PrintDownload PDFGet Adobe ReaderDownload to WordDownload as HTMLDownload as XMLCitation Manager
Save to Favorites
Guideline Summary
Guideline Title
Management of rhinosinusitis and allergic rhinitis.
Bibliographic Source(s)
Singapore Ministry of Health. Management of rhinosinusitis and allergic rhinitis. Singapore: Singapore Ministry of Health; 2010 Feb. 93 p. [188 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Infective rhinosinusitis and allergic rhinitis

Guideline Category
Counseling
Diagnosis
Evaluation
Management
Treatment
Clinical Specialty
Allergy and Immunology
Family Practice
Infectious Diseases
Internal Medicine
Obstetrics and Gynecology
Otolaryngology
Pediatrics
Surgery
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Nurses
Patients
Physician Assistants
Physicians
Guideline Objective(s)
  • To provide evidence based management strategies for the diagnosis and treatment of the two most common causes of rhinosinusitis, i.e., infective rhinosinusitis and allergic rhinitis at the primary care level and guidelines for specialist referral
  • To help clinicians manage rhinosinusitis based on the best available evidence as well as expert opinion in areas where studies are lacking
Target Population

Patients with known or suspected infective or allergic rhinosinusitis in Singapore

Interventions and Practices Considered

Diagnosis/Evaluation

  1. Evaluation of signs/symptoms and patient and family history
  2. Immediate referral to an ear, nose, and throat (ENT) specialist, when signs/symptoms indicate
  3. Differential diagnosis of rhinosinusitis
  4. Otoscopy to exclude otitis media in paediatric acute and chronic rhinosinusitis
  5. Skin prick testing

Treatment/Management

  1. Decongestants (intranasal and oral)
  2. Topical ipratropium
  3. Dextromethorphan to treat cough
  4. Nasal saline spray and/or irrigation
  5. Antihistamines and combination antihistamine/decongestants
  6. Antibiotics for bacterial rhinosinusitis
  7. Analgesics
  8. Intranasal steroid
  9. Mattress encasings or high-efficiency particulate air filters for allergic rhinitis
  10. Intranasal ipratropium
  11. Topical chromones
  12. Montelukast as a treatment option for seasonal allergic rhinitis and asthma
  13. Sublingual immunotherapy (SLIT) for allergic rhinitis
  14. Patient education on allergen avoidance
  15. Special considerations for rhinosinusitis during pregnancy

Note: The following are considered but not recommended: plain sinus x-rays; vitamin C, zinc, and Echinacea for common cold; mucolytics; antral lavage, inferior meatal antrostomy (except possibly in primary ciliary dyskinesia), and Caldwell-Luc operation for paediatric chronic rhinosinusitis; and oral or intramuscular corticosteroids.

Major Outcomes Considered
  • Incidence, type, severity, and duration of symptoms
  • Sensitivity and specificity of diagnostic tests
  • Effectiveness of treatment
  • Duration of treatment
  • Level of medication use with treatment
  • Patients compliance with treatment
  • Incidence and severity of complications of rhinosinusitis and allergic rhinitis
  • Adverse effects of treatment
  • Safety of treatment
  • Quality of life
  • Cost-effectiveness

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Searches were run on PubMed (1966-2009), EMBASE (1947-2009), the Cumulative Index to Nursing & Allied Health (CINAHL) database (1984-2009) and PsycINFO (1806-2009) for searching evidence related to management of rhinosinusitis and allergic rhinitis. Additionally both the Cochrane Library (2009, Issue 7) and Centre for Reviews and Dissemination databases (DARE, NHS EED and HTA) were searched for systematic reviews and cost-effectiveness studies. The guideline developers also performed Internet search on websites of guidelines agencies and professional societies that published clinical practice guidelines and consensus evidence on the given condition. These included the search for the last five years of the existing clinical practice guidelines (2005-2009) from sources of overseas guidelines agencies and professional bodies, e.g., National Guideline Clearinghouse, National Health Service (NHS) National Library of Guidelines, the Guidelines International Network, Agency for Healthcare Research and Quality (AHRQ), Canadian Medical Association (CMA) Clinical Practice Guidelines, New Zealand Guidelines Group, Australia's Clinical Practice Guidelines Portal websites.

