Bilateral Endoscopic Nasal Polyp Score (NPS)1,3

Polyp size is assessed endoscopically to determine the nasal polyp score (NPS).

The NPS scale ranges from 0 (no polyp) to 4 (large polyps) for each nostril. These scores are tallied from each nostril for a total score ranging from 0 to 8.

Stage Endoscopic Appearance Description
0 No polyps.
1 Small polyps restricted to the middle meatus; do not extend below the lower border of the middle turbinate.
2 Polyps extend below the lower border of the middle turbinate.
3 Large polyps extend down to the lower border of the inferior turbinate, or polyps are medial to the middle turbinate.
4 Large polyps that result in complete obstruction of the nasal cavity.

22-Item Sino-Nasal Outcome Test (SNOT-22)1,6

The 22-item sino-nasal outcome test (SNOT-22) is a validated questionnaire used to assess the impact of CRSwNP on HRQoL.

It includes questions specifically designed to measure nasal blockage, and sense of taste and smell.

  • The range of the SNOT-22 score is 0 to 110.
  • Lower scores indicate less impact.

Take a Closer Look: The SNOT-22

The SNOT-22 questionnaire provides a 6-point scale which is used to assess 22 symptoms and social or emotional consequences in patients with CRSwNP.

Each symptom or consequence is ranked on a 6-point scale:

  • No problem (0 pts)
  • Very mild problem (1 pt)
  • Mild or slight problem (2 pts)
  • Moderate problem (3 pts)
  • Severe problem (4 pts)
  • Problem as bad as it can be (5 pts)

The following list contains the 22 symptoms and social or emotional consequences ranked in the SNOT-22:

  • Need to blow nose
  • Sneezing
  • Runny nose
  • Cough
  • Post nasal discharge
  • Thick nasal discharge
  • Ear fullness
  • Dizziness
  • Ear pain
  • Facial pain/pressure
  • Difficulty falling asleep
  • Waking up at night
  • Lack of good night’s sleep
  • Waking up tired
  • Fatigue
  • Reduced productivity
  • Reduced concentration
  • Frustrated/restless/irritable
  • Sad
  • Embarrassed
  • Sense of taste/smell
  • Blockage/congestion of nose

Lund-Mackay CT Scoring System1,4,5

The Lund-Mackay scoring system is used in conjunction with CT for scanning of nasal polyps.

Sinus System Possible Score* Grading
Maxillary 0, 1, or 2 0 = no mucosal thickening
1 = partial opacification
2 = total opacification
Anterior ethmoid 0, 1, or 2
Posterior ethmoid 0, 1, or 2
Sphenoid 0, 1, or 2
Frontal 0, 1, or 2
Osteomeatal complex 0 or 2 only

CT Computed Tomography

*Calculated per side (total score of 0 to 24 across both sinuses)

This system uses a score of 0 to 2, which reflects the absence (0), partial (1), or complete (2) opacification of each sinus as well as of the vital ostiomeatal complex (0 is not obstructed and 2 is obstructed).

The maximum score possible for each side is 12 (total score of 0 to 24 across both sides), higher scores indicate worse status.

Evaluation of Nasal Symptoms and Olfactory Function11

Nasal Congestion Score

The nasal congestion score (NCS) is a self-evaluation of symptoms of congestion.

The NCS is a monthly average of the patient’s own daily morning assessment of the severity of their congestion symptoms over the previous 24 hours.

The NCS is graded according to the following 4-point scale:

0 is equal to absent symptoms (no sign/symptom evident).

1 is equal to mild symptoms (sign/symptom clearly present, but minimal awareness; easily tolerated).

2 is equal to moderate symptoms (definite awareness of sign/symptom that is bothersome but tolerable).

3 is equal to severe symptoms (sign/symptom that is hard to tolerate; causes interference with activities of daily living and/or sleeping).

Total Rhinosinusitis Symptoms Score (TSS)1,2

The Total Rhinosinusitis Symptoms Score (TSS) is a calculated composite score (ranging between 0 to 9) consisting of the sum of rhinosinusitis symptoms assessed each morning by the patient.

TSS assesses the following symptoms:

  • Nasal congestion.
  • Loss of sense of smell.
  • Rhinorrhea.

Each symptom is graded on a 4-point scale (0 - 3):

0 indicates no symptoms.

1 indicates mild symptoms that are easily tolerated.

2 indicates awareness of symptoms that are bothersome but tolerable.

3 indicates severe symptoms that are hard to tolerate and interfere with daily activity.

Olfactory Dysfunction13

  • Loss of smell is one of the most significant symptoms to patients, and has a substantial impact on QoL.
  • In addition, the impairment of the sense of smell seems to correlate with disease severity and maybe the first sign of disease recurrence.
  • However, the exact mechanism underlying impaired olfaction is still not fully understood.
  • May be related to nasal airflow reduction, local edema-induced compression of olfactory nerves, as well as mucosal inflammation.

