Sniffing out the problem Jonathan Hern. Commissioning Guide for Chronic Rhinosinusitis ENTUK and RCS...
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Transcript of Sniffing out the problem Jonathan Hern. Commissioning Guide for Chronic Rhinosinusitis ENTUK and RCS...
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
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
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)
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
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
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)
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