What interim management can be recommended for a patient with persistent nasal symptoms and decreased hearing lasting over 3 months, prior to their otolaryngology (ear, nose, and throat) appointment?

Interim Management for Persistent Nasal Symptoms and Hearing Loss

For a patient with persistent nasal symptoms and decreased hearing for over 3 months, I recommend starting intranasal corticosteroids (such as fluticasone propionate) once daily and saline nasal irrigation twice daily while awaiting otolaryngology consultation. 1, 2

First-Line Treatment Approach

Intranasal Corticosteroids

• Medication: Fluticasone propionate nasal spray
• Dosing: 200 mcg once daily in the morning 3, 4
• Expected results: May begin to experience relief within the first day, though full effectiveness takes several days of consistent use 3
• Duration: Can be safely used for up to 6 months in adults 3

Nasal Saline Irrigation

• Perform twice daily (morning and evening)
• Supported by level Ib evidence for nasal obstruction symptoms 1
• Helps remove secretions and crusts in the nose
• Use isotonic saline solution

Addressing Hearing Loss

Patient Education

• Explain that the hearing loss is likely conductive and related to eustachian tube dysfunction and/or middle ear effusion
• Hearing testing is recommended when symptoms persist for 3 months or longer 1
• While waiting for the ENT appointment, suggest:
  • Having speakers face the patient when talking
  • Reducing background noise during conversations
  • Using higher volume settings on devices temporarily

When to Seek Immediate Care

Advise the patient to seek more urgent care if they experience:

• Severe pain in the face
• Thick, discolored nasal discharge
• Fever above 38.5°C (101.3°F)
• Sudden worsening of hearing loss
• Development of ear pain or drainage

Monitoring and Follow-up

Self-Monitoring

• Keep a symptom diary tracking:
  • Nasal obstruction (especially upon waking)
  • Changes in hearing
  • Response to recommended treatments

Follow-up Visit

• Schedule a follow-up visit in 3-4 weeks to:
  • Assess response to therapy
  • Review symptom diary
  • Consider additional interventions if needed

Common Pitfalls to Avoid

1. Inappropriate antibiotic use: Antibiotics are not recommended for chronic rhinosinusitis without evidence of acute bacterial infection 1

2. Antihistamine-decongestant combinations: These are ineffective for chronic rhinosinusitis and otitis media with effusion 1

3. Oral steroids without specialist consultation: While potentially effective for nasal polyps, these should be initiated by the specialist due to potential systemic side effects 1

4. Delaying hearing evaluation: If hearing loss is significant or causing functional impairment, consider audiology referral concurrent with ENT referral 1

5. Misattributing symptoms: Ensure that nasal valve collapse is not being missed as a potential cause of obstruction 2

Intranasal corticosteroids have proven efficacy for various nasal conditions including allergic rhinitis, non-allergic rhinitis, and nasal polyps 4, 5, 6. Multiple studies have demonstrated that once-daily dosing is as effective as twice-daily dosing 4, 7, 8, which may improve adherence while awaiting specialist evaluation.