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 prior to referral

Imaging (including x-ray and CT) is not recommended in primary care and is not a pre-requisite to referral.

 

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. 9. 

There is no role for prolonged courses of antibiotics in primary care⁴.

 

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

• Follow guideline on Allergic Rhinitis.

 

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

*Refer any patient with concerning clinical findings as outlined in the Nasal Malignancy guideline via ENT Advice and Guidance – the consultant will consider the clinical information and advise regarding appropriate prioritisation and urgency of referral.

Do not send via Fast Track ENT Suspected Cancer or urgent ENT OPA, as this will result in the referral being returned and may delay 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.

 

Routine ENT referral:

• moderate or severe symptoms after a 3-month trial of intranasal steroids and nasal saline irrigation.
• nasal symptoms with an unclear diagnosis in primary care.
• treatment with topical steroids is contraindicated.
• patients with co-existent immunodeficiency.
• patients with co-existent conditions, such as primary ciliary dyskinesia, cystic fibrosis* and/or NSAID-eosinophilic respiratory disease (Samter’s Triad: aspirin sensitivity, asthma, CRS).
• as part of surgical access or dissection to treat non-sinus disease (for example pituitary surgery, orbital decompression for eye disease, nasolacrimal surgery)

 

Suspected or confirmed nasal polyps in children – consider Cystic Fibrosis and refer early to paediatrics.

 

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
4. NHS CIOS Commissioning Policies and Evidence-based Interventions

 

Page Review Information

Review date	15th May 2025
Next review date	15th May 2026
GP speciality lead	Dr Laura Vines

Contributors

Ms Aileen Lambert, Consultant ENT Surgeon Mr Neil Tan, Consultant ENT Surgeon