Inclusion/exclusion criteria were used specific to the clinical questions to be answered. In general, search filters were used to further focus the type of studies to randomised controlled trials and systematic reviews of randomised controlled trials. If there is a paucity of higher level evidence, lower level evidence may be considered.

The searches used keywords and MeSH headings or the controlled vocabulary specific to the databases for the condition specified.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Levels of Evidence

Level Type of Evidence
1++ High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias
1+ Well conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
1- Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
2++ High quality systematic reviews of case control or cohort studies. High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
2+ Well conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal
2- Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
3 Non-analytic studies, e.g., case reports, case series
4 Expert opinion
Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Clinical practice guidelines from the World Health Organization, USA, and the European Union were evaluated and local data when available were included in this clinical practice guideline. Recommendations are based on locally available prescriptions and procedures. The workgroup was made up of otorhinolaryngologists with a special interest in rhinology and paediatric otorhinolaryngology, pediatricians, and a general practitioner.

Rating Scheme for the Strength of the Recommendations

Grades of Recommendation

Grade Recommendation
A At least one meta-analysis, systematic review of randomised controlled trials (RCTs), or RCT rated as 1++ and directly applicable to the target population; or
A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
B A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
GPP
(good practice points)
Recommended best practice based on the clinical experience of the guideline development group
Cost Analysis

Cost-Effectiveness Issues

Allergic rhinitis imposes a substantial economic burden on society with indirect costs of productivity loss being larger than the direct health costs. It has been estimated that the burden of illness cost for allergic rhinitis ranges from US 2 to 5 billion dollars in USA. The many variables in the study of cost effectiveness of allergic rhinitis management such as identification of allergic rhinitis patients, differences in cost assignment, and difficulties in assigning indirect costs such as reduced productivity preclude formal cost-effectiveness evaluations that compare incremental costs and benefits of alternative treatment strategies. Although there are presently no strong cost-effectiveness arguments available comparing each specific treatment option in allergic rhinitis, management in general is important in reducing a substantial economic burden on society.

Method of Guideline Validation
Not stated
Description of Method of Guideline Validation

Not applicable

Recommendations

Major Recommendations

Definitions of the levels of evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, 4) and the grades of recommendations (A, B, C, D, and Good Practice Point [GPP]) are provided at the end of the "Major Recommendations" field.

Management of Common Cold (Acute Viral Rhinosinusitis) and Use of Antibiotics in Acute Bacterial Rhinosinusitis

Acute Viral Rhinosinusitis (Common Cold)

A - Antibiotics are not recommended for treatment of the common cold in children or adults. (Grade A, Level 1++)

A - Dextromethorphan should be considered as a treatment option for adults with cough caused by the common cold. (Grade A, Level 1++)

A - Topical (intranasal) or oral nasal decongestants, used for up to three days, is recommended for adolescents and adults with the common cold. (Grade A, Level 1+)

A - Topical ipratropium may be considered as a treatment option for nasal congestion in children older than six years and in adults with moderate to severe common cold. (Grade A, Level 1+)

A - Codeine and other narcotics, dextromethorphan, antihistamines, and combination antihistamine/decongestants are not recommended to treat cough or other cold symptoms in children. (Grade A, Level 1++)

A - First-generation antihistamines and combination antihistamine/decongestants may be considered for cough and cold symptoms in adults if the benefits outweigh the adverse effects. (Grade A, Level 1++)

A - Vitamin C, zinc, and Echinacea are not recommended for active treatment of common cold due to lack of effectiveness in preventing the common cold. (Grade A, Level 1++)

Use of Antibiotics in Acute Bacterial Rhinosinusitis

Adults

A - Antibiotics are not recommended for adults with non-severe acute bacterial rhinosinusitis (mild pain and temperature <38.3 degrees centigrade) till after 10 days of symptoms from onset. (Grade A, Level 1+)

D - Besides severity of illness, the patient's age, general health, cardiopulmonary status, and co-morbid conditions should be considered in deciding start of antibiotic treatment in patients with acute bacterial rhinosinusitis. (Grade D, Level 4)

