Endotype-Guided Imaging in Chronic Rhinosinusitis: HRCT/CBCT and MRI Metrics, Structured Reporting, and Radiomics-A Systematic Review

Chronic rhinosinusitis (CRS) is a heterogeneous inflammatory disease of the paranasal sinuses. Imaging, particularly high-resolution computed tomography (HRCT), cone-beam computed tomography (CBCT) in selected scenarios, and magnetic resonance imaging (MRI), supports diagnosis, treatment planning, and follow-up by combining anatomic mapping, disease extent, remodeling, and complication assessment. This systematic review synthesizes evidence on endotype-aware imaging in CRS and proposes a structured reporting model grounded in quantitative, management-oriented criteria. Methods: Following PRISMA 2020, the review protocol was registered in PROSPERO 2026 (CRD420261356154); we searched MEDLINE, Scopus, Embase, and Cochrane (January 2000–September 2025). Ninety-six studies were included in qualitative synthesis; 38 studies reported quantitative outcomes summarized descriptively. We evaluated HRCT/CBCT/MRI protocols, radiologic indices (Lund–Mackay, GOSS), diagnostic performance in relevant clinical domains, imaging–endotype correlations, and radiomics/artificial intelligence (AI) applications. Key Results: HRCT served as the reference modality for anatomic assessment and preoperative planning in most cohorts; CBCT was selectively used for bony evaluation with lower radiation exposure than conventional CT, albeit without reliable soft-tissue characterization. MRI was mainly applied for soft-tissue characterization, unilateral disease, and suspected complications. Radiomics/AI studies reported areas under the receiver operating characteristic curve (AUC) ranging from 0.79 to 0.93 for distinguishing type 2-high from non-type 2-high CRS, with external validation reported in a minority of studies. Conclusions: Endotype-aware imaging can support more precise, quantitative CRS management when interpreted together with clinical, endoscopic, and biomarker data. Structured reporting and radiomics may contribute to standardization, but require prospective validation and transparent reporting to enable clinical translation within multidisciplinary care pathways aligned with international guidance.