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Chronic Rhinosinusitis Care Pathway Overview

This pathway has been published with the aim of supporting GPS in providing best practice care to patients with chronic rhinosinusitis. It includes updated information on antibiotic prescribing based on October 2017 NICE guidance Sinusitis (acute): antimicrobial prescribing. The aim of the pathway is to ensure that only appropriate patients are referred into the ENT service, and support Primary Care management wherever possible.

Please click on the relevant flowchart box to be taken directly to textual information.     


Red Flags
Immediate referral:
  • Periorbital oedema/erythema
  • Displaced globe
  • Double vision
  • Ophthalmoplegia
  • Reduced vision acuity
  • Severe unilateral/bilateral frontal headache
  • Frontal swelling
  • Signs of meningitis
  • Neurological signs

Rhinosinusitis occurs when the lining of the sinuses gets infected or irritated, becomes swollen, and creates extra mucus. The swollen lining may also interfere with drainage of mucus. Chronic rhinosinusitis refers to a condition that lasts at least 12 weeks, despite being treated, and causes at least two of the following symptoms:

  • Nasal congestion
  • Mucus discharge from the nose or mucus that drips down the back of the throat
  • Facial pain, pressure, or "fullness"
  • A decreased sense of smell

Chronic rhinosinusitis is different from the more common form of rhinosinusitis (called acute rhinosinusitis), which is a temporary infection of the sinuses that often occurs following colds. Chronic rhinosinusitis is a more persistent problem, which requires a specific treatment approach. It is sometimes overlooked by both patients and health care providers because the symptoms are more low-grade and chronic. 

Initial Primary Care Assessment
  • Assess the patient for any Red Flag symptoms and refer accordingly- see pathway above
  • Nasal examination- swelling, redness, pus
  • Oral examination- posterior discharge
  • Exclude dental infection
  • X-ray- Not recommended
  • Computersied tomography (CT) scan- Not recommended 
Initial Primary Care Management

Inform patient of the natural course of chronic rhinosinusitis, and that it may last for several months, but does not usually require referral.

If the person has an associated disorder, such as allergic rhinitis, asthma, or dental infection advise them that good control of these is also likely to benefit  their rhinosinusitis symptoms.

Advise the person to:

  • Practice good dental hygiene to reduce the risk of dental infection (which can be associated with chronic sinusitis)
  • Stop smoking (and avoid passive smoking) where applicable
  • Avoid underwater diving if there are prominent symptoms

Consider nasal irrigation with saline solution to relieve congestion and nasal discharge.

Please see Prescribing section for further guidance.

When to Refer

Refer Red Flags immediately.

Generally referral from chronic rhinosinusitis is not required. Consider referrals to an ENT specialist if the patient has:

  • Frequent recurrent episodes of acute rhinosinusitis which are troublesome (such as more than three episodes requiring antibiotics in a year)
  • Unremitting or progressive facial pain (but refer urgently if a tumour is suspected)
  • Nasal polyps whcih are causing significant nasal obstruction
  • Had a trial of intranasal corticosteroids for 3 months which was ineffective

GHFT offers an ENT Advice and Guidance service via eRS. Specialist advice can be sought via this route as an alternative to referral. 

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