Rhinosinusitis & Nasal Polyps

Overview

ENT Clinics are currently under extreme pressure as a result of COVID recovery and increased demand for appointments.

Please consider using primary care management pathways where possible and only refer patients if these options have been exhausted. When referring, please also warn patients of long waits for outpatient appointments. The ENT service kindly requests that if patients approach referrers requesting an appointment to be expedited not to ask them to ring the hospital as they will not be able to help. Only submit written requests to expedite if there is clinical deterioration or concern. Do not submit another eRS referral in this situation as these requests will be returned.

Current waits for outpatient clinics in ENT are as follows (January 2024):

• Otology- 8 months
• Rhinology- 6 months
• Head and Neck- 5 months

Rhinosinusitis is defined as inflammation of the nose and paranasal sinuses.

Acute rhinosinusitis

Acute rhinosinusitis in adults is diagnosed if there is sudden onset of two or more symptoms, one of which should be either nasal blockage / obstruction / congestion or nasal discharge (anterior / posterior nasal drip) and facial pain/ pressure or reduction or loss of smell.

There is usually complete resolution of symptoms within 12 weeks of onset. (1)

Most cases of acute rhinosinusitis are self limiting and antibiotics are not routinely indicated.

Acute bacterial sinusitis is suspected when symptoms last longer than 10 days and include discoloured or purulent nasal discharge, severe local pain, fever greater than 38ºC, and deterioration after an initial mild illness. Please see Antibiotic prescribing guidelines for advice on appropriate antibiotic use. 

Chronic rhinosinusitis

Chronic rhinosinusitis is diagnosed when symptoms last for longer than 12 weeks (1,2).

• In adults, it is diagnosed by the presence of nasal blockage (obstruction/congestion) or nasal discharge  (anterior/posterior nasal drip) with facial pain or pressure (or headache) and/or reduction (or loss)of the sense of smell,  lasting for longer than 12 weeks without complete resolution. 
• In children, it is diagnosed by the presence of nasal blockage (obstruction/congestion) or nasal discharge (anterior/posterior nasal drip) with facial pain/pressure and/or cough (daytime and night-time), lasting for longer than 12 weeks.

Chronic rhinosinusitis is a highly prevalent condition affecting 10% of the UK adult population. It is associated with significant reduction of quality of life, high health-care utilisation and significant absenteeism/presenteeism.

Chronic rhinosinusitis is sub-categorised by the presence or absence of nasal polyps (CRSwNP or CRSsNP respectively).

Allergic Rhinitis

For advice on management of allergic rhinitis please see the Immunology & Allergy Guidelines.

There are also prescribing guidelines in the BNSSG Formulary for Allergic Rhinitis

Who to refer

Red Flags - consider 2WW or HOT clinic referral if there are red flags (see section below)

Manage in Primary care - If there are no red flags then patients should be managed in primary care using the guidelines in the 'Before Referral' section below.

Advice and Guidance - If management in primary care has not been effective then please consider requesting advice from ENT Advice and Guidance. However please be aware that even if the guidance is to refer then the Non Cosmetic Nasal Treatment and Sinusitis Policy will still apply and referrals may be returned if prior approval is required.

Prior Approval - If referral for treatment in secondary care is required then referrals require prior approval . Please refer to the Non Cosmetic Nasal Treatment and Sinusitis Policy (which applies to all ages) for further information and submit the completed prior approval application form together with supporting evidence and your referral. Please note, with regards to CRS and nasal polyps the policy states that prior approval criteria will be met if:

A clinical diagnosis of CRS has been made (as set out in RCS/ENT-UK Commissioning guidance*) in primary care and patient still has moderate/severe symptoms after a 3-month trial of intranasal steroids and nasal saline irrigation. (please consider the treatment advice in the Before Referral section below and provide evidence of treatments tried in the PA application)

AND

In addition, for patients with bilateral nasal polyps there has been no improvement in symptoms 4 weeks after a trial of 5-10 days of oral steroids (prednisolone 0.5mg/kg to a max of 60 mg). (please consider the treatment advice in the Before Referral section below and provide evidence of treatments tried in the PA application)

OR

Patient has nasal symptoms that are atypical or there are concerns about the diagnosis. (see red flag section below).

*The diagnostic definition is included in the Overview section above, or see links in the resources section below (1,2)

Exceptional Funding - If the patient does not meet the criteria in the prior approval policy and there are exceptional circumstances then you can consider applying for Exceptional Funding for the patient. You can do this by completing the EFR application form and by emailing it from an nhs.net account to BNSSG.EFR@nhs.net.

Red Flags

Please see Head and Neck 2WW guidelines.

Refer all patients with unilateral nasal obstruction with bloody discharge via 2WW pathway.

