Sniffing out the problem

Jonathan Hern

Commissioning Guide for Chronic Rhinosinusitis

• ENTUK and RCS• Based on European position paper on sinusitis• Guidance for primary and secondary care

treatment of sinusitis

Introduction

• Acute sinusitis• Duration < 12 weeks• Aetiology usually infective• Chronic sinusitis• Duration > 12 weeks• Aetiology multifactorial including inflammatory,

infective and obstructive (sinus ventilation and drainage)

• 10% prevalence in UK

Acute sinusitis

• History• Presence of 2 or more symptoms for < 12

weeks• Either nasal obstruction and/or discharge• Facial pain/pressure• Reduced sense of smell

Acute sinusitis

Acute sinusitis

Paediatric acute sinusitis

Chronic Sinusitis in primary care

• History• Presence of 2 or more symptoms for > 12 weeks• Either nasal obstruction and/or discharge• Facial pain/pressure• Reduced sense of smell• Subcategorised by presence or absence of nasal

polyps• CRSwNP or CRSsNP• Unilateral symptoms raise suspicion of neoplasia

Primary care

• Examination• Anterior rhinoscopy• Otoscope or endoscope• Discharge• Inflammation• Nasal polyps• Turbinate hypertrophy

Assessment of severity

• 10cm Visual analogue scale• Mild (VAS 0 -3)• Moderate/severe (VAS>3)

Allergic rhinitis

• Nasal itching• Sneezing• Rhinorrhoea• Epiphora• Asthma (assess control)

Red flags

• Unilateral symptoms• Cacosmia• Epistaxis/crusting• Diplopia• Reduced visual acuity• Globe displacement• Periorbital oedema• Severe frontal headache• Neurological signs

Primary care

• Treatment• Nasal douching• Intranasal corticosteroids (mometasone or

fluticasone)• Bilateral nasal polyps visible on AR

Prednisolone EC 30mg OD 7 days with topical steroid drops (fluticasone or betamethasone)

Options not advised in primary care in Chronic Sinusitis

• Plain x-rays• Oral antibiotics

Reassess symptom control after 3 months

• Mild symptoms (VAS 0 -3) continue with medical treatment

• Moderate/severe (VAS >3) assess treatment compliance and technique and refer to secondary care if not improving

Treatment of chronic sinusitis in primary care

Secondary care

• History• Reassess history and consider diagnosis and

treatment of co-morbidity• Allergy ASA triad• Systemic condition (vasculitides, Churg-

Strauss, sarcoidosis)• Ciliary dyskinesia

Secondary care

• Examination• Nasal endoscopy• Purulent middle meatal discharge (swab)• Polyps• Middle meatal oedema

SNOT 22

• Disease specific patient related outcome measure

Secondary care

• CT scanning• Uncertainty from nasal endoscopy (2 out of 3

rule)• Neoplasia suspected• Complications of CRS (orbital/neurological)• Allergy testing SPT or RAST and IgE

Secondary care

• Continue nasal saline irrigation• CRSwNP• Prednisolone, steroid drops/spray, consider

Doxycycline 100mg OD 3 weeks• CRSsNP• Steroid spray, consider 4-6 weeks of macrolide

antibiotic (most likely effective if IgE levels not elevated; avoid clarithromycin with statins in patients with IHD)

Treatment of CRSsNP

Treatment of CRSwNP

Surgery

• Endoscopic sinus surgery• Balloon sinuplasty• Ethmoid or frontal stratus• CT mandatory before surgery. CT score <4

alternative diagnosis should be considered• Many patients likely to require long term

maintenance therapy with saline irrigation and topical steroids

Variation in treatment

Conclusion

• Primary and Secondary Care Pathways• Consider earlier referral • Early surgery• Long term medical maintenance therapy