{"id":4397,"date":"2022-05-03T11:47:20","date_gmt":"2022-05-03T10:47:20","guid":{"rendered":"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/rhinosinusitis-adult\/"},"modified":"2026-02-10T10:44:55","modified_gmt":"2026-02-10T10:44:55","slug":"rhinosinusitis-adult","status":"publish","type":"page","link":"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/entadult\/nose\/rhinosinusitis-adult\/","title":{"rendered":"Rhinosinusitis (Adult)"},"content":{"rendered":"\n<p>Chronic rhinosinusitis is a chronic disease requiring ongoing long-term&nbsp;medical management: the ideal is for optimal, prolonged therapy to reduce inflammatory components prior to considering referral. <em>Please see Primary Care Management for full details.<\/em> <\/p>\n\n\n\n<p>Referrals for septal deformities or deviations&nbsp;are 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).<\/p>\n\n\n\n<p class=\"has-alert-red-color has-text-color has-link-color wp-elements-1c438a16fa9d4eba5d2a337fab8c6266\"><strong><u>Sinonasal Cancers<\/u><\/strong>.<\/p>\n\n\n\n<p class=\"has-alert-red-color has-text-color\">The <a href=\"https:\/\/www.rightdecisions.scot.nhs.uk\/scottish-referral-guidelines-for-suspected-cancer\/head-and-neck-and-thyroid-cancers\/\" target=\"_blank\" rel=\"noreferrer noopener\">Scottish Referral Guidelines for Suspected Cancer<\/a> emphasise that sinonasal cancers are rare, whilst benign rhinosinusitis symptoms are common.<\/p>\n\n\n\n<p class=\"has-alert-red-color has-text-color has-link-color wp-elements-fdfcdea3b7725719e58d26e67efb37d4\">The associated clinical features include progressive or new unilateral nasal obstruction with one or more of:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li class=\"has-alert-red-color has-text-color has-link-color wp-elements-55e58f7e67944ff3b1a5e407fb313c02\">Proptosis<\/li>\n\n\n\n<li class=\"has-alert-red-color has-text-color has-link-color wp-elements-01b6f362122e9a0a50561ba390c2ac74\">Epistaxis<\/li>\n\n\n\n<li class=\"has-alert-red-color has-text-color has-link-color wp-elements-b10cc5b5dd17ec6194bf911d0834bb85\">Dental pain or loosening dentures<\/li>\n\n\n\n<li class=\"has-alert-red-color has-text-color has-link-color wp-elements-111d1d8eeaa321a808a64f2e94f73efa\">Cranial nerve palsy or nasal (not facial) pain.<\/li>\n<\/ul>\n\n\n\n<p class=\"has-alert-red-color has-text-color has-link-color wp-elements-ba0e0505229f22eda4fa03017799e91c\">However, sinus and nasal symptoms are common presenting features in primary care and are frequently benign (e.g. rhinosinusitis or benign nasal polyps). If there is concern that there is a nasal or paranasal cancer, please refer via the USC pathway.<\/p>\n\n\n\n<p><strong><u>Rhinitis<\/u><\/strong>.<\/p>\n\n\n\n<p>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:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Nasal discharge<\/li>\n\n\n\n<li>Nasal obstruction<\/li>\n\n\n\n<li>Sneezing\/Irritation<\/li>\n<\/ul>\n\n\n\n<p>The <a href=\"https:\/\/formulary.nhs.scot\/east\/ear-nose-and-oropharynx\/\" target=\"_blank\" rel=\"noreferrer noopener\">East Region Formulary<\/a> outlines principles of treatment, including the need in some for prolonged and combination treatment.<\/p>\n\n\n\n<p><strong>C.M. &amp; A.H. &#8211; 10\/2\/26<\/strong><\/p>\n\n\n\n<div class=\"wp-block-getwid-tabs\" data-active-tab=\"0\"><ul class=\"wp-block-getwid-tabs__nav-links\"><\/ul>\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Referral Guidelines<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<h4 class=\"wp-block-heading\">Who to refer <\/h4>\n\n\n\n<p class=\"has-alert-red-color has-text-color has-link-color wp-elements-f7c1e2901f18d92fd736385e890916f2\">Refer as USC where suspicion of a nasal or paranasal cancer (see sinonasal cancer above).