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Nasal Steroids

 

Patient resources

https://www.nhs.uk/conditions/steroid-nasal-sprays/

 

 

Indications

Consider prescribing nasal steroids in the following clinical circumstances:

  1. Allergy
     
  2. Sinusitis
    • Acute: commence if symptoms persist for >10 days with no improvement
    • Chronic: consider a course of intranasal steroids for up to 3 months
       
  3. Nasal polyps
     
  4. Nasal discharge (anterior or posterior, clear or mucopurulent)

 

Contraindications

  1. Active untreated nasal infection (fungal, bacterial or viral)
     
  2. Pulmonary TB

 

Nasal steroid ladder

In the absence of red flags, ENT suggest taking a stepwise approach to using nasal steroids:

 

1. Self-care

  • Remove potential allergens
  • For mild symptoms, consider OTC treatment including:
  • Nasal saline douche e.g. Neilmed Sinus Rinse
  • Non-sedating oral antihistamines e.g. Cetirizine
  • Short courses of topical decongestants e.g. Sudafed (beware rhinitis medicamentosa when used for >5d)

 

2. Topical steroid sprays- trial regularly for at least 4 weeks

  • Add in for mod-severe symptoms
  • Fluticasone proprionate(Flixonase / Nasofan)/ fluticasone furoate(Avamys)/ mometasone furoate (Nasonex) sprays
  • Can be continued longterm with minimal risk of systemic absorption
  • If there is some bleeding, check technique and consider topical vaseline and 2 week break
  • For allergic rhinitis, combination intranasal fluticasone propionate and azelastine is the medication of choice
  • Please see below for instructions on nasal spray usage

 

3. Topical steroid drops - trial regularly for at least 6 weeks

  • Fluticasone proprionate 400mcg/unit dose nasal drops (Flixonase nasule)
  • Half an ampoule (200mcg) BD into each nostril
  • Please see below for instructions on nasal droplet usage
  • If there is some bleeding, check technique and consider topical vaseline and 2 week break

 

4. (Oral steroids)

  • Only start oral steroids if patient has had polyps confirmed with a scope by ENT or are clearly obvious on anterior rhinoscopy. Please note the difference between an inferior turbinate and a nasal polyp as per the images below

 

5. Refer

  • Patients with on-going troublesome symptoms despite a recent trial of the treatments outlined in steps 1-3

 

Left nasal cavity. This is a normal left inferior turbinate. Note its attachment to the lateral nasal wall and healthy, pink surface appearance. The nasal septum is on the left hand side of the image.

 

Right nasal cavity. IT = inferior turbinate. NP = nasal polyp. Note the difference in appearance of the pink IT and pale yellow, glassy NP.

 

Nasal steroid application technique

 

 

 

 

References

https://cks.nice.org.uk/topics/corticosteroids-topical-skin-nose-eyes/management/intranasal-corticosteroid-treatment/

 

 

Review Date                April2022

Next Review Date        April 2023

GP Sifter                      Dr Laura Vines

Contributors                 Ms Aileen Lambert

                                    Mr Neil Tan

Version                        2.0