Completeness of Surgery Matters in Chronic Rhinosinusitis with Nasal Polyps

Devyani Lal, MD, and Kevin C. Welch, MD, on behalf of the Rhinology and Allergy Education Committee

Chronic rhinosinusitis with nasal polyps (CRSwNP) remains one of the most challenging inflammatory diseases managed by general otolaryngologists. Endoscopic sinus surgery (ESS) continues to play a central role even as medical therapy advances.^1,2 Yet, the operation itself varies widely from limited, targeted procedures to more comprehensive “full-house” approaches.³ That variability reflects a practical question at the center of CRSwNP care: How much surgery is enough to deliver durable control and reduce the cycle of recurrent polyps, repeated steroids, and revision procedures?^1-4

Traditionally, ESS outcomes in CRSwNP have been judged by symptom improvement and disease control using patient-reported measures such as the Sino-Nasal Outcome Test (SNOT-22),⁵ visual analog scales (VAS), and postoperative endoscopy.^1,2 A recent consensus document from a European group explored the concept of remission as an aspirational target,⁶ defining it in CRSwNP as at least 12 months of control without bothersome symptoms, without oral corticosteroids or additional ESS, and without endoscopic signs of active disease.⁶ This goal has renewed attention on a factor surgeons can directly influence: the quality and completeness of the operation itself.

No universal definition of the optimal extent of ESS exists for CRSwNP, and shared decision-making with patients is necessary to discuss treatment goals and surgical procedures.^3,4

Emerging consensus coalesces around “complete ESS” for CRSwNP. Complete sinus surgery should aim to achieve three key goals in CRSwNP management: maximal reduction of inflammatory disease burden by removal of all polyps and debris; durable, wide openings that support postoperative debridement and surveillance; and delivery of topical therapy for maintenance. Complete ESS for CRSwNP involves maximally opening the sinuses (maxillary, sphenoid, and frontal), performing a complete ethmoidectomy with removal of ethmoid partitions to remove polyps, debris, and inflammatory tissue, creating wide, stable ostia to facilitate postoperative topical therapy, and using a mucosa-preserving technique to minimize scarring and osteitis.^4,7–10,13

In addition, intentional treatment of the middle turbinates and inclusion of septoplasty may also improve long-term outcomes.^13-17 Done well, this strategy creates a “neo sinus cavity” optimized for irrigation, topical corticosteroid delivery, and office-based postoperative management.^10-14

Incomplete or inadequate surgery increases the risk of persistent inflammation, early recurrence, impaired topical drug delivery, and iatrogenic recalcitrance.^13,14 Physicians should ascertain that complete ESS has been performed before concluding that the disease is truly recalcitrant or before escalating to biologic therapy unless patient factors or contraindications merit otherwise.

The recently proposed Completion of Surgery Index (CoSI) is an objective measure of the extent and completeness of surgery.¹³

Less Surgery Versus More Surgery: What Does the Evidence Show?

A major barrier to consensus is the lack of standardized definitions for “limited,” “complete,” and “extensive” ESS. Across studies, these labels are applied inconsistently, limiting direct comparisons. A systematic review and meta-analysis of limited versus extensive surgery in chronic rhinosinusitis underscored this heterogeneity in surgical definitions and techniques.³

Even with those limitations, a consistent pattern appears in CRSwNP cohorts. More comprehensive approaches, characterized by wide maxillary antrostomies, complete ethmoidectomy, sphenoidotomy, and frontal sinusotomy, are associated with improved objective endoscopic outcomes, better postoperative access, and lower revision rates.^3,4,14–18 In contrast, patient-reported symptom improvement (for example, SNOT‑22 change) is often similar between limited and extensive strategies, which has fueled skepticism about whether more surgery adds value.³

This disconnect matters because symptoms do not consistently reflect the burden of disease or predict the long-term consequences of incomplete surgery in a chronic inflammatory disease with high recurrence risk. Creation of wide ethmoidal corridors and wide sinusotomies is necessary to facilitate adequate topical drug delivery through sinus irrigations.^9,11

Impact of Incomplete Surgery on Disease Course

Although concerns about morbidity, technical difficulty, and the expanding role of biologics continue to drive debate about when more extensive surgery is necessary,^1,2,4,13 common findings at revision surgery for persistent disease include residual ethmoid partitions, scarring of ethmoidal septations to the middle or superior turbinate, lateralized middle turbinates, persistent frontal recess obstruction, osteitis, and anatomy that limits access for topical therapies.^17,19 These anatomic issues may perpetuate inflammation and reduce the effectiveness of postoperative medical management and support “completeness” of dissection.^13,17,18

