Chronic rhinosinusitis with or without polyps

Scope

This guidance covers adults with nasal/sinus symptoms that have persisted for greater than 3 months.

Many patients will respond to conservative treatment, thus avoiding not only a referral to secondary care, but also potentially an operation – see management section below.

Assessment

Signs and Symptoms

  • Blocked nose
  • Usually less pain than in Acute Sinusitis but significant purulent post nasal drip
  • Reduced sense of smell

History and Examination

  • Polyps may be visible in the anterior part of the nose

Red Flags

If patient presents with:

  • Unilateral symptoms of obstruction with blood-stained discharge a 2ww referral should be made directly to ENT

Other features that are concerning and may warrant an urgent referral or advise from ENT include:

  • Unilateral polyp or obstruction over 3 weeks
  • Objective facial swelling
  • Paraesthesia of cheek
  • Persistent unexplained epistaxis
  • Loosening of teeth
  • Orbital pathology e.g. proptosis

Investigations

There is no place for plain x rays of the sinuses or CT scans in primary care.

Management

Many patients will respond to conservative treatment, thus avoiding not only a referral to secondary care, but also potentially an operation.

First line treatment in primary care should consist of:

  • Start with 3 months of continuous intranasal steroid spray
    • The type of spray is less important than the duration of its use. Care should be taken if steroid treatments are used in other sites, and it would be sensible to monitor growth in younger children. Raised intraocular pressure may occur, and patients with known glaucoma should be carefully monitored
  • Saline douching of nose. This is simple, safe, effective and cheap. There are ready made douches available that are well tolerated, and there is good evidence that use of these will reduce the symptoms of chronic rhinosinusitis
    • Sterimar: very convenient spray & can be bought over counter
    • Neilmed sinus rinse or Neti pots offer a better more vigorous douche-
    • ½ teaspoon salt
    • ½ teaspoon bicarbonate of soda
    • ½ pint of warm clean water (see patient info leaflet)

Treatment Adjuncts:

  • For severe symptoms of nasal obstruction consider use of steroid drops for up to 4 weeks, not repeating more than once a year
  • If symptoms of nasal allergy coexist (such as sneezing, rhinorrhoea and itching), then the use of a non-sedating antihistamine is recommended
  • Oral steroids: In patient with known bilateral nasal polyps without other contraindication e.g. prednisolone 20-30mg (see formulary 6.3 Corticosteroids), for 10-14 days dependent on size

Attention to smoking cessation and optimisation of asthma treatment if appropriate.

BSACI guidelines for the management of rhinosinusitis and nasal polyposis

Referral

Referral Criteria

Referral to ENT if failure of medical treatment as suggested in the 'Management' section above:

  • Patient has not responded to 3 months of continuous intranasal steroid spray with douching +/- appropriate adjuncts
  • and patient would consider surgical treatment

Referrals submitted without this information may be returned.

Referral Instructions

Information to include in referral:

  • History of allergy, any previous testing for allergy
  • History of chronic lung disease and effectiveness of management

e-Referral Service Selection

  • Specialty: Ear, Nose & Throat
  • Clinic Type: Nose/Sinus
  • Service: DRSS-Western-ENT- Devon CCG-15N

Referral Forms

DRSS referral form

Supporting Information

Evidence

European Position Paper on Rhinosinusitus and Nasal Polyps 2012

Pathway Group

This guideline has been signed off on behalf of the NHS Devon Clinical Commissioning Group.

Publication date: July 2019

Last updated: 01-12-2020

 

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