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

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