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, ChurgStrauss, 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