion Our review has shown that there is already significant evidence which demonstrates an association between OD and the novel coronavirus – COVID-19. It is unclear if this finding is unique to this coronavirus as individual viral phenotypes rarely present in such concentrated large numbers. We have demonstrated that OD is comparatively more predictive for COVID-19 positivity compared to other associated symptoms. We recommend that people who develop OD during the pandemic should be self-isolate and this guidance should be adopted internationally to prevent transmission.