Objectives We set out to create Consensus Guidelines, based on current evidence and relative risks of adverse effects and the costs of different treatments, that reflect the views of the British Rhinological Society (BRS) Council on where the use of biologics should be positioned within treatment pathways for CRSwNP, specifically in the setting of the National Health Service (NHS). Methods An expert panel of 16 members was assembled. A review of the literature and evidence synthesis was undertaken and circulated to the panel We used the RAND/UCLA methodology with a multi-step process to make recommendations on the use of biologics. Setting and participants N/A Results Recommendations were made, based on underlying disease severity, prior treatments and co-morbidities. A group of patients for whom biologics were considered an appropriate treatment option for CRSwNP was defined. Conclusions Although biologics are not currently available for the treatment of CRSwNP, the BRS Council have defined a group of patients who have higher rates of ‘failure’ with current treatment pathways, higher resource use and are more likely to suffer with uncontrolled symptoms. We would urge NICE to consider approval of biologics for such indications without applying further restrictions on use.

Key Points • Clinical N3b staging is defined as unequivocal and unambiguous signs of extra nodal extension (ENE), such as skin involvement, muscle invasion or nerve dysfunction, supported by radiological evidence. • There is a paucity of studies determining interobserver reliability of clinical detection of overt ENE. • A prospective comparative cohort study assessing 12 Head and Neck surgeons’ inter-observer agreement in detecting the components of overt ENE. • We reveal high surgeon agreement in the ability to detect lymph nodes, the presence of skin involvement and in surrounding nerve involvement. • Variability of surgeon assessment was seen in the assessment of overt muscular involvement.