Definitions of Smell Impairment14

Term Description
Normosmia Normal sense of smell
Hyposmia Decreased sense of smell
Hyperosmia Increased sense of smell
Anosmia Total loss of smell
Specific anosmia Inability to identify a certain odor
Parosmia Aberrant perception of odor

Loss of Smell Score (LoS)1,2

The loss of smell score is a patient-collected assessment of the daily symptom severity of decreased or loss of smell.

The loss of smells score is graded using a 0 to 3 categorical scale, where 0 = no symptom, 1 = mild LoS, 2 = moderate LoS, 3 = severe LoS.

VAS score

Visual Analog Scale (VAS), 0 to 10.

This VAS is ideal in the classification of symptoms of rhinosinusitis into mild (VAS 0–3), moderate (>3–7), and severe (>7–10).

University of Pennsylvania Smell Identification Test (UPSIT)7,8

  • A self-administered test that uses microencapsulated odorants that are released by scratching standardized odor-impregnated test booklets
  • The individual “scratches and sniffs” each odor in the booklet, then selects from four multiple-choice answers corresponding to the perceived smell
  • The UPSIT score ranges from 0 to 40, where higher scores indicate better status

A particular strength of this test is that a clinician can distinguish patients:

  • Normal sense of smell, normosmia score (35-40)
  • Different levels of reduction; mild (score of 31), moderate (score of 26-30)
  • Severe microsmia score (9-25), anosmia score (0-18)

Updates in the Guidelines 20199

EUFOREA* Guidelines

Defining response to biological treatment in CRSwNP patients

Evaluation of 5 criteria

  • Reduced nasal polyp size
  • Reduced need for systemic corticosteroids
  • Improved quality of life
  • Improved sense of smell
  • Reduced impact of comorbidities

Response For Treatment

EUFOREA* Consensus

Indications for biological treatment in CRSwNP patients
  • Evidence of Type 2 Inflammation
  • Need for systemic corticosteroids (2 or more courses in the past year)
  • Significantly impaired quality of life
  • Significant loss of smell
  • Diagnosis of comorbid asthma

*European Forum for Research and Education in Allergy and Airway diseases

Updates in the Guidelines 202010

EPOS** Guideline

Indications for biological treatment in CRSwNP
Presence of bilateral polyps in a patient who had ESS*
Criteria Cut-off Points
Evidence of Type 2 Inflammation Tissue eos ≥ 10/hpf, OR blood eos ≥ 250, OR total IgE ≥100
Need for systemic corticosteroids or contraindication to systemic steroids ≥ 2 courses per yr, OR long term (>3 months) low dose steroids
Significantly impaired quality of life SNOT-22 ≥ 40
Significant loss of smell Anosmic on smell test (score depending on test)
Diagnosis of comorbid asthma Asthma needing regular inhaled corticosteroids

Response For Treatment

Defining response to biological treatment in CRSwNP

Evaluation of 5 criteria

  • Reduced nasal polyp size
  • Reduced need for systemic corticosteroids
  • Improved quality of life
  • Improved sense of smell
  • Reduced impact of comorbidities
Excellent response 5 criteria
Moderate response 3 - 4 criteria
Poor response 1 - 2 criteria
No response 0 criteria

*Exceptional circumstances excluded (e.g., not fit for surgery)
**European Position Paper on Rhinosinusitis and Nasal Polyps

EUFOREA Expert Board Meeting on Uncontrolled Severe CRSwNP15

Evaluation of the clinical response to a biologic within 6 months of treatment: ‘‘continue or stop’’ suggestions

Selection of a biologic drug and monitoring of its effectiveness

Prediction of response in an individual patient is not possible today

Diagnosis of Uncontrolled Severe CRSwNP


Persistent or recurring CRSwNP despite long-term INCS, and having received at least one course of systemic corticosteroids* in the preceding 2 years and/or previous sinonasal surgery*

- Long-term low dose systemic corticosteroids is not recommended in CRSwNP

- One course of systemic corticosteroids refers to a minimum of 5 days of systemic corticosteroids at a dose of 0.5-1 mg/Kg/day or more

- Previous sinonasal surgery refers to any surgical procedure from the resection of polyps to conventional ESS or extended approaches


Bilaterlal CRSwNP with a NPS of ≥ 4, and persistent symptoms despite long-term INCS with the need for add-on treatment

- Bilateral polyposis (by nasal endoscopy)

- NPS ≥ 4 out of 8

- Presence of persistent symptoms assessed by:

  • Loss of smell score (0-3) ≥ 2 points
  • NCS (0-3) ≥ 2 points
  • SNOTT-22 ≥ 35 points
  • Total symptoms VAS ≥ 5 out of 10 cm

*unless having a medical contraindication/rejected by the patient

For the indication of Type 2 biologics including anti-IL4 receptor alpha (Dupilumab), anti-IgE (Omalizumab) and anti-IL5/R (Mepolizumab, Benralizumab), an underlying Type 2 inflammation should be highly likely

ESS, Endoscopic Sinus Surgery; INCS, Inhaled Corticosteroid; NCS, Nasal Congestion Score; NPS, Nasal Polyp Score; SNOT-22, 22-item Sino-Nasal Outcome Test; VAS, Visual Analog Scale.

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