<\/p>\n\n\n\n<p><strong>Referrals are also accepted for:<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Skin prick testing for allergy<\/li>\n\n\n\n<li>Failure of medical therapy (1st and 2nd line OR as per previous ENT recommendations) for recurrent acute sinusitis or chronic rhinosinusitis \u2013 see Primary Care Management for full detail.<\/li>\n\n\n\n<li>Structural deformity<\/li>\n\n\n\n<li>Persistent unilateral symptoms particularly if associated with serosanguinous discharge or facial pain<\/li>\n\n\n\n<li>Unilateral polyp or mass<\/li>\n<\/ul>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Primary Care Management<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<h4 class=\"wp-block-heading\">History<\/h4>\n\n\n\n<p>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.<\/p>\n\n\n\n<h4 class=\"wp-block-heading\">Examination<\/h4>\n\n\n\n<p>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.<\/p>\n\n\n\n<h4 class=\"wp-block-heading\">Investigation<\/h4>\n\n\n\n<p>If allergy is suspected and <em>this diagnosis is going to change management<\/em>, IgE&nbsp;screen (in primary care) or&nbsp;preferably skin prick tests (can be undertaken after referral to ENT).&nbsp; Patients&nbsp;must stop antihistamines&nbsp;at least 72 hours before skin prick testing.<\/p>\n\n\n\n<h4 class=\"wp-block-heading\">Differential diagnosis<\/h4>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Rhinosinusitis<\/li>\n\n\n\n<li>Structural obstruction<\/li>\n\n\n\n<li>Nasal hyperactivity<\/li>\n\n\n\n<li>Hormonal<\/li>\n\n\n\n<li>Drug induced<\/li>\n\n\n\n<li>Cancer (very rare)<\/li>\n<\/ul>\n\n\n\n<h4 class=\"wp-block-heading\">Management<\/h4>\n\n\n\n<p><strong>Primarily medical therapy using the least aggressive combination that gives symptom control.<\/strong><\/p>\n\n\n\n<ol class=\"wp-block-list\">\n<li>Regular saline nasal douching (&nbsp;<a rel=\"noreferrer noopener\" href=\"\/files\/sites\/2\/ENT-NHS-Lothian-Salt-Water-Rinse.pdf\" target=\"_blank\">Please see leaflet&nbsp;on Salt Water Rinse<\/a>).<\/li>\n\n\n\n<li>Allergen avoidance<\/li>\n\n\n\n<li>Antihistamine (if allergy suspected) also leukotriene antagonists may be considered in asthmatics<\/li>\n\n\n\n<li>Topical nasal steroid sprays (Minimum 2 bottle trial of first and second line before referral to secondary care)<\/li>\n\n\n\n<li>Systemic steroids (Prednisolone 25 mg a day for 2 weeks, only,&nbsp;is an option for all forms of Rhinitis)<\/li>\n\n\n\n<li>See the East Regional Formulary for recommendations for:<br>&#8211; <a href=\"https:\/\/formulary.nhs.scot\/east\/ear-nose-and-oropharynx\/nose\/sinusitis\/\" target=\"_blank\" rel=\"noreferrer noopener\">Sinusitis<\/a><br>&#8211; <a href=\"https:\/\/formulary.nhs.scot\/east\/ear-nose-and-oropharynx\/nose\/rhinitis\/\" target=\"_blank\" rel=\"noreferrer noopener\">Rhinitis<\/a><br>&#8211; <a href=\"https:\/\/formulary.nhs.scot\/east\/ear-nose-and-oropharynx\/nose\/nasal-polyps\/?m=treatment-of-nasal-polyps\" target=\"_blank\" rel=\"noreferrer noopener\">Nasal Polyps<\/a><\/li>\n<\/ol>\n\n\n\n<p><strong>Treatment of Allergic Rhinitis<\/strong><\/p>\n\n\n<div class=\"wp-block-image\">\n<figure class=\"aligncenter\"><img decoding=\"async\" src=\"\/files\/sites\/2\/ENT-Rhinitis-Allergen-Table.png\" alt=\"ENT Rhinitis Allergen Table.png\" \/><figcaption class=\"wp-element-caption\">NHS Lothian<\/figcaption><\/figure>\n<\/div>\n\n\n<p><strong>Effects of Medication on Symptoms<\/strong><\/p>\n\n\n\n<figure class=\"wp-block-table is-style-regular\"><table><tbody><tr><td><strong>Nasal Preparation<\/strong><\/td><td><strong>Sneezing<\/strong><\/td><td><strong>Itching<\/strong><\/td><td><strong>Rhinorrhoea<\/strong><\/td><td><strong>Congestion<\/strong><\/td><\/tr><tr><td>Antihistamines<\/td><td>+++++<\/td><td>++++<\/td><td>+++<\/td><td>0<\/td><\/tr><tr><td>Anticholinergics<\/td><td>0<\/td><td>0<\/td><td>+++++<\/td><td>0<\/td><\/tr><tr><td>Topical