A - The first-line empiric antibiotic for adults with acute bacterial rhinosinusitis is amoxicillin. If the patient is allergic to amoxicillin, trimethoprim-sulfamethoxazole or macrolides may be used. (Grade A, Level 1+)

A - For adults with acute bacterial rhinosinusitis, the recommended duration of appropriate oral antibiotic regime is 7 days. Clinician assessment after 7 days is recommended. Antibiotic regime can be extended to 14 days if patient's symptoms fail to resolve. (Grade A, Level 1++)

B - A second-line antibiotic such as high dose amoxicillin-clavulanate, ampicillin-sulbactam or fluoroquinolone should be considered in adults with acute bacterial rhinosinusitis if there is no clinical response after at least 7 days of first line antibiotics. (Grade B, Level 2+)

Children

D - Appropriate antibiotic regimes are recommended for children with the following conditions:

  1. Non-severe acute bacterial rhinosinusitis: In a child with protracted symptoms with asthma, chronic bronchitis, or acute otitis media.
  2. Severe acute bacterial rhinosinusitis: In ambulatory patients, an oral antibiotic resistant to beta-lactamase enzymes (amoxicillin-clavulanate or a second generation cephalosporin such as cefuroxime axetil).
  3. Severe illness or toxic condition: In a child with suspected or proven suppurative complication.

(Grade D, Level 4)

D - Intravenous antibiotic effective against penicillin-resistant Streptococcus pneumonia, beta-lactamase producing Haemophilus influenzae and Moraxella catarrhalis should be used in children with severe acute bacterial rhinosinusitis. (Grade D, Level 4)

D - Amoxicillin (45 mg/kg/day, doubled if age under 2 years or with risk factors for resistance) is recommended for a child with non-severe acute bacterial rhinosinusitis with protracted symptoms. If the symptoms do not improve within 72 hours, an antibiotic against the resistant organism prevalent in the community should be considered. Azithromycin or clarithromycin as first-line therapy is recommended in penicillin allergy. (Grade D, Level 4)

Management of Infective Rhinosinusitis in Adults

Acute Rhinosinusitis

Diagnosis

GPP - Other diagnosis should be considered in adults with acute rhinosinusitis who present with unilateral symptoms of bleeding, crusting, or cacosmia. (GPP)

D - Immediate referral to an ear, nose, and throat (ENT) specialist is indicated for acute rhinosinusitis in adults who present with sinister signs indicative of complications of acute intermittent rhinosinusitis. These include:

  • Peri-orbital oedema
  • Displaced globe
  • Double vision
  • Ophthalmoplegia
  • Reduced visual acuity
  • Severe unilateral or bilateral frontal headache
  • Frontal swelling
  • Signs of meningitis or focal neurological deficits

(Grade D, Level 4)

D - Plain sinus x-rays are not recommended for the diagnosis of acute rhinosinusitis in adults. (Grade D, Level 4)

Treatment of Acute Rhinosinusitis

D - Alleviate symptoms of mild acute rhinosinusitis in adults with the following options

  • Decongestants
  • Nasal saline spray and/or irrigation
  • Antihistamines, only in patients with concomitant allergic rhinitis
  • Analgesics

(Grade D, Level 4)

D - Treat underlying inflammatory process of moderate to severe acute rhinosinusitis in adults with:

  • Intranasal steroid
  • Antibiotic, empiric: 7-14 days

Alleviate symptoms with the following options:

  • Decongestants
  • Nasal saline spray and/or irrigation
  • Antihistamines, in patients with concomitant allergic rhinitis
  • Analgesics

(Grade D, Level 4)

GPP - The workgroup recommends that patients with acute rhinosinusitis should be reviewed for symptom resolution. Patients whose symptoms worsen or persist despite therapy should be referred to a specialist for further evaluation and management. (GPP)

A - Nasal steroid spray twice daily is recommended for adults with acute rhinosinusitis which has not resolved after 5 days of initial presentation. (Grade A, Level 1+)

A - Oral corticosteroids are not recommended for adults with acute rhinosinusitis. (Grade A, Level 1+)

