CHFT: NASAL BLOCKAGE / DISCHARGE +/- FACIAL PAIN IN ADULTS ←Click to view pathway image Source of image goes here Chronic nasal blockage / discharge, with or withour facial pain Encompassing: chronic rhinitis, allergic rhinitis, sinusitis, inflammatory nasal polyps, nasal neoplasm ↓ Are nasal symptoms bilateral or unilateral?BilateralUnilateral ↓ If there is septal deviation, and no other symptoms consider referral for septoplasty Urgent referral if symptoms could be due to a neoplasm (very uncommon): associated with symptoms such as facial pain, diplopia or bleeding. If symptoms are due to ALLERGY (sneezing, itchy, runny), refer to allergy box on the right → Initial therapy with saline nasal spray QDS, +/- saline irrigation BD Add in steroid nasal spray, +/- antihitamine Broad spectrum antibiotics if purulent nasal discharge Information and advice for self help Advise against long term nasal decongestants such as xylometazoline If symptoms are due to ALLERGY consider immunoglobulin assay (serum RAST test for HDM, animal dander, pollen). Make patient aware that condition is not curable, but can be managed; Patient information leaflet Allergen avoidance Importance of concordance with treatment Nasal spray technique Symptoms improved after 6 weeks?NoYes ↓ Topical steroid drops for 4 weeks (remember to restart initial therapy after 4 weeks) Consider oral steroids (prednisolone 30-40mg OD for 5-7 days then stop) Broad spectrum antibiotics only if purulent nasal discharge (amoxicillin, doxyxycline or clarithromycin) for 2 weeks Symptoms improve?NoYes ↓ Continue self management. Consider maintainance nasal saline spray / nasal douche +/- steroid spray. Refer to ENT clinic. Include the following information: Patient history and examination findings Treatment tried: duration and response Any trial of steroids Any side-effects Immunoglobulin assay (RAST) results ↓ ENT assessment, investigation, diagnosis and treatment ↓ When appropriate, will be discharged from ENT clinic with advice for ongoing management in primary care, including management of recurrences How to use a nasal spray? Whilst standing, lean head forward slightly. Hold spray in the right hand for the left nostril and vice versa. Insert nozzle just inside your nostril and aim slightly towards your ear on the side you are spraying. Once applied, breathe in gently & keep your head down for 10 seconds. How to use nose drops? Lie on your back with your head hanging off the edge of the bed. Apply drops and remain in this position for 1-2 minutes. Notes on nasal polyps Polyps are associated with blockage and loss of taste and smell. Small polyps may respond to topical treatment. Consider oral steroids for large polyps or in a patient with polyps and asthma.