Abstract
Chronic rhinosinusitis with nasal polyps (CRSwNP) management remains controversial regarding the optimal timing and choice between biological therapies and endoscopic sinus surgery (ESS). This umbrella review aimed to synthesize and compare the effectiveness of these interventions through a systematic evaluation of existing evidence. A comprehensive umbrella review was conducted across multiple databases from inception to December 2024. Systematic reviews and meta-analyses comparing biological therapies with ESS in adult CRSwNP patients were included. Study quality was assessed using AMSTAR-2 criteria. Primary outcomes included SNOT-22 scores, nasal polyp scores, and adverse events. Four high-quality systematic reviews encompassing 847 patients were analyzed. ESS demonstrated superior early effectiveness (SNOT-22 mean difference: -12.4 points, 95% CI: -15.8 to -9.0, p<0.001 at 3 months), while dupilumab showed comparable long-term outcomes (48- week SNOT-22 mean difference: -2.3 points, 95% CI: -5.7 to 1.1, p=0.18). Nasal polyp scores favored ESS (G = 0.332 [0.205, 0.458], p = 3.26e-07), while olfactory improvement was superior with dupilumab. Adverse event profiles were distinct but manageable for both interventions. This umbrella review reveals complementary strengths of ESS and biological therapies, with ESS providing rapid symptomatic relief and biologics offering progressive improvement, particularly in olfactory function. Treatment selection should consider temporal response patterns, specific symptom priorities, and individual patient factors.

Key words: Chronic rhinosinusitis, nasal polyps, biological therapy, endoscopic sinus surgery, dupilumab, systematic review