D - Antihistamines are not recommended in the treatment of acute bacterial rhinosinusitis in adults. (Grade D, Level 4)

A - Antihistamines may be used as an adjunct to antibiotic treatment in acute bacterial rhinosinusitis patients with concomitant allergic rhinitis. (Grade A, Level 1+)

D - New generation oral antihistamines are preferred in adults with acute rhinosinusitis for their favourable efficacy/safety ratio and pharmacokinetics. Refrain from first generation antihistamines to avoid sedation and anti-cholinergic side effects. (Grade D, Level 4)

GPP - Topical decongestants may be used for adults with acute rhinosinusitis whose symptoms fail to resolve after 10 days of initial presentation. (GPP)

GPP - The duration of treatment with topical decongestants should be limited to less than 10 days to avoid rhinitis medicamentosa. (GPP)

A - Nasal hypertonic saline irrigation, alone or in conjunction with other adjunctive measures, may be used to reduce symptoms and medication use in adults with frequent acute rhinosinusitis. (Grade A, Level 1+)

D - Mucolytics are not recommended to be prescribed routinely for adult patients with acute rhinosinusitis. (Grade D, Level 4)

Chronic Rhinosinusitis

Diagnosis

GPP - All adults with persistent and recurrent rhinosinusitis should be referred to a specialist for nasal endoscopy to assess for differential causes. (GPP)

GPP - Other diagnosis should be considered in adults with chronic rhinosinusitis who present with unilateral symptoms of bleeding, crusting, or cacosmia. (GPP)

D - Immediate referral to an ENT specialist is indicated for chronic rhinosinusitis in adults who present with sinister signs such as:

  • Peri-orbital oedema
  • Displaced globe
  • Double vision
  • Ophthalmoplegia
  • Reduced visual acuity
  • Severe unilateral or bilateral frontal headache
  • Frontal swelling
  • Signs of meningitis or focal neurological deficits

(Grade D, Level 4)

D - Sinus x-rays are not recommended to support the diagnosis of chronic rhinitis in adults. (Grade D, Level 4)

Treatment of Chronic Rhinosinusitis without Nasal Polyps

D - For chronic rhinosinusitis without nasal polyps, alleviate symptoms with the following options:

  • Nasal saline irrigation

Treat underlying inflammatory process with:

  • Intranasal steroid
  • Antibiotic, in patients with acute exacerbation of chronic rhinosinusitis, culture directed: 10-14 days

(Grade D, Level 4)

C - Short-term oral antibiotics are recommended for acute exacerbation of chronic rhinosinusitis without nasal polyps. (Grade C, Level 2+)

A - Nasal corticosteroids may be prescribed for chronic rhinosinusitis without nasal polyps. (Grade A, Level 1+)

A - Nasal saline irrigation may be prescribed for chronic rhinosinusitis without nasal polyps. (Grade A, Level 1+)

GPP - Oral steroids, oral/topical decongestants, mucolytics, or antihistamines are not recommended in treatment of chronic rhinosinusitis without nasal polyps. (GPP)

Treatment of Chronic Rhinosinusitis with Nasal Polyps

D - For chronic rhinosinusitis with nasal polyps, alleviate symptoms with the following options:

  • Nasal saline irrigation
  • Antihistamines, in patients with concomitant allergic rhinitis

Treat underlying inflammatory process with:

  • Intranasal steroid

(Grade D, Level 4)

GPP - Adults with chronic rhinosinusitis with nasal polyps should be reviewed for symptom control. Patients whose symptoms worsen during or persist despite therapy should be referred to a specialist for further evaluation and management. (GPP)

C - Short-term oral antibiotics are recommended to improve symptoms in acute exacerbation of chronic rhinosinusitis with nasal polyps. (Grade C, Level 2+)

C - Long-term, low-dose macrolide therapy may be considered for chronic rhinosinusitis patients with nasal polyps. (Grade C, Level 2+)

GPP - Management by a specialist is recommended for patients with chronic rhinosinusitis with nasal polyps being prescribed long-term, low-dose macrolide therapy, in view of its side effects. (GPP)

