Role of Previous Sinus Surgery Extent in Indication of Biologic Treatment for CRSwNP

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a relapsing, type 2-driven disease. Endoscopic sinus surgery (ESS) often improves symptoms, but recurrence is common, and biologics are now available for severe cases. The optimal extent of ESS before initiating biologics remains uncertain. The Amsterdam Classification of Completeness of Endoscopic Sinus Surgery (ACCESS) offers an objective measure of surgical completeness. This retrospective study analyzed the relationship between surgical completeness and postoperative disease control in patients eligible for biologic therapy. Seventy-one patients underwent revision ESS for recurrent CRSwNP at a tertiary center (2018-2022). Patients fulfilling ≥3 EPOS/EUFOREA 2023 biologic eligibility criteria at surgery were included. Demographic and clinical data were collected, and surgical completeness was graded using ACCESS based on preoperative CT. Minimum followup was 18 months. Controlled disease was defined as stability with topical therapy alone; uncontrolled patients required biologics or further surgery. Fifty-four patients (76%) met biologic eligibility criteria (mean age 54 years; 46% female; 76% asthma; 19% aspirin-exacerbated respiratory disease). Mean eosinophil count was 527/μl and mean number of prior procedures 2.4. After revision ESS, 45 patients (83%) achieved disease control, whereas 9 (17%) remained uncontrolled (8 required dupilumab, 1 underwent extended surgery). The mean ACCESS score was significantly higher in controlled versus uncontrolled patients (10.1 vs. 3.7, p<0.05). No correlation was found between number of prior surgeries and ACCESS score. Extent of prior ESS, quantified by ACCESS, is associated with postoperative outcomes in CRSwNP patients eligible for biologics. Low ACCESS scores predict need for biologics, supporting ACCESS as a tool for treatment selection in the biologic era.