Chronic rhinosinusitis

Background:

Most patients who present complaining of “sinusitis” do not have sinusitis at all. The most common diagnosis in patients presenting with self-reported “sinus type” headaches is migraine (50-80% of cases), followed by chronic mid-facial segment pain.

Rhinosinusitis is considered chronic if symptoms persist for >12 weeks

Clinical criteria for the diagnosis of rhinosinusitis are:

               Two or more symptoms

                              One of which should be: Nasal congestion OR Nasal discharge

                              +/- facial pain/pressure

                              +/- reduction in sense of smell

If these criteria are not met, other causes should be considered e.g. migraine or chronic mid-facial segment pain.

Examination may reveal oedematous nasal mucosa, nasal polyps or mucopus.

Patients with associated asthma or aspirin sensitivity (termed Samters triad) tend to have worse disease burden and are more resistant to treatment

How to manage:

Sterimar nasal spray, 2 sprays each nostril, QID

Topical nasal steroid spray for at least 6 weeks

If no improvement, consider other diagnoses e.g. migraine, chronic mid-segment facial pain.

If chronic rhinosinusitis still felt to be most likely, trial topical nasal steroid drops for 6 weeks then return to nasal spray long term.  Chronic use of nasal steroid drops can result in adrenal suppression. Nasal steroid sprays however are safe in the long term at doses stated in the BNF. Patients should be educated that stopping their nasal steroids sprays may result in their symptoms worsening.

Ensure asthma is well managed and consider secondary care referral to respiratory for this as improved asthma control has been proven to improve chronic rhinosinusitis symptom control also

Referral guidance:

Referral to ENT on a routine basis is indicated if problematic symptoms persist despite conservative measures. Any patients referred without an appropriate course of steroid treatment will be returned to the referrer.

Caution

Unilateral or bleeding polyps should raise suspicion of malignancy. Check vision and eye movements as well as facial sensation as these can be affected by an invasive malignancy.

Consider also migraine / chronic mid-segment facial pain