Revision outcomes also hint at a key clinical reality: Results depend heavily on what was addressed during the previous surgery. Long-term series report revision rates around 18–20% in CRSwNP, with higher risk in phenotypes such as allergic fungal rhinosinusitis (AFRS), aspirin-exacerbated respiratory disease (AERD), asthma, and patients with prior polypectomy.^8,14 Disease biology matters, but surgical factors remain a modifiable contributor. However, when residual disease is adequately cleared, patients undergoing revision ESS can show meaningful improvement in sinonasal outcomes and even asthma control, suggesting that some “recalcitrant” cases represent surgical under-treatment.^13,19

Frontal Sinus Surgery and the Question of “More”

The debate becomes most visible in the frontal sinus. Extended frontal procedures such as a Draf III (modified Lothrop) can reduce polyp recurrence and revision rates in selected patients, particularly those with severe or refractory disease.²⁰ But routine Draf III in primary CRSwNP remains controversial because of morbidity, technical demands, and may be of uncertain benefit for milder disease, where the frontal neo-ostium can facilitate adequate topical nasal irrigation through less extensive procedures.^3,4 In CRSwNP, the surgeon should maximally open the frontal sinus to the extent it takes to permit adequate irrigation of the frontal sinus.

Similarly, routine middle turbinate resection (MTR) in CRSwNP remains controversial and is not supported for most patients.²¹ Although polypoid change of the middle turbinate is associated with more severe disease and higher recurrence risk, ^22,23,24 randomized and observational data do not show a sustained objective or quality-of-life benefit from routine MTR at primary ESS.²¹ Short-term endoscopic differences have been reported, but advantages do not persist, and frontal sinus outcomes appear similar whether the turbinate is preserved or resected.^21,23 Routine resection also carries trade-offs, including potential destabilization of nasal anatomy, risk of scarring or lateralization if not meticulously managed, and concerns regarding olfaction.

A selective strategy is better supported: preserve a stable, healthy middle turbinate when possible, using medialization, spacing, or limited trimming when needed to facilitate access and reduce adhesions. In select cases in which the middle turbinate is severely diseased or unstable, carefully performed resection may be considered. Overall, current data favor intentional, case-specific management of the middle turbinate rather than routine resection as part of optimal surgery for CRSwNP.

Regardless, these debates ascribed to similar philosophies. Complete ESS for CRSwNP is appropriate, mucosa-preserving surgery with thorough dissection of the sinuses to create wide, durable access to the paranasal sinuses for long-term maintenance treatment, and shared decision-making with patients must be prioritized.^3,4

The Completion of Surgery Index (CoSI): A New Lens on Surgical Adequacy

CoSI was developed as an objective, endoscopy‑based tool to quantify the extent and adequacy of ESS in patients with CRSwNP.¹³ Scored from 0 to 100, CoSI reflects how completely each sinus cavity has been surgically opened, with higher scores indicating more comprehensive surgery.¹³ Rather than forcing surgery into a binary label, CoSI provides an objective assessment of residual partitions, incomplete openings, and anatomic barriers that can undermine disease control or limit topical therapy delivery.¹³

CoSI and Outcomes in Revision Surgery

Data from patients undergoing revision ESS demonstrate the clinical relevance of CoSI. In one cohort of 75 patients with CRSwNP undergoing revision surgery, preoperative CoSI scores averaged approximately 49, indicating substantial residual surgical targets from prior operations.¹³

More importantly, CoSI appears to stratify who benefits most from revision. Patients with lower preoperative CoSI scores (<70) experienced substantially greater SNOT-22 improvement after revision ESS, approaching the gains seen after primary surgery, whereas those with higher CoSI scores (≥70) improved, but to a more modest degree.¹³ In practice, an objective assessment of completeness can help distinguish patients most likely to benefit from additional revision surgery from those who may also need adjunctive strategies.

CoSI as a Clinical and Research Tool

Beyond revision surgery, CoSI offers a way to standardize reporting, improve surgical quality discussions, and strengthen research comparisons by defining the extent of surgery in measurable terms rather than subjective impressions.

