Symptoms

• Nasal obstruction (blockage or congestion)
• Discharge
• Facial pain or pressure
• Reduced or absent sense of smell

Examination

• Nasal inflammation, mucosal oedema, mucopurulent nasal discharge
• Associated pathology such as nasal polyps.
• Anatomical abnormalities such as septal deviation

Urgent referral via the 2-week Suspected Head and Neck Cancer pathway is required if there are:

• unilateral symptoms (persistent purulent discharge or nasal obstruction with epistaxis) or clinical findings (unilateral nasal mass or polyp)
• orbital symptoms (such as diplopia or reduced visual acuity)
• neurological symptoms or signs.

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

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.
  • It is important that it is used in the correct way (see patient information on MyHealth-Devon)
  • Please refer to Formulary guidance on suitable formulations 12.2.1 Drugs used in nasal allergy (devonformularyguidance.nhs.uk)
• Nasal saline irrigation.
  • This is simple, safe, effective, and cheap.
  • There are ready made douches available to buy over the counter that are well tolerated. (see patient information on MyHealth-Devon)

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 (5-10 days): In patient with known bilateral nasal polyps without other contraindication (see formulary 6.3 Corticosteroids).

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

Patients should be advised to avoid allergic triggers and practise good dental hygiene to reduce the risk of dental infection (which can be associated with CRS).

BSACI guidelines for the management of rhinosinusitis and nasal polyposis

Referral Criteria

Referral for specialist assessment will only be funded when:

1. Patients have received a 3-month trial of intranasal steroids† and nasal saline irrigation AND have no improvement in symptoms of chronic rhinosinusitis (CRS) which is defined as:

• Two or more persistent symptoms, one of which includes nasal obstruction (blockage or congestion) OR nasal discharge (anterior/posterior nasal drip).
• Additional symptoms may include facial pain/pressure OR reduction or loss of smell.

Patients with bilateral nasal polyps should also have had no improvement in symptoms 4 weeks after a trial of 5-10 days of oral steroids†.

OR

2. There is a concern regarding significant pathology that requires urgent ENT specialist opinion, but the patient does not have symptoms and signs that warrant a two week wait suspected cancer referral.

OR

3. Patients have unilateral symptoms (persistent purulent discharge or nasal obstruction with epistaxis) or clinical findings (unilateral nasal mass or polyp), orbital or neurological features. These patients should be referred via the 2-week suspected Head and Neck cancer pathway.

† (unless contraindicated)

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-Eastern-Ear Nose and Throat-Devon ICB-15N

Referral Form

DRSS Referral form

Patient Information

MyHealth-Devon -Rhinitis

Evidence

European Position Paper on Rhinosinusitus and Nasal Polyps 2012

Sinusitis | Health topics A to Z | CKS | NICE (March 2021)

Pathway Group

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

Publication date: July 2019

Updated: February 2023 in line with updated commissioning policy