A - Nasal corticosteroid therapy may be used in adults with chronic rhinosinusitis with nasal polyps. (Grade A, Level 1+)

C - Antihistamines are not recommended in chronic rhinosinusitis with nasal polyps. (Grade C, Level 2+)

Management of Infective Rhinosinusitis in Children

GPP - Allergic rhinitis often coexists with paediatric acute and chronic rhinosinusitis. The history should evaluate for symptoms of allergic rhinitis and identify possible allergens. (GPP)

GPP - Otoscopy should be performed routinely to exclude otitis media in paediatric acute and chronic rhinosinusitis. (GPP)

D - Plain X-ray is not recommended routinely to confirm the diagnosis of rhinosinusitis in children. (Grade D, Level 4)

A - Topical corticosteroids may be used in children as an adjunct to antibiotics. It can reduce the cough and nasal discharge earlier in acute bacterial rhinosinusitis. (Grade A, Level 1+)

GPP - Topical decongestants should be used in children no longer than 4-5 days to avoid toxicity and rhinitis medicamentosa. (GPP)

D - Saline nose drops or sprays may be considered to decrease the mucus trapping and crusting associated with acute rhinosinusitis in children. (Grade D, Level 3)

D - The workgroup recommends antibiotics use only in acute exacerbation of paediatric chronic rhinosinusitis, by following the recommendations from the Consensus Meeting in Brussels, 1996:

  • For chronic rhinosinusitis, especially with frequent exacerbations, 2 weeks of oral antibiotics is advised. The antibiotic is changed if there is no response within 5-7 days.
  • Failing this, sinus secretions for culture or investigations to exclude recalcitrant causes are considered.
  • If there is slow response, a second 2-week course can be prescribed.
  • In rare cases with clear-cut improvement but persisting symptoms, a third course can be given before surgery is considered.
  • Parenteral antibiotic may be appropriate if oral antibiotics fail.

(Grade D, Level 4)

C - Nasal douching may be considered for paediatric chronic rhinosinusitis. (Grade C, Level 2+)

D - Antral lavage, inferior meatal antrostomy (except possibly in primary ciliary dyskinesia), Caldwell-Luc operation (risks damage to un-erupted teeth) are not recommended in paediatric chronic rhinosinusitis. (Grade D, Level 3)

Management of Allergic Rhinitis

GPP - The diagnosis of allergic rhinitis should be made based upon concordance between a typical history of allergic symptoms and diagnostic tests. (GPP)

D - The workgroup recommends using the algorithm for the diagnosis and assessment of severity of allergic rhinitis proposed by Allergic Rhinitis and Its Impact on Asthma (ARIA) 2008 (refer to Figure 6 in the original guideline document). (Grade D, Level 4)

GPP - Besides a nasal examination for allergic rhinitis, look out for:

  • Ocular signs of irritation, e.g., allergic conjunctivitis; redness and rubbing of eyes indicative of itchiness.
  • Chest examination to rule out concurrent asthma.

(GPP)

D - The workgroup recommends using the algorithm for the classification of allergic rhinitis proposed by ARIA 2008 (refer to Figure 7 in the original guideline document). (Grade D, Level 4)

D - The workgroup recommends using the algorithm for the management of allergic rhinitis proposed by ARIA 2008 (refer to Figure 8 in the original guideline document). (Grade D, Level 4)

GPP - Mattress encasings or high-efficiency particulate air filters for house dust mite and pet allergy in adults with rhinitis should be part of the overall management of allergic rhinitis. (GPP)

A - Second-generation oral or intranasal H1-antihistamines are recommended for the treatment of allergic rhinitis and conjunctivitis in adults and children. (Grade A, Level 1++)

A - Intranasal glucocorticosteroids are strongly recommended for the treatment of allergic rhinitis in adults and children. (Grade A, Level 1++)

D - Intramuscular glucocorticosteroids and the long term use of oral preparations are not recommended for the treatment of allergic rhinitis due to safety concerns. (Grade D, Level 3)

A - Topical H1-antihistamines are recommended for the treatment of allergic rhinitis and conjunctivitis. Its therapeutic effects are superior and faster than oral antihistamines. (Grade A, Level 1+)

