SRP 117 ENT Nasal Obstruction Surgery

Policy Number: SRP 117
Policy Name: Surgery for Nasal Airway Obstruction
Status: Nasal Obstruction ENT Referrals – Individual Prior Approval
Status: Nasal Obstruction Surgery – Group Prior Approval
Effective Date: 1 March 2026
Next Review Date: 1 April 2028

Nasal surgery is mostly performed for cosmetic reasons and is not routinely commissioned.  However, there are some conditions where nasal breathing and functionality are affected with an impact on activities of daily living and quality of life, when such procedures may be considered if specific criteria are met. 

Nasal obstruction, and the resultant impact on breathing, can occur due to one or more underlying factors.  These include a deviated septum (displacement of the cartilage wall between the nostrils), nasal polyps (benign growths within the nasal cavity), and inflammation of nasal structures such as the sinuses or turbinates (the ridges of bone and tissue inside the nose), often caused by allergy or infection.

MSE ICB commissions surgery for nasal obstruction on a restricted basis for:

  • Nasal obstruction due to chronic sinusitis/nasal polyps (endoscopic sinus surgery).
  • Nasal obstruction due to a deviated septum (septoplasty).

For these indications, primary care must obtain prior approval before referring patients to secondary care providers for consideration of nasal obstruction surgery.  This is to ensure inappropriate out-patient appointments are avoided and patient expectations are properly managed.

Where nasal obstruction is primarily due to adenoidal hypertrophy, commissioning criteria are set out in SRP 011 ENT Adenoidectomy.

Surgery for nasal obstruction due to other causes is not commissioned by MSE ICB unless there are exceptional clinical circumstances.

This policy does not apply to any patient with red flag features such as unilateral symptoms or clinical findings, orbital, or neurological features who should be referred urgently/via 2-week wait depending on local pathways.

Nasal Obstruction Surgery – ENT Referrals

Status: Individual Prior Approval

Patients are eligible to be referred for specialist secondary care assessment in the following circumstances:

  1. Disease-specific symptom patient reported outcome measure1 confirms severe symptoms that are significantly interfering with daily activities (for example severe difficulty in sleeping or during exercise/ exertion).
    (1. e.g. Nasal Obstruction Symptom Evaluation (NOSE) or Sinonasal Outcome Test (SNOT-22) score)
    AND
  2. trial of appropriate medical and conservative measures2 (including assessment of technique and compliance).

AND one of:

  • A. There is a possible association with septal or nasal wall deformities.
    OR
  • B. A clinical diagnosis of chronic sinusitis / nasal polyps has been made (as set out RCS/ENT-UK Commissioning guidance)
    OR
  • C. Patient has severe nasal obstruction symptoms with an unclear diagnosis.

2 Medical Management:

  • Intranasal corticosteroids (INCS) and nasal saline irrigation should be offered to all patients unless contraindicated.  Refer if no improvement (objective measurement) after 3-months and following confirmation of correct technique / compliance with INCS.
  • For patients with bilateral nasal polyps, offer trial of oral prednisolone (0.5mg/kg for 5 -10 days to a max of 60mg) followed by topical nasal drops as per RCS/ENT-UK Commissioning guidance.  Assess response at four weeks, refer if no improvement (objective measurement).

2 Conservative Management / Differential Diagnosis:

  • Advise on avoidance of exacerbating factors.
  • Exclude overuse of nasal decongestant sprays as a cause of rhinitis medicamentosa.
  • Consider and exclude differential diagnosis e.g. allergic rhinitis, non-allergic rhinitis, and drug-induced rhinitis.  Consider RAST (IgE) tests for common allergens: house dust mite, grass, trees, moulds, pets (If positive, treat as per allergic rhinitis, see NICE CKS).

No investigations, apart from clinical assessment, should take place in primary care or be a pre-requisite for referral to secondary care (e.g. X-ray, CT scan).

There is no role for prolonged courses of antibiotics in primary care.

