When is it appropriate to refer a patient with chronic rhinosinusitis for specialist evaluation or surgery?

Referral for specialist evaluation or surgical management of chronic rhinosinusitis is appropriate when:

• Symptoms persist despite compliance with at least 6 to 12 weeks of treatment, including intranasal corticosteroids and other conservative measures.
• The patient is immunocompromised, or there is suspicion of an allergic or immunological cause complicating management.
• There is an anatomical defect causing obstruction, such as nasal polyps or adenoid hypertrophy.
• Symptoms significantly affect quality of life or are recurrent despite treatment.
• Sinusitis is associated with unusual or resistant bacteria.
• There is doubt about the diagnosis or suspicion of neoplasm (e.g., persistent unilateral symptoms like nasal obstruction, discharge, nosebleeds, crusting, or facial swelling), which requires urgent referral.
• In children, recurrent episodes of otitis media and pneumonia or suspicion of adenoid hypertrophy warrant referral.
• Consider specialist advice if intranasal corticosteroids are being considered for children, or if oral corticosteroids or long-term antibiotics are contemplated.

Specialist evaluation may include diagnostic nasal endoscopy, CT imaging, allergy testing, and immune function tests to confirm diagnosis, exclude complications, and guide management including surgery.

Endoscopic sinus surgery or adenoidectomy may be considered especially in children under 6 years or when medical management fails.

Immediate referral or hospital admission is indicated if there are severe systemic infections, signs of sepsis, intraorbital or intracranial complications, or if the patient is systemically very unwell.

These recommendations are based on the European Position Paper on Rhinosinusitis and Nasal Polyps 2020 (EPOS 2020), NICE guidelines, and expert consensus.