Acute Sinusitis Care Pathway

Review in progress


Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.

Scope

This guidance refers to:

  • This guidance covers sinusitis of less than 3 months duration. Usually follows viral upper respiratory tract infection (URTI).

This guidance does not cover:

  • Sinusitis of more than 3 months duration

Assessment

Signs & Symptoms

Acute sinusitis usually follows a common cold, and is defined as an increase in symptoms after 5 days, or persistence of symptoms beyond 10 days, but less than 12 weeks

ADULTS

  • Nasal blockage OR Discoloured nasal discharge (anterior or posterior) WITH
  • Facial pain*/pressure (or headache) AND/OR Reduction (or loss) of the sense of smell

CHILDREN

  • Nasal blockage OR Discoloured nasal discharge (anterior or posterior) WITH
  • Facial pain*/pressure (or headache) AND/OR Cough (daytime and night-time)

*facial pain in absence of nasal symptoms unlikely to be due to sinusitis

Suspect acute bacterial sinusitis when at least three of the following features are present:

  • Discoloured or purulent discharge (with unilateral predominance)
  • Severe local pain (with unilateral predominance)
  • A fever greater than 38°C
  • A marked deterioration after an initial milder form of the illness (so-called 'double-sickening')
  • Elevated ESR/CRP (although the practicality of this criterion is limited)

Red Flags

Arrange admission if acute sinusitis is associated with a severe systemic infection, or a serious complication including:

  • Orbital involvement — indicated by peri-orbital oedema or cellulitis, a displaced globe, double vision, ophthalmoplegia, or reduced visual acuity
  • Intracranial involvement — indicated by severe frontal headache, swelling over the frontal bone, symptoms or signs of meningitis, or focal neurological signs
  • Persistent unilateral symptoms such as:
    • Blood-stained discharge
    • Crusting
    • Nasal obstruction
    • Non-tender facial pain
    • Facial swelling
    • Unilateral nasal polyps

Investigations

Plain sinus X-ray not indicated

Management

Advise patient to:

  • Have plenty of rest
  • Drink enough fluids to avoid feeling thirsty
  • Ask their local community pharmacist to recommend medicines to help with symptoms or pain (or both)
  • Use a tissue and wash your hands to prevent the spread of infection
  • Rest, applying warm face packs and washing out the nose with a steady stream of saline solution (available from pharmacy)
  • Keep well by eating healthily, including at least five portions of fruit and vegetables every day.

Management of suspected viral sinusitis

  • Simple analgesia - Please refer to the Prescribing Guidelines for up to date guidance - NHS SWYAPC - Upper Respiratory Tract Infection
  • Intra-nasal decongestant (for a maximum of 1 week, in adults only), oral decongestants generally not recommended for sinusitis
  • Irrigating the nose with saline solution
  • Applying warm face packs
  • Drinking adequate fluids and rest
  • Consider intra-nasal corticosteroid for people with severe or prolonged symptoms
  • Explain that acute sinusitis is caused by a virus in more than 98% of people, takes on average 2.5 weeks to resolve, and that antibiotics are only likely to help when there are features indicative of bacterial infection

Management of suspected bacterial sinusitis

  • Manage as above and consider antibiotic treatment if criteria met in assessment, also consider if:
    • Unilateral sinus tenderness
    • Worsening of symptoms after 3-5 days
    • Lack of improvement after 7-10 days of observation
    • Have co-morbidity that puts them at risk of complication
  • Antibiotic choice:
    • Amoxicillin for 7 days, or
    • Phenoxymethylpenicillin for 7 days, or
    • Doxycycline (not in children less than 12 years of age), erythromycin, or clarithromycin if the person has a known allergy to penicillin, for 7 days.
  • If there is no improvement after 48 hours of treatment with a first-line antibiotic, or if it is poorly tolerated, consider the following second-line treatments:
    • Co-amoxiclav (give the maximum dose, that is 500/125 mg three times a day) for 7 days.
    • Azithromycin for 3 days (if the person is allergic to penicillin)
    • Seek specialist advice if a second-line antibiotic is ineffective

Treatments that are not recommended:

  • Steam inhalation
  • Oral corticosteroids
  • Antihistamines (unless there is co-existing allergic rhinitis)
  • Complementary or alternative medicines
  • Mucolytics

Referral

Referral Criteria

  • Red Flags
  • Severe symptoms
  • Failure of second line treatment
  • Recurrent episodes develop

Referral Requirements

  • The following information should be provided with the referral
    • History and treatment as per guidance
    • Any significant dental history if known

Referral Instructions

  • e-consultation is not currently available for this specialty
  • Referrals should be made via ICG to TRISH (if training has been undertaken) - See user guides (EMIS & S1) for further information.
  • For those Practices who have not received ICG training referrals should be made via eRS
  • Please identify speciality and clinic type

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about the options they face. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation.

Patient information/Public Health/Self Care

Evidence/additional information

Assurance & Governance

  • This guidance was developed on: 09.2017
  • This guidance was ratified by: The OSCAR Assurance Group
  • Date ratified: 09.2017
  • Publication Date: 09.2017
  • Review Date: 09.2019
  • Ref No: ENT10 - 09.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
Only the electronic version is maintained, once printed this is no longer a controlled document

 

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