Chronic Rhinosinusitis - Paediatric

Chronic rhinosinusitis is a multifactorial condition, defined by symptoms lasting longer than 12 weeks.

It affects mostly older children, in the 10-to-15-year age group.

Diagnostic Criteria

Characteristic symptoms in addition to objective evidence of sinonasal inflammation on examination
Presence of nasal blockage (obstruction / congestion) or nasal discharge (anterior / posterior nasal drip)

AND

Facial pain / pressure and / or cough (day and night)
Lasting for longer than 12 weeks.

Predisposing factors include exposure to cigarette smoke, bacterial infection, allergy, physical obstruction, immune deficiency, cystic fibrosis and prolonged use of intranasal decongestants.

Patients with coexisting allergic rhinitis may also have symptoms such as sneezing, watery rhinorrhoea, nasal itching and itchy watery eyes.

C.M & G.T – 27-10-26

Virtually all can be managed medically without referral as chronic rhinosinusitis is largely a chronic inflammatory condition. Please see Primary Care Management for further detail.

Who to refer:

Note: Periorbital cellulitis is a red flag for acute ethmoiditis, and these children should be referred to A&E without delay.

Please refer to outpatients children and young people aged under 16 with:

Unilateral symptoms
Obstruction without other symptoms
Where initial management has failed.

Those aged 16 and older should be referred to adult services.

How to refer

By SCI Gateway to RHCYP if aged under 16; and to ENT Adult services if aged 16 or over.
If referring for nasal polyps, please provide photos as the vast majority of possible polyps are engorged turbinates (see RefHelp Nasal Polyps)

Anterior rhinoscopy (using otoscope and large speculum)

Signs which support a diagnosis of chronic sinusitis such as nasal inflammation, mucosal oedema and mucopurulent discharge
Associated pathology such as nasal polyps

Assess for predisposing factors

Allergic rhinitis
Asthma
Immunosuppresion
Exposure to cigarette smoke (active / passive).

Management

Address predisposing factors including allergen avoidance
Regular nasal douching with saline solutions (spray or rinse preparations)
Intranasal steroids with low bioavailability for a minimum of 3 months
Oral antihistamine if suspect allergy
Treat eye symptoms if present (Sodium cromoglycate)
Plain X-rays should NOT be performed.

Nasal corticosteroid with low bioavailability – according to age group (years):

Azelair + rhinolast are licensed for 6+.
Fluticasone propionate is licensed for 4+.
Fluticasone furoate is licensed for 6+.
Azelastine hydrochloride + Fluticasone propionate and Olopatadine hydrochloride + Mometasone furoate are licensed for over 12.
Combination therapy (intranasal + antihistamine) can be started from 6+ as individual sprays or off license with Azelastine hydrochloride + Fluticasone propionate.
Mometasone licenced 3+

If unsuccessful after 3 months:

Ensure treatment compliance