从复发预测到疾病控制：慢性鼻窦炎伴鼻息肉治疗后动态风险分层与精准管理研究进展

From recurrence prediction to disease control: dynamic risk stratification and precision management after surgery for chronic rhinosinusitis with nasal polyps

摘要:

慢性鼻窦炎伴鼻息肉（chronic rhinosinusitis with nasal polyps，CRSwNP）具有炎症异质性强、病程迁延及治疗后易复发等特点。内镜鼻窦手术（ESS）可改善通气引流和局部药物递送，但不能改变基础免疫炎症背景。当前管理理念正由单纯关注息肉复发转向基于疾病控制状态的动态风险分层，通过整合临床表型、炎症内型、解剖状态和治疗反应持续调整策略。既往手术史、哮喘或非甾体抗炎药加重性呼吸道疾病（NSAID-ERD）、较高病变负荷及嗜酸粒细胞升高可提示初始高风险，术后早期的症状、SNOT-22、内镜、嗅觉及全身糖皮质激素使用可用于再分类。对规范基础治疗后仍控制不佳、尤其具有2型炎症特征的患者，生物制剂可作为重要的升级治疗。其适应证应结合2型炎症证据、疾病严重程度、既往手术及全身糖皮质激素需求进行评估，并根据鼻息肉负荷、嗅觉、生活质量、激素需求及哮喘控制动态评价疗效。本文综述CRSwNP治疗后的动态风险分层及局部治疗、再次手术和生物制剂管理，为长期精准治疗提供参考。

Abstract:

Chronic rhinosinusitis with nasal polyps (CRSwNP) is characterized by marked inflammatory heterogeneity, a prolonged course, and frequent recurrence after treatment. Endoscopic sinus surgery (ESS) improves ventilation, drainage, and topical drug delivery but does not alter the underlying immune-inflammatory background. Management is therefore shifting from simply detecting polyp recurrence to dynamic risk stratification based on disease control, integrating clinical phenotype, inflammatory endotype, anatomic status, and treatment response to guide ongoing adjustment. Previous surgery, asthma or nonsteroidal anti-inflammatory drug-exacerbated respiratory disease (NSAID-ERD), high disease burden, and eosinophilia may indicate high initial risk, whereas early postoperative symptoms, SNOT-22, endoscopic findings, olfactory recovery, and systemic corticosteroid exposure can support risk reclassification. For patients who remain uncontrolled despite appropriate standard therapy, particularly those with type 2 inflammation, biologics may serve as an important treatment-escalation option. Eligibility should be assessed according to evidence of type 2 inflammation, disease severity, previous surgery, and systemic corticosteroid requirement, and treatment response should be evaluated dynamically using nasal polyp burden, olfaction, quality of life, corticosteroid requirement, and asthma control. This review summarizes dynamic risk stratification and risk-adapted use of topical therapy, revision surgery, and biologics after CRSwNP treatment to support long-term precision management.