In clinic, structured assessment of surgical completeness can also support shared decision-making: surgeons can explain why additional surgery is (or is not) expected to help, and when it is reasonable to transition to intensified medical therapy or biologics, based on objective anatomic findings.

By providing a reproducible metric, CoSI can help compare surgical completeness across settings, stratify revision candidates by likelihood of benefit, separate surgical factors from inflammatory biology, and improve interpretation of outcomes in both surgical and biologic studies.

Biologic Therapy and Surgery: Complementary, Not Competing

Biologic therapies have transformed CRSwNP care, offering effective options for patients with persistent disease despite surgery and standard medical therapy.^24–29 Their success has raised a new question: in the biologic era, does surgical extent still matter?

Current evidence suggests that surgery and biologics are best viewed as complementary rather than competing therapies. ESS plays a critical role in removing inflammatory burden, creating sinus access, and enabling effective topical therapy, all of which may enhance or modulate the response to biologics.¹¹

Comparative data also help frame expectations. In a study of 111 CRSwNP patients³⁰ matched to inclusion criteria modified from key biologic trials for dupilumab LIBERTY NP SINUS‑24&52,²⁹ omalizumab POLYP‑1&2,²⁷ and mepolizumab SYNAPSE,²⁶ Miglani and colleagues³⁰ reported that at 24 and 52 weeks, complete ESS produced SNOT‑22 improvements comparable to dupilumab (Miglani et al., 2023). ESS and dupilumab were also similar for smell identification at 24 weeks, while ESS was superior to omalizumab for SNOT‑22 improvement and achieved larger reductions in polyp size than omalizumab, dupilumab, and mepolizumab.³¹

As biologics become more integrated into routine practice, prior surgical completeness has gained new relevance. Multicenter data in dupilumab-treated patients suggest that the extent of prior ESS influences both objective and subjective response.³¹ Using the ACCESS score,¹⁸ a CT-based system analogous to CoSI, the authors Alicandri-Ciufelli, et al.³¹ reported that patients with more extensive prior surgery demonstrated better nasal polyp scores across timepoints, improved SNOT‑22 and VAS symptom scores, and lower overall polyp burden. Interestingly, they also showed reduced olfactory recovery, underscoring the balance among disease clearance, mucosal preservation, and functional outcomes.

The practical takeaway is that surgery and biologics are not competing therapies; they are tools that interact. The effectiveness of topical therapy and potentially biologics depends in part on the surgical foundation.

Practical Takeaways for the Comprehensive Otolaryngologist

In day-to-day practice, the literature on completeness supports a few key takeaways:

1. Define surgical goals upfront. Is the objective symptom control, remission, or preparation for long-term medical therapy?

2. Avoid under-treating diffuse disease. Limited surgery in widespread CRSwNP may predispose patients to early recurrence and revision surgery or unnecessary treatment with biologics.

3. Recognize incomplete surgery as a modifiable risk factor. Not all “recalcitrant” disease is biological.

4. Use completeness to guide revision decisions. Patients with low CoSI scores may benefit substantially from revision ESS.

5. Integrate surgery and biologics thoughtfully. Optimal outcomes often require both, applied at the right time and in the right sequence.

Conclusions

As CRSwNP treatment paradigms evolve, surgical quality and the completeness with which key sinus targets are addressed have come into sharper focus. While no single operation fits every patient, evidence increasingly supports the idea that thoughtful, complete ESS provides a durable platform for disease control, improves postoperative access for topical therapy and surveillance, and may reduce the downstream burden of revision surgery.

For the comprehensive otolaryngologist, objective assessment of surgical adequacy (for example, with CoSI) and deliberate integration of surgery with modern medical and biologic options can make outcomes more predictable and more patient-centered—moving care from short-term symptom relief toward durable control and, for some patients, remission.

• Completeness matters. Inadequate initial surgery can contribute to persistent disease, impaired topical therapy delivery, and the need for revision ESS.
• More surgery is not always better, but incomplete surgery is rarely benign. Surgical extent should be tailored to disease severity, anatomy, and patient factors.
• Objective tools such as CoSI can help guide decision‑making, particularly in revision settings.
• Biologics do not replace surgery. Instead, they function best as part of an integrated treatment strategy built on sound surgical foundations.
• Shared decision‑making is essential. Patients benefit from understanding the goals of surgery: control, remission, or symptom palliation, and how surgical choices affect long‑term management options.

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