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Nasal Treatment

Checked: 23-09-2022 by Jenny Henry Next Review: 23-09-2022

Nasal Polyps and Chronic Rhinosinusitis

Please see Rhinosinusitis & Nasal polyps for further advice on management in primary care and when to refer.

Referral Guidance

Funding Requirements

If malignancy is not suspected then referrals for certain nasal treatments may require prior approval or exceptional funding.

Referral for cosmetic surgery to the nose is not funded on the NHS as stated in the Cosmetic Surgery or Treatment policy and will only be considered in exceptional circumstances.

Referral for other non- cosmetic nasal treatments are subject to the Nasal Treatment – Non Cosmetic for All Ages policy, and prior approval is required. This policy has a section on referrals for Septoplasty/ Septorhinoplasty and advises:

Requests for corrective nasal surgery will be considered where:

1. The patient has:

a. A Post-traumatic nasal injury causing bilateral, continuous and chronic nasal airway obstruction associated with septal/bony deviation of the nose.

b. Nasal deformity secondary to a cleft lip/palate or other congenital craniofacial deformity.

c. Documented physical clinical problems caused by bilateral obstruction of the nasal airway and all conservative treatments have been exhausted*.

Note: Patients with acute nasal trauma within the last two weeks can be referred to ENT hot clinic or be seen following referral from ED (see nasal fracture section below)

*With regards to 'documented physical clinical problems' this could include one of more of the following: Difficulty breathing through the nose, nasal congestion, postnasal drip, nasal voice, mouth breathing, snoring, sleep apnoea, headaches, facial pain, decreased sense of smell.

With regards to 'all conservative treatments have been exhausted' this should include evidence that the following have been tried for a minimum of 3 months : Nasal douching, nasal steroids, advice on smoking cessation (further details on the Rhinosinusitis & Nasal Polyps page).

Diagnostic uncertainty

If a patient has atypical or red flag symptoms please see the section below for advice about when to refer.

If you still have concerns, you can request ENT advice and guidance for further support in managing your patient.

Red Flags

Please see Head and Neck - USC (2WW) guidelines.

Consider more urgent action (admission/urgent referral/discussion with ENT registrar on call) for patients with nasal symptoms and any of the following:

Crusting
Cachosmia
Orbital symptoms (including diplopia, ophthalmoplegia and reduced visual acuity)
Facial swelling
Signs of meningitis
Severe frontal headache
Neurological signs

Consider urgent referral in patients with unilateral symptoms, including unexplained nasal blockage and/or epistaxis (Patients should be examined to rule out septal deviation and bleeding from Little's area, which do not require an urgent referral).

(Updated July 25)

Nasal Fracture

Patients who have sustained a nasal injury/ fracture within the last 2 weeks can be offered an ENT Hot clinic appointment. This is the correct referral route for immediate post trauma fractures.

Patients will initially be assessed using a telephone triage system, in order to determine their suitability for manipulation under anaesthesia (MUA) in HOT clinic. Please provide a valid telephone number on their referral document as the patient can expect a phone call within 7 days of their injury date.

Red Flags: Septal Haematoma: it is the responsibility of the referring clinician to exclude a septal haematoma. If one is suspected or cannot be excluded, it should be discussed with the on-call ENT SHO for urgent assessment. Irreversible tissue necrosis occurs within 96 hours.

Please note that after 2 weeks following the injury, manipulation is no longer appropriate and patients can only be referred to outpatient clinic if they meet criteria laid out in the Nasal Treatment – Non Cosmetic for All Ages policy and prior approval has been obtained.

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.