Also consider more urgent action (admission/2WW referral/discussion with ENT registrar on call) in patients with nasal symptoms and any of the following:

• unilateral symptoms
• bleeding
• crusting
• cacosmia (perceived malodorous smell within the nose)
• orbital symptoms
• periorbital oedema/erythema
• displaced globe
• double vision
• reduced visual acuity
• ophthalmoplegia
• severe unilateral or bilateral frontal headache
• frontal swelling
• sign of meningitis
• neurological signs

Before referral

If there are no red flags present then consider the following:

Self-care (for all patients)

• Saline irrigation – to relieve congestion and nasal discharge. (This is not included in BNSSG formulary but patients can make their own - see attached leaflet - or purchase from community pharmacy)

  Nasal Irrigation - UH Bristol pt leaflet :

• positive pressure squeeze bottles are available to aid douching
• high volume irrigation is more effective than saline sprays
• Nasal douche e.g Neilmed Sinus Rinse or Sterimar, both OTC
• Steam inhalation is not recommended, because of a risk of burns, unless from a hot bathtub or shower
• Practice good dental hygiene to reduce the risk of infection, which can be associated with chronic rhinosinusitis
• Stop smoking and avoid passive smoking.
• Avoid underwater diving if there are prominent symptoms.
• OTC nasal steroids (beclomethasone, mometasone, fluticasone are all available over the counter)

Prescribing:

The following treatments are available in primacy care but patients should be reviewed regularly to assess for red flags and consider referral if indicated:

• Topical corticosteroid spray
• For all topical treatments ensure patients have advice on correct application technique. See patient leaflets on how to use nasal sprays and drops.
• First line - Use beclomethasone or mometasone (both available otc). Beclomethasone, a first generation steroid, is cheaper but may have a small risk of systemic side effects. Mometasone is a second generation steroid, is more expensive, may have less risk of systemic side effects and is generally favoured by ENT specialists. BNSSG Formulary-Nose
• Initial treatment should be tried for 3 months
• Second line - If first line steroid is not effective then assess compliance and technique and consider switch to 2nd line steroid (mometasone or fluticasone) and use for 3 months.
• Third line - Dymista (azelastine/fluticasone) can also be used as a 3rd line option if monotherapy is not effective.
• Topical corticosteroid drops - If no response to sprays consider course of Fluticasone* or Betamethasone nasal drops. It is important to use correctly (5). Try for a month before evaluating if they were effective. (4). (*February 2024 update - there may be supply issues with fluticasone nasules - see advice on recommended alternatives from ENT UK)
• Oral antihistamine - Consider adding antihistamine if symptoms thought to have an allergic origin.
• Montelukast may be useful in rhinitis and is licensed if the patient also has asthma. Chronic rhinitis can also exacerbate asthma symptoms (4)  but evidence for use in chronic rhinosinusitis  is weak (3).
• Oral antibiotics -  Macrolides have  an anti inflammatory as well as antibacterial effect. Evidence for their use is weak and the EPOS2020 guidelines (3) do not recommend them to due to risk of side effects in longer term use.
• Oral steroids - a short course of oral steroids may be helpful in shrinking nasal polyps (see below).

Nasal Polyp

If confidence level is high ie. you have identified a visible polyp or there is previous evidence of polyps or chronic sinusitis based on specialist review, consider intensive treatment of 1 week oral prednisolone 20-30mg daily followed by 4-6 weeks fluticasone nasules, 1/2 AMP each side once or twice a day.

The EPOS2020 steering group felt that 1-2 courses of systemic corticosteroids per year can be a useful addition to nasal corticosteroid treatment in patients with partially or uncontrolled disease (3).

Surgical intervention in the treatment of Nasal Polyps will only be considered in patients who fail to improve after a trial of maximal medical treatment for a period of at least 6 months, and this information is fully documented within the patient’s clinical records and prior approval as been confirmed - see the Non Cosmetic Nasal Treatment and Sinusitis Policy.

ENT UK advise: “Polyps respond and shrink using drops or sprays in up to 80% of people. New nasal steroid sprays can be taken to control symptoms for many years as very little is absorbed into the body and they can work well, but many take up to six weeks of treatment before their full effect can be felt.”

Unilateral polyps which bleed or are associated with other red flags should be referred via 2WW (or discuss with on call ENT registrar).

Unilateral polyps which do not bleed should be referred urgently for diagnostic opinion (or discuss with on call ENT registrar if more immediate concerns).

Imaging

Plain x-ray - There is no role for plain X-ray in assessment of chronic rhinosinusitis (plain X-ray, despite low cost and availability, has limited usefulness due to underestimation of bony and soft tissue sinus pathology).

CT scan - CT imaging is usually reserved for those who fail medical therapy as an aid to surgical management or have complicated infection/more serious conditions and should not be used routinely in primary care.

Referral

Please check the information on the page above and in the nasal treatment policy before referral.

Consider using ENT Advice and Guidance.

If criteria are met and referral is considered necessary then please submit your referral to ENT via eRS together with completed prior approval funding forms if required. Referrals that are submitted without completed Prior Approval forms or do not meet criteria will be returned.

Rhinitis medicamentosa

Prolonged use of topical nasal decongestants (for more than 7-10 days) may result in rebound congestion of the nasal mucosa. This prompts further application of the decongestant and a vicious circle of use develops.

Other drugs known to cause this include antihypertensives (eg, angiotensin-converting enzyme (ACE) inhibitors, methyldopa, beta-blockers), chlorpromazine, gabapentin, penicillamine, aspirin, non-steroidal anti-inflammatory drugs (NSAIDs), cocaine, exogenous oestrogens and oral contraceptives. (1)

Treatment

1. Cessation of use of the medication concerned. It can take 2 weeks for symptoms to improve. Warn patients that symptoms may initially seem worse before they start to get better. (2)

2. Nasal saline douches and/ or nasal steroid sprays can help in recovery and help  treat other underlying causes.

(1) Non-allergic Rhinitis. Learn about Non-allergic Rhinitis | Patient

(2) Rhinitis Medicamentosa Treatment & Management: Medical Care, Surgical Care, Consultations (medscape.com)

(3) Rhinitis Medicamentosa: How Long It Lasts & Treatment Options (clevelandclinic.org) - information for patients.

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.