Postoperative Recurrence of Chronic Rhinosinusitis with Nasal Polyps: Endotype Mechanisms, Predictive Models, and Novel Strategies for Precision Treatment.

BACKGROUND: Postoperative recurrence of chronic rhinosinusitis with nasal polyps (CRSwNP) represents a significant clinical challenge. Traditional phenotype-based classifications have proven inadequate for predicting recurrence and guiding individualized management, while advances in immune endotype research are revealing the molecular mechanisms driving recurrence.

SUMMARY: This review systematically examines the endotype-specific mechanisms, predictive models, and treatment strategies for postoperative recurrence of CRSwNP. It highlights five core controversies: whether type 2 inflammation is truly the strongest recurrence driver, given evidence that mixed type 1/3 inflammation may lead to earlier relapse; the absence of head-to-head comparative evidence for biologic selection; the questionable operability of endotyping in routine practice; the persistent lack of effective therapies for non-type 2 and mixed endotypes; and the lack of prospective evidence for endotype-driven surgical strategies. The review further critiques the translational barriers facing current predictive models, including inconsistent recurrence definitions, insufficient external validation, and poor accessibility of input variables. Pharmacological treatments, biologics, and surgical strategies tailored to specific endotypes are also summarized.

KEY MESSAGES: (1) Type 2 inflammation remains central to recurrence, but mixed endotypes may drive earlier and more refractory relapse. (2) Current predictive models lack external validation and calibration data, limiting their clinical utility. (3) Biologics targeting type 2 pathways have transformed treatment, yet evidence for non-type 2 patients is absent. (4) Endotype-guided precision management-integrating prediction, pharmacotherapy, biologics, and surgery-requires prospective validation in multicenter trials.