Please also aim for TREATMENT OPTIMISATION:
- Chronic rhinosinusitis is a chronic disease requiring ongoing long-term medical management:
- during the pandemic this will need to be both optimised and prolonged before referral considered
- ORAL STEROIDS can be used judiciously – details on the LJF.
- the ENT specialist view is that topical nasal fluticasone can be used for longer than 12 weeks without specialist referral during pandemic times
- Referrals for rhinosinusitis will be accepted for red flag symptoms where urgent diagnosis is required
- Nasal polyps can be treated with Doxycycline 100mg for 3 weeks in addition to fluticasone nasules / beclomethasone drops.
- Nasal and sinus tumours are exceptionally rare
- Referrals for septal deformities or deviations will be accepted where there is significant airway obstruction. However patients need to be informed that there will be a long waiting time for assessment and surgery (up to 2 years).
Rhinitis is inflammation of the nasal mucosa. Clinically it is defined as 2 or more of the following symptoms for more than 1 hour on most days:
- Nasal discharge
- Nasal obstruction
- Sneezing/Irritation
Referral to ENT
- Skin prick testing for allergy
- Failure of medical therapy (1st and 2nd line OR as per previous ENT recommendations) for recurrent acute sinusitis or chronic rhinosinusitis
- Structural deformity
- Persistent unilateral symptoms particularly if associated with serosanguinous discharge or facial pain
- Unilateral polyp or mass
History
Symptoms as above. Seek out other respiratory disease such as asthma. Check occupation (exposure to inhaled irritants), history of allergies/atopy, drug and smoking history.
Examination
Assess any obvious nasal deformity. Objectively assess airflow (condensation on cold metal or mirror). Perform anterior rhinoscopy and look for septal deviation, enlarged turbinates, nasal discharge and other unusual pathology such as polyps or tumours.
Investigation
If allergy is suspected and this diagnosis is going to change management, IgE screen (in primary care) or preferably skin prick tests (can be undertaken after referral to ENT). Patients must stop antihistamines at least 72 hours before skin prick testing
Differential diagnosis
- Rhinosinusitis
- Structural obstruction
- Nasal hyperactivity
- Hormonal
- Drug induced
Management
Primarily medical therapy using the least aggressive combination that gives symptom control.
- Regular saline nasal douching ( Please see leaflet on Salt Water Rinse).
- Allergen avoidance
- Antihistamine (if allergy suspected) also leukotriene antagonists may be considered in asthmatics
- Topical nasal steroid sprays (Minimum 2 bottle trial of first and second line before referral to secondary care)
- Topical nasal steroid drops (Flixonase nasules)– although the BNF states this is not suitable for primary care we have no objection to courses up to 12 weeks being prescribed if nasal sprays have been ineffective. Courses longer than that should only be on the recommendation of secondary care
- Systemic steroids (Prednisolone 25 mg a day for 2 weeks, only, is an option for all forms of Rhinitis)
Treatment of Allergic Rhinitis 2
Effects of Medication on Symptoms
| Nasal Preparation | Sneezing | Itching | Rhinorrhoea | Congestion |
| Antihistamines | +++++ | ++++ | +++ | 0 |
| Anticholinergics | 0 | 0 | +++++ | 0 |
| Topical Steroid | +++++ | +++++ | +++ | +++ |
| Decongestant | 0 | 0 | + | +++++ |
| Mass cell stabiliser | +++++ | +++ | + | 0 |
| Leukotriene Antagonists | +++ | ++ | 0 | ++++ |
Hayfever NHS Choices Note that immunotherapy is not available under NHS care in Scotland
Managing Hayfever and Pollen: the ENT UK patient information leaflet
