Bilateral vs unilateral chronic rhinosinusitis in HIV: distinct clinical and inflammatory characteristics from a surgical cohort

The European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) 2020 classification for chronic rhinosinusitis (CRS) hasn’t been extensively characterized in people living with HIV (PLWH), a population with a high burden of sinonasal disease. This study aimed to characterize the clinical features of surgical HIV-associated CRS and compare bilateral versus unilateral disease. This single-center, retrospective surgical cohort study included 60 consecutive patients with HIV-associated CRS requiring endoscopic sinus surgery between January 2020 and June 2025 at Beijing You’ an Hospital, a national designated center where a large proportion of HIV-associated CRS surgical cases have been managed in China. Demographic, clinical, laboratory (including eosinophil/neutrophil counts), and radiological (Lund-Mackay score, E/M ratio) factors were analyzed. Univariate comparisons were performed using the Mann–Whitney U test for continuous variables and χ 2 test (or Fisher’s exact test) for categorical variables to identify factors associated with bilateral CRS. The cohort comprised 60 PLWH (median age 36.0 years; 95.0% male), with bilateral CRS being predominant (78.3%). The most common sinonasal symptoms were nasal blockage (96.7%), purulent rhinorrhea (48.3%), and hyposmia (40.0%). Patients with bilateral CRS had a significantly higher prevalence of nasal blockage and sleep disturbance compared to those with unilateral disease (p = 0.04 and p = 0.03, respectively). Univariate analysis revealed significant differences between bilateral and unilateral CRS in eosinophil parameters (both count and percentage: p < 0.001), neutrophil percentage (p = 0.02), Lund-Mackay CT scores (p = 0.007), and the ethmoid-to-maxillary sinus ratio (p = 0.04). In PLWH with CRS requiring surgery, bilateral disease was the predominant presentation and was associated with greater radiographic severity and a higher peripheral eosinophil count. These findings suggest potential clinical relevance of the EPOS 2020 anatomic classification in this population, but this requires prospective validation.