What criteria should I use to decide whether to refer a patient with acute sinusitis for specialist evaluation?

Refer a patient with acute sinusitis for specialist evaluation if any of the following criteria are met:

• Symptoms persist without improvement after 6 to 12 weeks despite appropriate treatment compliance.
• The patient is immunocompromised.
• Symptoms significantly affect the patient’s quality of life.
• There is suspicion of an allergic or immunological cause.
• There is an anatomical defect causing obstruction.
• Comorbidities complicate management, such as nasal polyps or asthma.
• Sinusitis is associated with unusual or resistant bacteria.
• There are recurrent episodes of otitis media and pneumonia in a child.
• There is suspicion of adenoid hypertrophy.
• There is doubt about the diagnosis.
• Presence of cacosmia (foul smell) requires immediate referral.
• Signs of severe systemic infection, sepsis, or complications such as intraorbital/periorbital cellulitis, displaced eyeball, double vision, ophthalmoplegia, reduced visual acuity, intracranial complications (e.g., meningitis symptoms, severe frontal headache, focal neurological signs), or reduced consciousness warrant urgent hospital admission and specialist care.
• Symptoms suggestive of neoplasm (persistent unilateral symptoms like nasal obstruction, discharge, nosebleeds, crusting, or facial swelling) require urgent suspected cancer pathway referral.

Specialist evaluation is typically by an ear, nose, and throat (ENT) specialist or immunologist, with urgency depending on clinical judgement.