Endoscopic Sinus Surgery

Status: Group Prior Approval

Patients can be considered for standalone endoscopic sinus surgery when the following criteria are met:

  • A diagnosis of chronic sinusitis (CRS)/nasal polyps has been confirmed from clinical history and nasal endoscopy and/or CT scan.
    AND
  • Disease-specific symptom patient reported outcome measure confirms severe symptoms that are significantly interfering with daily activities (for example severe difficulty in sleeping or during exercise/ exertion).
    e.g. Nasal Obstruction Symptom Evaluation (NOSE); Sinonasal Outcome Test (SNOT-22) after trial of appropriate medical therapy (including counselling on technique and compliance) as outlined in RCS/ENT-UK Commissioning guidance ‘Recommended secondary care pathway’.
    AND
  • Pre-operative CT sinus scan has been performed and confirms presence of CRS/nasal polyps.  Note: a CT sinus scan does not necessarily need to be repeated if performed sooner in the patient’s pathway.
    AND
  • Patient and clinician have undertaken appropriate shared decision-making consultation regarding undergoing surgery including discussion of risks and benefits of surgical intervention.  This must be fully documented in the patient’s notes.

There are a number of medical conditions whereby endoscopic sinus surgery may be required outside the above criteria and in these cases are not subject to the above criteria and continue to be routinely funded:

  • Any suspected or confirmed neoplasia.
  • Emergency presentations with complications of sinusitis (e.g. orbital abscess, subdural or intracranial abscess)
  • Patients with immunodeficiency
  • Fungal Sinusitis
  • Patients with conditions such as Primary Ciliary Dyskinesia, Cystic Fibrosis or NSAID-Eosinophilic Respiratory Disease (NSAID-ERD, Samter’sTriad Aspirin Sensitivity, Asthma, CRS)
  • Treatment with topical and / or oral steroids contra-indicated.
  • As part of surgical access or dissection to treat non-sinus disease (e.g. pituitary surgery, orbital decompression for eye disease, nasolacrimal surgery).
  • Recurrent acute sinusitis where diagnosis has been confirmed during an acute attack if possible, by nasal endoscopy and/or a CT sinus scan.

Septoplasty

Status: Group Prior Approval

NB: This policy does not apply to:

  • Immediate post trauma nasal manipulation under anaesthetic (MUA) which should occur within three weeks of trauma.  Failure to engage with this treatment within the recommended period post-trauma or dissatisfaction with the outcome of the MUA is unlikely to be considered exceptional.
  • To facilitate sinus surgery access

Septoplasty can be considered where the patient has:

  • A septal/bony deviation causing significant and persistent nasal blockage.
    OR
  • Nasal deformity secondary to a congenital craniofacial deformity causing significant functional impairment.

Septoplasty is routinely funded as part of reconstructive head and neck surgery.

Septoplasty is not routinely funded for other indications (including allergic rhinitis) due to insufficient evidence of effectiveness.

N.B Septorhinoplasty is not routinely funded – see below.

Turbinate surgery is only funded as an adjunct for septal deviation- or polyp-related nasal obstruction where clinically indicated and where criteria outlined above are met. 

Turbinate surgery as a sole procedure has been assessed as a Low Clinical Priority by MSE ICB and will not be funded unless there are exceptional clinical circumstances.

Nasal Surgery – Not Routinely Commissioned

Status: Not Funded

The following are not routinely funded by MSE ICB:

MSE ICB will not approve funding for patients who are unhappy with the outcome of previous surgeries including immediate post-trauma corrections (whether provided by the NHS or private providers) unless meet criteria as defined in this policy.

See also SRP092 Snoring and Snoring ENT Referrals.

Cleft lip/palate patients are funded through NHS England commissioned Cleft Lip/Palate clinical management pathway and not funded by MSE ICB.

Patients not meeting the above criteria will not be funded unless there are clinically exceptional circumstances.

Individual funding requests should only be made where the patient demonstrates clinical exceptionality. 

Further information on applying for funding in exceptional clinical circumstances can be found on the ICB website.

NB This replaces SRP 089Septoplasty