How should I assess and manage a patient presenting with chronic rhinosinusitis?

Assessment of Chronic Rhinosinusitis:

• Confirm symptoms persisting for 12 weeks or longer.
• Assess for associated conditions such as asthma, allergic rhinitis, immune dysfunction, nasal polyps, or anatomical obstruction.
• Evaluate for red flags requiring urgent referral or hospital admission, including severe systemic infection, signs of sepsis, orbital or intracranial complications, or suspicion of neoplasm (e.g., persistent unilateral symptoms, cacosmia).
• Consider diagnostic nasal endoscopy and imaging (CT) if referred to secondary care to confirm diagnosis and rule out complications.
• In children with nasal polyps or sinonasal colonisation with Pseudomonas spp., consider testing for cystic fibrosis or ciliary dyskinesia.

Management in Primary Care:

• Advise the patient on the chronic nature of the condition and provide written information.
• Address and manage contributing factors: stop smoking, avoid allergic triggers, control asthma and allergic rhinitis, and maintain good dental hygiene.
• Recommend nasal saline irrigation with isotonic saline to relieve congestion and discharge; avoid baby shampoo or hypertonic saline solutions.
• Consider a course of intranasal corticosteroids (e.g., mometasone or fluticasone) for up to 3 months, especially if allergic causes are suspected; use in children with specialist advice.
• In cases of severe nasal blockage, a short-term nasal decongestant may be added temporarily to corticosteroid treatment.
• Antibiotics are not routinely recommended; consider specialist advice before long-term antibiotics due to limited evidence and risk of adverse effects.
• Systemic corticosteroids may be considered for adults with partially controlled or uncontrolled disease, but only with specialist input due to potential adverse effects.
• Refer to ENT or immunology specialists if symptoms persist beyond 6–12 weeks despite treatment, if immunocompromised, if quality of life is significantly affected, or if there are complicating factors such as nasal polyps, anatomical defects, or unusual infections.