Nasal Disorders

Last updated 31 May 2026 · ENT

📋 Key Information Summary

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Nasal discharge character is the single most useful bedside clue: clear watery suggests allergic/viral rhinitis; thick purulent suggests acute bacterial sinusitis; unilateral bloody/foul discharge mandates urgent exclusion of foreign body or malignancy.
Allergic rhinitis (AR) affects approximately 1 in 5 Australians and is the most common chronic nasal disorder managed in primary care; intranasal corticosteroids (INCS) are first-line pharmacotherapy.
Acute bacterial sinusitis (ABS) should be diagnosed when symptoms persist ≥ 10 days without improvement, or worsen after initial improvement ("double sickening"); first-line antibiotic is amoxicillin 500 mg TDS for 5–7 days.
Nasal polyps are associated with chronic rhinosinusitis, asthma, and aspirin-exacerbated respiratory disease (AERD); intranasal corticosteroids are the mainstay; biologic therapy (dupilumab) is PBS-listed for severe cases.
Epistaxis — most bleeds originate from the anterior septum (Kiesselbach's plexus); first-aid measures (lean forward, compress soft part of nose × 10 min) control > 90% of cases.
Recurrent or posterior epistaxis in patients on anticoagulants or with hepatic/renal disease warrants ENT referral; posterior packing carries aspiration and airway risk and should be performed in hospital.
Hyposmia / anosmia may follow viral upper respiratory infections (including COVID-19), head trauma, or signal intracranial pathology; persistent unilateral anosmia with nasal obstruction warrants urgent imaging.
Nasal tumours — squamous cell carcinoma is the most common sinonasal malignancy; unilateral nasal obstruction, epistaxis, facial pain, or cranial nerve palsy in an adult > 40 years should prompt urgent ENT referral (2-week wait).
Australian-specific considerations: CA-MRSA is prevalent in remote Aboriginal and Torres Strait Islander communities and must be considered when purulent nasal/sinus infections fail initial therapy; nasal swab culture guides decolonisation regimens.
Allergic rhinitis and asthma frequently co-exist (up to 80% of asthmatics have AR); poorly controlled AR worsens asthma outcomes — always assess both conditions together per ASCIA guidelines.
Epistaxis in children is almost always anterior and benign; recurrent bilateral epistaxis with easy bruising warrants FBC and coagulation screen to exclude bleeding diathesis.
MBS item 104 (specialist consultation) applies for ENT referrals; bulk-billing incentives apply for ATSI patients and those in rural/remote areas under the Practice Incentives Program (PIP).

Introduction & Australian Epidemiology

Nasal disorders encompass a broad spectrum of conditions ranging from self-limiting infectious rhinitis to life-threatening malignancies. They represent one of the most common reasons for primary care consultation in Australia, with allergic rhinitis alone accounting for an estimated 4.6 million GP encounters annually. The Australian climate — characterised by high pollen loads in temperate zones, dust in arid regions, and humidity in tropical north Queensland — creates a distinctive allergen profile that influences disease prevalence and seasonality.

The economic burden is substantial: direct healthcare costs for allergic rhinosinusitis in Australia exceed

.2 billion per year when pharmacy, GP, specialist, and hospital costs are combined. Indirect costs from absenteeism and reduced workplace productivity further inflate this figure. Epistaxis accounts for approximately 1 in 200 emergency department presentations nationally, with peaks during winter (dry mucosa) and hay-fever season (mucosal inflammation).

This guideline provides an evidence-based approach to the diagnosis and management of common nasal disorders in Australian primary care and specialist practice, aligned with Therapeutic Guidelines (eTG), ASCIA, RACGP, and Australasian Society of Clinical Immunology and Allergy recommendations.

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Red-flag symptoms requiring urgent ENT referral: Unilateral nasal obstruction with epistaxis in adults > 40 years; new-onset unilateral anosmia; cranial nerve palsy (especially V2, VI); non-healing nasal septal perforation; saddle-nose deformity; persistent purulent rhinorrhoea refractory to standard therapy. These may indicate malignancy, granulomatosis with polyangiitis (GPA), or other systemic disease.

Typical Symptoms & Nasal Discharge Characteristics

A systematic approach to nasal symptoms begins with characterising the discharge (rhinorrhoea), as colour, consistency, laterality, and associated features narrow the differential diagnosis rapidly.