A - Intranasal ipratropium may be considered as a treatment option for rhinorrhoea associated with allergic rhinitis. (Grade A, Level 1+)

A - Topical chromones should be considered as a treatment option for allergic rhinitis and conjunctivitis. However, they are only moderately effective. (Grade A, Level 1+)

A - Montelukast may be considered as a treatment option for seasonal allergic rhinitis and asthma in patients over 6 years of age. It should not be used more than 4 weeks since there is limited data of its efficacy in patients with persistent allergic rhinitis for more than 4 weeks. (Grade A, Level 1+)

C - Intranasal decongestants may be used for a short period of time in patients with severe nasal obstruction caused by allergic rhinitis. (Grade C, Level 2+)

C - Oral decongestants (and their combination with oral H1-antihistamines) may be considered in the treatment of allergic rhinitis in adults, but side effects are common. (Grade C, Level 2++)

GPP - Education of the patient and/or patient's carer on the management of allergic rhinitis should be considered as an option to maximize compliance and optimize treatment outcomes. (GPP)

Paediatric Aspects of Allergic Rhinitis

GPP - Symptoms of sneezing, nasal itching, discharge, and congestion that persist longer than 2 weeks should prompt a search for a cause other than infection in children. (GPP)

GPP - It is recommended to ask about family history of atopy and progression of atopy of the child. (GPP)

B - Skin prick tests should be performed and interpreted reliably early in life. (Grade B, Level 2+)

GPP - The principles of treatment are the same in children as in adults with allergic rhinitis, but dosages should be adapted and care should be taken to avoid the side effects involving impairment of growth and cognitive development. (GPP)

GPP - Pharmacologic management for allergic rhinitis in children should be individualized and polypharmacy avoided. (GPP)

A - Intranasal glucocorticosteroid with bioavailability of <1% such as fluticasone propionate or mometasone furoate should be considered as a treatment option for allergic rhinitis and allergic conjunctivitis. (Grade A, Level 1++)

B - Intranasal glucocorticosteroids with high bioavailability such as betamethasone should not be used in children with allergic rhinitis due to its effect upon growth and growth velocity. (Grade B, Level 1++)

A - Oral and depot glucocorticosteroid preparations should be avoided in children with allergic rhinitis due to negative effect on short-term growth and growth velocity. (Grade A, Level 1+)

A - Second-generation H1-antihistamines such as cetirizine, levocetirizine, and loratadine should be considered as a treatment option in the treatment of allergic rhinitis in children. (Grade A, Level 1+)

GPP - Nasal saline drops or spray may be considered in children with allergic rhinitis to clear the nose before eating or sleeping. (GPP)

A - Sublingual immunotherapy (SLIT) should be considered in children above age 5 years who have poor symptomatic control of allergic rhinitis despite maximal therapy or who cannot or will not take medication. (Grade A, Level 1++)

GPP - The family and the child should be educated about the recurrent or persistent nature of the disease, allergen avoidance and avoidance of allergen triggers and respiratory tract irritants, the most important of which is tobacco smoke. (GPP)

Management of Rhinitis in Pregnancy

D - Nasal endoscopy on a decongested nose may be considered as an option to differentiate pregnancy rhinitis from sinusitis. (Grade D, Level 4)

D - Imaging studies are not recommended to make a diagnosis in rhinitis in pregnancy. (Grade D, Level 4)

D - Skin prick tests are not recommended for rhinitis in pregnancy because use of potent antigens in skin testing may be associated with systemic reactions. (Grade D, Level 4)

GPP - In treating rhinitis of pregnancy, all drug therapy should ideally be avoided especially in the first trimester. If drug therapy cannot be avoided then treatment will depend upon the predominant symptoms, with the topical agents as first line since they have minimal systemic exposure. (GPP)

C - Chromones are safe with no known teratogenic effect but they are moderately effective. They may be given for the treatment of rhinitis in the first 3 months of pregnancy, 3-4 times daily. (Grade C, Level 2+)

C - If chromones are ineffective and poorly tolerated, they should be replaced with antihistamines. Chlorpheniramine and tripelennamine are the antihistamines of choice for pregnant women with rhinitis. Cetirizine and loratadine may be considered after the first trimester. (Grade C, Level 2+)

