What are the treatment recommendations for rhinosinusitis and nasal polyps according to the EPOS (European Position Paper on Rhinosinusitis and Nasal Polyps) 2020 Classification?

EPOS 2020 Classification and Treatment Recommendations

Classification System

EPOS 2020 introduces a new anatomic-based classification dividing chronic rhinosinusitis (CRS) into primary versus secondary disease, then further subdividing into localized versus diffuse disease based on anatomic distribution. 1

The classification distinguishes between:

• Chronic rhinosinusitis without nasal polyps (CRSsNP)
• Chronic rhinosinusitis with nasal polyps (CRSwNP) 1

First-Line Medical Treatment

Intranasal Corticosteroids

Intranasal corticosteroids are the cornerstone of treatment for both CRSsNP and CRSwNP, with strong evidence supporting their use for improving quality of life, reducing polyp size, and controlling symptoms. 1, 2

• Use mometasone furoate 200 μg daily or fluticasone propionate 400 μg daily as standard dosing 1
• These agents significantly improve disease-specific quality of life (SNOT-22 scores), reduce nasal obstruction, and decrease polyp scores 1
• Continue intranasal corticosteroids long-term, including postoperatively after endoscopic sinus surgery, as they prevent polyp recurrence 1
• Intranasal corticosteroids do not affect intraocular pressure or lens opacity at recommended doses 1

The evidence does not support higher dosages or specific delivery methods (sprays versus drops versus irrigation) over standard dosing due to lack of direct comparisons. 1

Short-Course Oral Corticosteroids

For acute exacerbations or severe CRSwNP, use prednisone 25-30 mg daily for 7-14 days followed by maintenance intranasal corticosteroids. 1, 3

• This regimen produces significant reduction in total symptom scores and nasal polyp scores within 2-3 weeks 1
• Greater improvement in symptoms, polyp scores, and quality of life persists for up to 12 weeks compared to intranasal corticosteroids alone 3
• Limit oral corticosteroid courses to 1-2 per year to minimize systemic adverse effects including adrenal suppression 3

Advanced Medical Therapies

Corticosteroid-Eluting Implants

Corticosteroid-eluting sinus implants releasing 1350 μg mometasone furoate over 90 days are an option for recurrent polyposis after sinus surgery. 1

• These implants reduce nasal obstruction by 0.28 points on a 0-3 scale (modest but significant) 1
• They reduce the need for surgery with an odds ratio of 0.37, meaning 63% lower likelihood of requiring surgery at 90 days 1
• Bilateral polyp grade improves significantly (SMD 0.40) compared to placebo 1
• No impact on intraocular pressure or lens opacity has been observed 1

Saline Irrigation

Saline irrigation is recommended, though the evidence is uncertain whether irrigation is superior to sprays. 4

Therapies NOT Recommended

Antibiotics

Topical antibacterial therapy does not improve symptoms more than placebo in CRS patients. 1

• Oral and topical antibiotics are discouraged for subacute or chronic use 4
• Intravenous antibiotics have very low quality evidence with uncertain benefit 1
• Antibiotics may be used for acute bacterial exacerbations but not as chronic therapy 4

Other Agents with Insufficient Evidence

The EPOS 2020 steering group cannot recommend phototherapy due to very low quality evidence from only two trials with variable results. 1

Filgastrim (r-met-HuG-CSF) showed no significant differences in quality of life measures (SF-36, EuroQol, McGill pain questionnaire) at any timepoint. 1

Antifungal agents offer no benefit and potential harm in general CRS populations. 4

Antileukotrienes are inferior to intranasal corticosteroids and unlikely to provide added benefit when used concomitantly. 4

Oral antihistamines and decongestants are unlikely to have benefits that outweigh potential harm. 4

Surgical Intervention

Endoscopic sinus surgery is indicated when medical therapy fails to control symptoms or when severe nasal polyposis causes obstruction. 2

• Surgery should be reserved for patients in whom polyps cause severe obstruction or recurrent sinusitis and for whom medical therapy has failed 5
• Continue intranasal corticosteroids postoperatively to prevent polyp recurrence 1
• There are no evidence-based criteria defining when maximum medical treatment has failed 4

Biologic Therapies

Dupilumab is recommended for severe CRSwNP when consensus-determined criteria are met. 4

• Omalizumab may be an option with concomitant poorly controlled asthma 4
• Mepolizumab and reslizumab may be used, particularly with concomitant uncontrolled asthma 4

Special Populations

Aspirin-Exacerbated Respiratory Disease (AERD)

Oral aspirin desensitization followed by aspirin ≥300 mg daily may be considered for patients with AERD. 4

• Aspirin desensitization may decrease the requirement for polypectomies and sinus surgery 5

Pediatric Patients

The pediatric acute and chronic rhinosinusitis chapters were completely rewritten in EPOS 2020 to address this previously under-covered population. 1

Critical Pitfalls

Never use oral corticosteroids as monotherapy for bacterial sinusitis—always combine with appropriate antibiotics when bacterial infection is suspected. 3

Do not extend oral corticosteroid treatment beyond 7-14 days as adverse event risk increases with duration. 3

For patients with diabetes, use the lower dose of 25 mg daily for 2 weeks rather than higher doses to minimize glycemic fluctuations. 3

Avoid chronic antibiotic use (oral or topical) as the evidence shows no benefit and potential for harm including antibiotic resistance. 1, 4