Discharge Character — Clinical Correlation

Discharge Type	Appearance	Likely Diagnosis	Key Features
Clear, watery	Thin, copious, bilateral	Allergic rhinitis; viral rhinitis; CSF leak	Allergic: sneezing, itch, conjunctivitis. CSF: unilateral, post-trauma, "halo sign"
Mucoid (white/grey)	Thick, tenacious	Chronic rhinosinusitis; vasomotor rhinitis	Post-nasal drip, hyposmia, facial pressure
Mucopurulent (yellow/green)	Thick, coloured, bilateral or unilateral	Acute bacterial sinusitis; adenoiditis (children)	≥ 10 days of symptoms or worsening after initial improvement
Purulent (frank pus)	Yellow-green, foul smell possible	Chronic sinusitis with nasal polyps; dental abscess eroding into maxillary sinus	Unilateral foul: dental origin or foreign body (children)
Bloody (epistaxis)	Bright red or dark clots	Epistaxis; nasal tumour; granulomatous disease	Unilateral recurrent: suspect structural/mass lesion
CSF rhinorrhoea	Clear, salty taste, unilateral	Skull base defect (trauma, surgery, spontaneous)	Positive "halo sign" on filter paper; β-2 transferrin assay confirms

Associated Symptoms

Nasal obstruction: Mucosal oedema (allergic, infectious), structural (deviated septum, turbinate hypertrophy), mass (polyps, tumour)
Sneezing: Allergic rhinitis (morning predominance), viral rhinitis (first 1–2 days), vasomotor rhinitis (irritant triggers)
Facial pain/pressure: Sinusitis (maxillary — cheek/tooth; frontal — forehead; ethmoid — between eyes; sphenoid — occipital/retro-orbital)
Hyposmia/anosmia: CRS with polyps, post-viral (including SARS-CoV-2), head trauma, neurodegenerative disease
Post-nasal drip: Allergic rhinitis, CRS, vasomotor rhinitis — contributes to chronic cough

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Clinical pearl: Unilateral symptoms in any category (obstruction, discharge, bleeding) are always more concerning than bilateral symptoms and warrant earlier investigation to exclude foreign body (children), tumour, or structural pathology.

Allergic Rhinitis & Sinusitis

Allergic Rhinitis (AR)

Allergic rhinitis is an IgE-mediated inflammatory disorder of the nasal mucosa triggered by aeroallergens. In Australia, the most prevalent allergens are ryegrass pollen (temperate regions), house dust mites (Dermatophagoides pteronyssinus and D. farinae), moulds (Alternaria, Cladosporium), and pet dander. AR is classified by the ARIA (Allergic Rhinitis and its Impact on Asthma) framework:

Mild

Intermittent AR

Symptoms < 4 days/week or < 4 consecutive weeks. Normal sleep, daily activities, work/school, and sport unaffected.

Setting: GP / pharmacy self-care

Moderate–Severe

Persistent AR

Symptoms ≥ 4 days/week and ≥ 4 consecutive weeks. At least one of: impaired sleep, daily activities, work/school, or sport affected.

Setting: GP — step-up pharmacotherapy; consider ENT/allergy referral

Diagnostic Approach

Clinical diagnosis supported by characteristic history (sneezing, rhinorrhoea, nasal itch, obstruction) and typical allergen exposure pattern
Skin prick testing (SPT) or serum-specific IgE (RAST) to confirm allergen sensitisation — available through allergists and some GP practices with allergy training
Anterior rhinoscopy: pale, oedematous turbinates with thin clear secretions
Nasal endoscopy (ENT): if polyps suspected, atypical features, or refractory symptoms

Pharmacological Management — Stepwise Approach

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Mometasone furoate nasal spray

Nasonex® · Generic · Intranasal corticosteroid (INCS)

Adult dose 2 sprays (50 µg/spray) each nostril OD for 2–4 weeks, reduce to 1 spray each nostril OD for maintenance

Paediatric dose 2–11 years: 1 spray each nostril OD. ≥ 12 years: adult dose

Route Intranasal

Duration Continuous during allergen exposure; may be used long-term

Renal adjustment Nil — negligible systemic absorption

Hepatic adjustment Nil required

PBS status ✔ PBS General Benefit

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Fexofenadine hydrochloride

Telfast® · Generic · Non-sedating antihistamine (H1 antagonist)

Adult dose 120–180 mg PO OD

Paediatric dose 6 months–2 years: 15 mg PO BD. 2–11 years: 30 mg PO BD. ≥ 12 years: adult dose

