Bilateral vs Unilateral Chronic Rhinosinusitis in HIV: Distinct Phenotypes from a Surgical Cohort

Background The European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) 2020 classification for chronic rhinosinusitis (CRS) lacks validation in people living with HIV (PLWH), a population with a high burden of sinonasal disease. This study aimed to phenotype surgical HIV-associated CRS and compare bilateral versus unilateral disease. Methods This single-center, population-based 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 nearly all 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 and multivariable logistic regression identified associations with bilateral CRS. Results The cohort comprised 60 PLWH (median age 36.0 years; 95.0% male), with bilateral CRS being predominant (78.3%). Univariate analysis revealed significant differences between bilateral and unilateral CRS in eosinophil parameters (both count and percentage: p < 0.001), neutrophil percentage (p = 0.018), Lund-Mackay CT scores (p = 0.007), and the ethmoid-to-maxillary sinus ratio (p = 0.037). On multivariable analysis, bilateral disease remained independently associated with a higher Lund-Mackay CT score (adjusted odds ratio [aOR] = 1.60, 95% CI: 1.02–2.51, p = 0.043) and an elevated blood eosinophil percentage (aOR = 2.27, 95% CI: 1.01–5.14, p = 0.049). Conclusions In PLWH, bilateral CRS is the dominant phenotype. Its association with radiographic severity and a type 2 inflammatory marker supports the use of the EPOS 2020 anatomic classification in this population.