C - Intranasal steroids should be prescribed as an alternative to or in combination with antihistamines for severe cases of rhinitis in pregnancy. (Grade C, Level 2+)

C - Budesonide is the only recommended intranasal steroid for rhinitis in pregnancy. (Grade C, Level 2+)

C - Topical decongestants like oxymetazoline may be considered as second-line therapy for short-term relief and when no other safer alternatives are available for the treatment of rhinitis in pregnancy. (Grade C, Level 2+)

C - Oral decongestants are not recommended for rhinitis in pregnancy. (Grade C, Level 2+)

C - Leukotriene modifiers are not recommended for allergic rhinitis in pregnancy. (Grade C, Level 2+)

A - Amoxicillin is the drug of choice for pregnant patients with rhinitis who are not allergic to penicillin. (Grade A, Level 1+)

D - Amoxicillin-clavulanate or cephalosporin may be given to pregnant women with rhinitis not responding to amoxicillin. (Grade D, Level 3)

C - Metronidazole should be used in rhinitis in pregnancy caused by anaerobic pathogens. (Grade C, Level 2+)

D - Immunotherapy is not recommended for rhinitis in pregnancy. However, it may be continued if the maintenance phase has been reached. (Grade D, Level 4)

Definitions:

Levels of Evidence

Level Type of Evidence
1++ High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias
1+ Well conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
1- Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
2++ High quality systematic reviews of case control or cohort studies. High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
2+ Well conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal
2- Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
3 Non-analytic studies, e.g., case reports, case series
4 Expert opinion

Grades of Recommendation

Grade Recommendation
A At least one meta-analysis, systematic review of randomised controlled trials (RCTs), or RCT rated as 1++ and directly applicable to the target population; or
A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
B A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
GPP
(good practice points)
Recommended best practice based on the clinical experience of the guideline development group
Clinical Algorithm(s)

The original guideline includes the following clinical algorithms:

  • Management scheme for primary care for adults with acute rhinosinusitis
  • Management scheme for primary care for adults with chronic rhinosinusitis
  • Summary of treatment evidence and recommendations for children with acute rhinosinusitis
  • Summary of clinical management scheme for chronic rhinosinusitis in children
  • Algorithm for management of allergic rhinitis
  • Treatment of rhinitis of pregnancy

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate diagnosis and management of rhinosinusitis and allergic rhinitis

Potential Harms
  • First-generation oral H1-antihistamines, which are often included in the formulations of oral decongestants, have central nervous system side effects, including sedation, fatigue, paradoxical hyperactivity, insomnia, and irritability and may further reduce the cognitive function of children with allergic rhinitis.
  • Studies have shown sublingual immunotherapy to be effective in young children with allergic rhinitis with only mild and transient local side effects.
  • See Tables 4 and 5 in the original guideline document for pregnancy risk category of drugs commonly used in the treatment of rhinosinusitis in pregnancy.

Contraindications

Contraindications

Intranasal glucocorticosteroids with high bioavailability such as betamethasone should not be used in children with allergic rhinitis due to its effect upon growth and growth velocity.

Qualifying Statements

Qualifying Statements
  • These guidelines are not intended to serve as a standard of medical care. Standards of medical care are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge advances and patterns of care evolve.
  • The contents of this publication are guidelines to clinical practice, based on the best available evidence at the time of development. Adherence to these guidelines may not ensure a successful outcome in every case. These guidelines should neither be construed as including all proper methods of care, nor exclude other acceptable methods of care. Each physician is ultimately responsible for the management of his/her unique patient, in the light of the clinical data presented by the patient and the diagnostic and treatment options available.
  • Evidence based clinical guidelines are only as current as the evidence that supports them. Users must keep in mind that new evidence could supersede recommendations in these guidelines. The workgroup advises that these guidelines be scheduled for review five years after publication or if new evidence appears that requires substantive changes to the recommendations.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Audit Criteria/Indicators
Clinical Algorithm
Patient Resources
Quick Reference Guides/Physician Guides
Slide Presentation
Staff Training/Competency Material
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Singapore Ministry of Health. Management of rhinosinusitis and allergic rhinitis. Singapore: Singapore Ministry of Health; 2010 Feb. 93 p. [188 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2010 Feb
Guideline Developer(s)
Singapore Ministry of Health - National Government Agency [Non-U.S.]
Source(s) of Funding