Route Oral

Renal adjustment eGFR 30–50: 60 mg OD; eGFR < 30: 60 mg OD with caution

Hepatic adjustment No specific recommendation — use with caution

PBS status ✔ PBS General Benefit

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Azelastine / Fluticasone propionate nasal spray

Dymista® · Combination INCS + antihistamine

Adult dose 1 spray each nostril BD (137 µg azelastine / 50 µg fluticasone per spray)

Paediatric dose ≥ 12 years: adult dose. Not recommended < 12 years

Renal adjustment Nil required

PBS status ⚡ PBS Authority Required — when INCS alone inadequate after ≥ 4 weeks

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Ipratropium bromide nasal spray

Atrovent Nasal® · Anticholinergic

Adult dose 2 sprays (21 µg/spray) each nostril BD–TDS for watery rhinorrhoea

Paediatric dose ≥ 6 years: 1–2 sprays each nostril BD–TDS

PBS status ✔ PBS General Benefit

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ASCIA recommendation: INCS should be started 1–2 weeks before the pollen season for patients with seasonal AR. Counsel patients on correct spray technique (aim laterally, away from septum) to maximise efficacy and minimise epistaxis.

Allergen Immunotherapy

Sublingual immunotherapy (SLIT) or subcutaneous immunotherapy (SCIT) should be considered when pharmacotherapy provides inadequate symptom control or when there is a clear allergen trigger confirmed on SPT/RAST. Australian programs typically target ryegrass, house dust mite, or Alternaria. Referral to a clinical immunologist/allergist is required. MBS item 106 applies.

Sinusitis

Acute Rhinosinusitis (ARS)

Most episodes of acute rhinosinusitis are viral (common cold) and self-limiting (7–10 days). Acute bacterial sinusitis (ABS) complicates 0.5–2% of viral upper respiratory infections.

Diagnostic Criteria for ABS (IDSA 2012 / eTG)

Persistent symptoms

Nasal discharge or daytime cough ≥ 10 days without improvement from onset

Severe onset

Purulent nasal discharge + high fever (≥ 39°C) + facial pain/tooth pain for ≥ 3–4 consecutive days at illness onset

Double sickening

Worsening symptoms (new onset fever, headache, increase in discharge) after initial improvement of a viral URI

Antibiotic Therapy for ABS

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Amoxicillin

Amoxil® · Generic · Aminopenicillin

Adult dose 500 mg PO TDS for 5–7 days (eTG); extend to 10–14 days if slow response

Paediatric dose 30–50 mg/kg/day PO in 3 divided doses for 5–7 days

Renal adjustment eGFR 10–30: 500 mg BD; eGFR < 10: 500 mg OD

PBS status ✔ PBS General Benefit

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Amoxicillin–clavulanate

Augmentin® · Generic · β-lactam / β-lactamase inhibitor

Adult dose 875/125 mg PO BD for 5–7 days (high-dose formulation)

Paediatric dose 45 mg/kg/day (amoxicillin component) PO in 2 divided doses

Renal adjustment eGFR 10–30: 500/125 mg BD; eGFR < 10: 500/125 mg OD

PBS status ✔ PBS General Benefit

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Doxycycline

Doxy® · Generic · Tetracycline

Adult dose 200 mg PO OD day 1, then 100 mg PO OD for 5–7 days total

Paediatric dose ≥ 8 years: 2 mg/kg/day PO BD (max 100 mg BD) day 1, then 2 mg/kg/day OD

Renal adjustment Not required

PBS status ✔ PBS General Benefit

Adjunctive Measures for Sinusitis

Intranasal saline irrigation (0.9% or hypertonic): evidence supports improved symptom clearance; available OTC (FESS®, Flo Sinus Care®)
Intranasal corticosteroids: Fluticasone or mometasone nasal spray — reduces mucosal oedema, particularly in AR-associated sinusitis
Short-course oral corticosteroids: Prednisolone 25–50 mg daily for 5–7 days may be considered in severe CRSwNP or when polyps cause significant obstruction
Oral decongestants (pseudoephedrine): Short-term use (≤ 5 days) for severe congestion; contraindicated in hypertension, cardiovascular disease, and within 14 days of MAOIs

Chronic Rhinosinusitis (CRS)

CRS is defined as symptomatic sinus inflammation lasting ≥ 12 weeks. It is subdivided into CRS without nasal polyps (CRSsNP) and CRS with nasal polyps (CRSwNP). Australian prevalence is approximately 10–12%. Diagnosis requires ≥ 2 of: nasal obstruction, anterior/posterior rhinorrhoea, facial pressure/pain, hyposmia/anosmia, plus either endoscopic or CT evidence of inflammation. Management involves prolonged INCS, saline irrigation, and ENT referral for endoscopic sinus surgery (ESS) if medical therapy fails after ≥ 3 months.

