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Nasal Steroids

 

This guideline applies to children and adults.

 


Introduction

The extent of systemic absorption following intranasal administration varies between steroids – mometasone furoate and fluticasone have negligible absorption, whilst betamethasone has high absorption and should therefore only be used short-term1.

 


Red Flag Features

Nasal malignancy

 


Key Features of Assessment

Indications:

  • Allergic rhinitis
  • Rhinosinusitis – acute (if symptoms worsen after 5 days or persist for more than 10 days without improvement) and chronic
  • Bilateral nasal polyps
  • Nasal discharge


Contraindications:

  • Active untreated nasal infection
  • Post-nasal/sinus surgery (until advised to give nasal steroids by specialist)
  • Pulmonary TB

 


Management

In the absence of red flag features, ENT recommend taking a stepwise approach to using nasal steroids:


 


Step 1: self-care

For mild symptoms

  • Remove potential allergens/triggers.
  • Nasal irrigation – either using home-made solution or Neilmed Sinus Rinse.
  • Non-sedating oral antihistamine.
  • Short course of topical nasal decongestant e.g. Sudafed – maximum 7 days to avoid rhinitis medicamentosa.

 

Step 2: topical nasal steroid sprays

For moderate symptoms

  • Provide patient information.
  • Trial regularly for at least 4 weeks.
  • It is essential that they are applied correctly.
  • In adults, preferred options include:
    • Fluticasone proprionate (Flixonase/Nasofan)
    • Fluticasone furoate (Avamys)
    • Mometasone furoate (Nasonex)
    • Allergic rhinitis: Fluticasone propionate and Azelastine
  • In children, preferred options include:
    • Mometasone furoate (Nasonex) – licensed from 3yo
    • Budesonide – licensed from 6yo
  • In adults, if clinically indicated, these sprays can be used long-term with minimal risk of systemic absorption. However, be mindful, there is a risk of septal perforation with long-term use.
  • Avoid beclomethasone (Beconase). Due to its high systemic absorption it has been shown to impair growth – especially when taken alongside other steroids.
  • If there is bleeding – check technique and consider topical Vaseline and a 2-week break.

 

Step 3: topical nasal steroid drops

For severe symptoms

  • Licensed for 16 years and over.
  • Trial regularly for up to 6 weeks.
  • It is essential they are applied correctly.
  • Preferred options include:
    • Fluticasone proprionate 400mcg/unit dose nasal drops half an ampoule (200mcg) BD into each nostril
  • Avoid beclomethasone drops.
  • Drops are not suitable for long-term maintenance, so once control of symptoms has been achieved it is advisable to step down to nasal steroid sprays.
  • If there is bleeding – check technique and consider topical Vaseline and a 2-week break.

 

(Step 4: oral steroids)

Only start oral steroids in adults if known polyps which have either been confirmed on nasoendoscopy by ENT or are clearly obvious on anterior rhinoscopy.

Unilateral polyps or a suspicious looking nasal mass warrants seeking ENT Advice and Guidance.


 

Image 1: Left nasal cavity with septum on left-hand side as you look at the image. This is a normal left inferior turbinate. Note its attachment to the lateral nasal wall and healthy, pink surface appearance.  It will be sensitive to touch.

Image 2: Right nasal cavity with septum on right-hand side as you look at the image. IT = inferior turbinate. NP = nasal polyp. Inferior turbinates are commonly mistaken for nasal masses or polyps. Note the difference in appearance of the pink turbinate and pale yellow, glassy polyp in this image. Sometimes polyps can be pink or grey, but unlike turbinates they are insensate.

 

Step 5: refer

Arrange routine adult ENT referral for patients with ongoing troublesome symptoms despite a recent adequate trial of treatments outlined in steps 1-3.

 

Application of nasal steroids

It is essential that nasal steroids are applied correctly:

 

 

Advice and Guidance

ENT Advice and Guidance is available if required.

 

Supporting Information

For professionals:

BNF – Treatment Summaries: Nose

 

For patients:

NHS – Steroid nasal sprays

 

References

  1. BNF – Treatment Summaries: Nose
  2. NICE CKS – Intranasal Corticosteroid Treatment

 

 

Page Review Information

Review date

05/04/2024

Next review date

05/04/2026

GP speciality lead

Dr Laura Vines

Contributors

Ms Aileen Lambert, Consultant ENT Surgeon

Mr Neil Tan, Consultant ENT Surgeon