Rhinosinusitis

 

This guideline applies to children and adults.

 

Introduction

Nasal inflammation can be:

• Allergic
• Non-allergic – idiopathic, environmental, hormonal, drug-induced
• Infective

 

Red Flag Features

Nasal malignancy

Sinusitis with complications, including:

• Orbital involvement
  • Periorbital oedema or erythema
  • Displaced globe
  • Double vision
  • Ophthalmoplegia
  • Reduced visual acuity

 

• Intracranial involvement
  • Severe headache
  • Front swelling
  • Features of meningitis
  • Neurological signs

Invasive fungal infection

• Rare, life-threatening condition in immunocompromised patients
• Can present with acute rhinosinusitis, epistaxis, visual disturbance, acute confusion and/or decreased consciousness

 

Key Features of Assessment

 

Examine:

• Face – tenderness and/or swelling over sinuses.
• Nasal cavity – inflammation, discharge, polyps. Differentiate polyps (grey/white and insensate) from nasal turbinates (pink and sensitive):
  • Bilateral polyps are part of chronic rhinosinusitis and can be managed medically.
  • Unilateral polyps require further investigation, as they may represent more sinister pathology.
• Exclude dental infection
• Exclude red flag pathology

 

Investigations

Imaging (including x-ray and CT) is not recommended in primary care.

 

Management

Most cases of acute rhinosinusitis are viral, and antibiotics are generally not required – reserve for patients who are systemically unwell, with features of a more serious illness/condition or high risk of complications.

 

Acute viral rhinosinusitis

Symptoms typically last 2-3 weeks.

• Do not offer antibiotics – 80% of cases resolve within 14 days without antibiotics¹
• Self-care:
  • Oral analgesia for pain/fever
  • Nasal decongestants (e.g. Sudafed – maximum 5 days) and/or
  • Saline irrigation – see patient advice on Nasal Irrigation
• There is no evidence for oral decongestants, antihistamines, mucolytics, steam inhalation or warm face packs².

 

Acute post-viral rhinosinusitis

If symptoms increase after 5 days or last longer than 10 days, treat as above and add in a topical steroid nasal spray.

 

Acute bacterial rhinosinusitis

• If symptoms last more than 10 days without improvement consider no antibiotic or back-up antibiotic, depending on likelihood of bacterial cause².
• Consider prescribing a high-dose nasal steroid for 14 days for adults and children aged 12y or over (off-label use)².
• Offer immediate antibiotic if systemically unwell, features of a more serious illness/condition or has a high risk of complications. Follow local Antimicrobial Guidelines for Primary and Community Services pg 6-7.

 

Chronic rhinosinusitis

This is a complex inflammatory disorder, where symptom control and improving quality of life are the primary aims (rather than cure). It requires lifelong management with nasal steroids. Most cases will not require surgery, but if surgery is required, patients will still often require lifelong nasal steroids.

• Offer regular saline irrigation and a long-term nasal steroid spray.
• Review at around 4 weeks:
  • If symptoms improving, continue.
  • If not, review technique, consider alternative diagnoses and switch to short-term topical steroid nasal drops.
• Move and up and down the nasal steroid ladder as appropriate.

 

Allergic rhinitis

• Identify and eliminate allergens if possible.
• Oral antihistamine.
• Topical steroid nasal spray with good compliance.
• If above fails, replace the spray with topical steroid nasal drops – drops are not suitable for long-term maintenance, but sprays are.

 

Advice and Guidance

Seek ENT Advice and Guidance for:

• Diagnostic uncertainty
• Suspected sinonasal malignancy
• Unilateral nasal polyp
• Nasal mass with concerning features or atypical appearance

 

Do not refer any suspected sinonasal malignancy via ENT 2WW or urgent OPA, as this will either result in the referral being returned and/or a delay in the patient being seen.

 

Referral

Same-day care

In adults with signs of orbital or intracranial involvement or invasive fungal infection, discuss with ENT first on-call to arrange admission.

In unwell children, arrange admission via paediatric on-call who will typically liaise with ENT as required.

 

Planned care

Routine adult ENT referral

• Acute rhinosinusitis and poor response to treatment
• Recurrent acute rhinosinusitis (with resolution between bouts) – 4 or more episodes per year
• Chronic rhinosinusitis with significant impact on quality of life AND failure to improve after 3 months of optimal medical management
• Bilateral nasal polyps complicating assessment and/or treatment
• Poor control of allergic rhinitis symptoms despite adequate trial of medical treatment
• Significant obstructive symptoms

Have a lower threshold for referral in patients with coexistent chronic lung disease.

 

Routine paediatric ENT referral

• Suspected or confirmed nasal polyps – consider Cystic Fibrosis and refer early to paeds

 

Supporting Information

For professionals:

NICE CKS – Sinusitis

 

For patients:

ENT UK – Sinusitis

NHS – Sinusitis

Treating your respiratory tract infection

 

References

1. Hansen, FS, Hoffmans, R. Complications of acute rhinosinusitis in The Netherlands. Oxford Academic. 2012 Apr.
2. NICE Sinusitis (acute): antimicrobial prescribing, visual summary
3. European Position Paper on Rhinosinusitis and Nasal Polyps, 2012

 

 

Page Review Information

Review date	28/03/2024
Next review date	28/03/2026
GP speciality lead	Dr Laura Vines
Contributors	Ms Aileen Lambert, Consultant ENT Surgeon Mr Neil Tan, Consultant ENT Surgeon