Steroid<\/td><td>+++++<\/td><td>+++++<\/td><td>+++<\/td><td>+++<\/td><\/tr><tr><td>Decongestant<\/td><td>0<\/td><td>0<\/td><td>+<\/td><td>+++++<\/td><\/tr><tr><td>Mass cell stabiliser<\/td><td>+++++<\/td><td>+++<\/td><td>+<\/td><td>0<\/td><\/tr><tr><td>Leukotriene Antagonists<\/td><td>+++<\/td><td>++<\/td><td>0<\/td><td>++++<\/td><\/tr><\/tbody><\/table><figcaption class=\"wp-element-caption\">NHS Lothian<\/figcaption><\/figure>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Resources and Links<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<p><a href=\"https:\/\/www.nhs.uk\/conditions\/hay-fever\/\" target=\"_blank\" rel=\"noreferrer noopener\">Hayfever NHS<\/a> Choices &#8211; note that&nbsp;immunotherapy&nbsp;is&nbsp;not available&nbsp;under NHS care in Scotland.<\/p>\n\n\n\n<p><a href=\"https:\/\/www.entuk.org\/patients\/conditions\/39\/hayfever_update_covid19_pandemic\" target=\"_blank\" rel=\"noreferrer noopener\">Managing Hayfever and Pollen<\/a>: ENT UK patient information leaflet<\/p>\n\n\n\n<p><a href=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/ENT-NASENDOSCOPY-June-2018.pdf\" data-type=\"URL\" data-id=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/ENT-NASENDOSCOPY-June-2018.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">ENT Nasendoscopy<\/a><\/p>\n\n\n\n<p><a href=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Salt-water-rinse-for-nose-and-sinus-symptoms.pdf\" data-type=\"URL\" data-id=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Salt-water-rinse-for-nose-and-sinus-symptoms.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">NHS Lothian salt water Rinse<\/a><\/p>\n<\/div><\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Chronic rhinosinusitis is a chronic disease requiring ongoing long-term&nbsp;medical management: the ideal is for optimal, prolonged therapy to reduce inflammatory components prior to considering referral. Please see Primary Care Management for full details. Referrals for septal deformities or deviations&nbsp;are accepted where there is significant airway obstruction. However, patients need to be informed that there will<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":4183,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"categories":[154],"class_list":["post-4397","page","type-page","status-publish","hentry","category-rhinosinusitisadult"],"publishpress_future_workflow_manual_trigger":{"enabledWorkflows":[]},"rttpg_featured_image_url":null,"rttpg_author":{"display_name":"NHS Lothian","author_link":"https:\/\/apps.nhslothian.scot\/refhelp\/author\/nhs-lothian\/"},"rttpg_comment":0,"rttpg_category":" <a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/category\/entadult\/nose\/rhinosinusitisadult\/\" rel=\"tag\">Rhinosinusitis<\/a>","rttpg_excerpt":"Chronic rhinosinusitis is a chronic disease requiring ongoing long-term&nbsp;medical management: the ideal is for optimal, prolonged therapy to reduce inflammatory components prior to considering referral. Please see Primary Care Management for full details. Referrals for septal deformities or deviations&nbsp;are accepted where there is significant airway obstruction. However, patients need to be informed that there will","_links":{"self":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/4397","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/comments?post=4397"}],"version-history":[{"count":12,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/4397\/revisions"}],"predecessor-version":[{"id":26706,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/4397\/revisions\/26706"}],"up":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/4183"}],"wp:attachment":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/media?parent=4397"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/categories?post=4397"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}