Singapore Ministry of Health

Guideline Committee

Workgroup on Management of Rhinosinusitis and Allergic Rhinitis

Composition of Group That Authored the Guideline

Workgroup Members: Clin A/Prof Siow Jin Keat (Chairman), Clinical Associate Professor, National University of Singapore, Senior Consultant, Dept of Otorhinolaryngology, Tan Tock Seng Hospital; Clin A/Prof Abhilash Balakrishnan, Clinical Associate Professor, National University of Singapore, Senior Consultant, Dept. of Otolaryngology, Singapore General Hospital and KK Women's and Children's Hospital; A/Prof Lynne Lim, Senior Consultant, Dept of Otolaryngology-Head & Neck Surgery National University Hospital and National University of Singapore; A/Prof Wang De Yun, Research Director, Dept of Otolaryngology-Head & Neck Surgery, National University Health System; Dr Leong Jern-Lin, Consultant, ASCENT Ear Nose Throat Specialist Group, Mount Elizabeth Medical Centre; Clin A/Prof Henry Tan, Deputy Chairman, Division of Surgery, Head and Senior Consultant, Dept of Otolaryngology (Paediatric Otolaryngology), KK Women's and Children's Hospital; Dr Anita Menon, Consultant, Infectious Disease Service, Dept of Paediatric Medicine, KK Women's and Children's Hospital; Dr Chao Siew Shuen, Senior Consultant, Dept of Otolaryngology-Head & Neck Surgery (Rhinology), National University Hospital; Dr Julian Lee Cheow Yew, Senior Consultant, Dept of Otolaryngology, Tan Tock Seng Hospital; Dr Jason Hwang Siew Yoong, Consultant, Dept of Otorhinolaryngology, Changi General Hospital; Clin A/Prof Dharmbir S Sethi, Clinical Associate Professor, National University of Singapore, Senior Consultant, Dept of Otolaryngology, Singapore General Hospital; Dr Chan Kwai Onn, Consultant, K O Chan ENT Sinus & Sleep Centre; Dr Nada Ali Alshaikh, Clinical Fellow, Dept of Otorhinolaryngology, Tan Tock Seng Hospital; A/Prof Goh Lee Gan, Associate Professor, Dept of COFM, Yong Loo Lin School of Medicine, President, College of Family Physicians, Singapore

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the Singapore Ministry of Health Web site External Web Site Policy.

Print copies: Available from the Singapore Ministry of Health, College of Medicine Building, Mezzanine Floor 16 College Rd, Singapore 169854.

Availability of Companion Documents

The following are available:

  • Management of rhinosinusitis and allergic rhinitis. Executive summary of recommendations. Singapore: Singapore Ministry of Health; 2010 Feb. 16 p. Electronic copies: Available in Portable Document Format (PDF) from the Singapore Ministry of Health Web site External Web Site Policy.
  • Various slide sets and speeches about infective rhinosinusitis and allergic rhinitis in adults and children and rhinitis in pregnancy are available from the Singapore Ministry of Health Web site External Web Site Policy.

Self-assessment questions and clinical quality improvement parameters are also available in the original guideline document External Web Site Policy.

Patient Resources

The following is available:

  • Your guide to understanding rhinosinusitis and allergic rhinitis. Singapore: Singapore Ministry of Health; 2011 Jan. 7 p. Electronic copies: Available in Portable Document Format (PDF) from the Singapore Ministry of Health Web site External Web Site Policy.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI Institute on March 29, 2013. This summary was updated by ECRI Institute on October 25, 2013 following the U.S. Food and Drug Administration advisory on Fluoroquinolone Antibacterial Drugs.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. Please contact the Ministry of Health, Singapore by e-mail at MOH_INFO@MOH.GOV.SG.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

Read full disclaimer...