Loss of smell is often the symptom patients with chronic rhinosinusitis with nasal polyps (CRSwNP) care about most — and the hardest to restore.
In his editorial introducing the October 2026 sinonasal issue of Annals of Allergy, Asthma & Immunology, Larry Borish offers a practical rule that cuts through the biologics-versus-surgery debate: the steroid smell test.
If a short course of systemic corticosteroids restores smell, the olfactory epithelium is still capable of responding. That response argues for chronic type 2–targeted therapy — the inflammation injuring the epithelium (with loss of integrity, sensory neuron apoptosis, and impaired regeneration) is reversible, and it should be treated as such.
If a short steroid course does not restore smell, pharmacologic restoration is unlikely. That patient should not cycle through repeated steroid bursts or escalating medical therapy in hope of a different result. Olfactory training may still help, but expectations — and the treatment plan — should change.
Borish pairs this with two other stewardship points from the same issue.
First, frequent “acute sinusitis” is usually not an immunodeficiency problem: the most common cause of recurrent acute sinusitis is underlying chronic rhinosinusitis, and that is where the evaluation should start.
Second, surgery is not the old-fashioned option. Functional endoscopic sinus surgery plus follow-on medical therapy can produce long-term remissions and creates the access needed for irrigant-delivered therapy — without which medical therapy often fails. Biologics, by contrast, shrink polyps only by about 50%, and a year of a biologic costs roughly 3 to 4 times FESS with medical therapy.
His sequence, in short: operate first, reserve biologics for early recurrence — with one clear exception. Severe asthma argues for an early biologic, where one drug can treat both the upper and lower airways.
It is a refreshingly testable framework: one short steroid course, one objective question — did smell come back? — and a decision that follows from the answer.
References
Borish L. Recent advances in our understanding of the comorbid complications and treatment of chronic rhinosinusitis with nasal polyposis (CRSwNP). Ann Allergy Asthma Immunol. 2026 Oct;137(4):409-410. doi:10.1016/j.anai.2026.07.023
https://www.annallergy.org/article/S1081-1206(26)00361-3/fulltext