Expert Consensus on Surgical Management of Primary Diffuse Type 2-Dominant Chronic Rhinosinusitis

Background: Chronic rhinosinusitis (CRS) poses significant challenges in surgical management due to the lack of clear guidelines, particularly in type 2 CRS. This review focuses on surgical approaches for primary diffuse type 2-dominant CRS, emphasizing preoperative and intraoperative strategies. Methods: A consensus group, comprising experts from Europe, United Kingdom, Australia, South Africa, North and South America, was assembled. Using a modified Delphi method, 67 statements were formulated following a literature review, with an additional statement added in the second iteration. Final recommendations were discussed during a consensus meeting in Santorini, Greece, in October 2023. Results: Out of the 68 proposed statements, consensus was achieved on 45. Most (34) statements received a median score of 7 (strongly agree), and 11 had a median score of 6 (agree). The finalized recommendations cover the indications, timing, extent of surgery, and intraoperative management for both primary and revision surgery in primary diffuse type 2-dominant CRS. A key focus is on complete sinus surgery, which involves creating a neo-sinus cavity by removing bone partitions in the ethmoid and opening the frontal and sphenoidal sinuses as needed. Adequate primary and revision surgery includes clearing all nasal polyps and diseased mucosa while ensuring ideal conditions for topical therapy. Additionally, there was consensus on performing complete sinus surgery before considering monoclonal antibody therapies, unless contraindicated. Conclusion: These 45 consensus statements, derived from both current evidence and expert opinion, provide valuable guidance for clinicians in the surgical management of primary diffuse type 2-dominant CRS.