1. Primary Care Management of Rhinitis Dr Julian Smith, MBBS MRCGP PGDipENT GPwSI Ear Nose & Throat St Albans & Harpenden ENT Community Services

2. Clinical Diagnosis Nasal discharge Blockage/congestion Sneeze/itching } Rhinitis definition 2 or more symptoms for > 1 hour on most days Allergic Rhinitis Non-Allergic Rhinitis History Examination Investigations

3. Management in Primary Care Pathway

4. Pre referral management RHINITIS Start with a trial of INS e.g. Fluticasone or Mometasone, for a minimum of 6 weeks, which must be taken regularly. If allergy test positive: topical antihistamines e.g. Azelastine.

5. Pre referral management CHRONIC SINUSITIS With a classical history, intensive medical treatment should be attempted before referral with INS to both nostrils for up to 6 weeks if severe in combination with Co-amoxiclav or Doxycycline for the first two weeks of the course. If no response after 6 weeks of good compliance with treatment, refer

6. Top Tips Individual patients vary in their response to treatments, therefore try different treatment(s) if the first fails Steroid sprays less likely to work with nasal blockage, so try drops instead Avoid chronic use of decongestants (rhinitis medicamentosa) ENT referral for unilateral symptoms nasal perforations/ulceration new onset unilateral polyps crusting high in nasal cavity recurrent infections periorbital cellulitis (emergency) Instruct patient on correct technique using sprays/drops

7. Technique

8. More Top Tips Postnasal space tumour; beware if recent onset nasal symptoms, especially blockage, bleeding or pain Is the patient Chinese? · Does the patient have adult glue ear? · Does the patient have recent headache? · Is there a neck lump? · Unilateral polyps require urgent histology, but if referring urgently, beware confusion with a large turbinate! Patients can feel a turbinate being touched with, e.g. a long probe, but polyps are asensate.