Nasal Polyps & Epistaxis

Nasal Polyps

Nasal polyps are benign, oedematous, semi-translucent grape-like projections arising from the paranasal sinus mucosa, most commonly from the ethmoid sinuses. They affect 1–4% of the adult population and are rare in children (consider cystic fibrosis if polyps found in a child).

Associations

Asthma — up to 40–70% of CRSwNP patients have coexisting asthma
Aspirin-exacerbated respiratory disease (AERD / Samter's triad): asthma + nasal polyps + NSAID/COX-1 sensitivity; present in 7–15% of asthmatic adults with polyps
Allergic fungal rhinosinusitis — especially in atopic patients in tropical/subtropical Australia
Cystic fibrosis — nasal polyps found in 10–40% of CF patients; bilateral
Primary ciliary dyskinesia

Management of Nasal Polyps

INCS — First-line

Mometasone 200 µg BD or fluticasone propionate 200 µg BD nasal spray; ≥ 8–12 weeks before assessing response. Intra-polyp injection may be used by ENT specialists.

Short-course oral corticosteroids

Prednisolone 25–50 mg PO OD for 5–7 days (eTG) for acute exacerbations with significant obstruction. Limit to 2–3 courses/year due to cumulative ADRs.

Biologic therapy

Dupilumab (Dupixent®) — anti-IL-4Rα monoclonal antibody. PBS-listed (Authority Required) for severe CRSwNP inadequately controlled by INCS ± surgery. Dose: 300 mg SC fortnightly. Significant reduction in polyp size and improvement in olfaction and SNOT-22 scores.

Endoscopic sinus surgery (ESS)

Refer to ENT when medical therapy fails. Functional ESS opens sinus ostia and removes polyps under direct endoscopic vision. Recurrence rate is 40–60% at 5 years, hence ongoing INCS post-surgery is standard practice.

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Red flag — unilateral polyp: A unilateral nasal polyp in an adult may represent an inverting papilloma (pre-malignant, 5–15% malignant transformation) or esthesioneuroblastoma. Unilateral polyps must always be biopsied under ENT guidance and are not suitable for empirical medical management.

Epistaxis

Epistaxis (nosebleed) is classified by location: anterior (90–95%) from Kiesselbach's plexus on the nasal septum, and posterior (5–10%) from branches of the sphenopalatine or ethmoid arteries. Posterior bleeds are more common in elderly patients, those on anticoagulants, and those with uncontrolled hypertension.

Aetiology

Category	Common Causes
Local	Digital trauma (nose picking — most common in children), dry air/heating, allergic rhinitis, nasal septal deviation, foreign body, INCS use, nasal septal perforation, tumour
Systemic	Anticoagulant/antiplatelet therapy (warfarin, DOACs, aspirin, clopidogrel), liver cirrhosis/coagulopathy, thrombocytopenia, hereditary haemorrhagic telangiectasia (HHT/Osler-Weber-Rendu), hypertension (association debated but may exacerbate), vasculitis

Stepwise Management of Epistaxis

First aid (patient self-care)

Sit upright, lean slightly forward, firmly compress the soft (cartilaginous) part of the nose against the midline septum for 10–15 minutes continuously. Avoid swallowing blood. Apply ice pack to nasal bridge. Spit out any blood in the mouth.

Chemical cautery

After achieving haemostasis, identify the bleeding point. Apply silver nitrate (75%) stick to the anterior septum for 5–10 seconds; bilateral cauterisation must be avoided (risk of septal perforation).

Anterior packing

Nasal tampon (Merocel®, Rapid Rhino®) or ribbon gauze impregnated with fusidic acid ointment. Leave in situ 24–48 hours. Prescribe prophylactic antibiotics (amoxicillin 500 mg TDS or co-trimoxazole) to prevent toxic shock syndrome.

Posterior packing / balloon tamponade

For posterior bleeds unresponsive to anterior measures. Requires hospital admission and continuous pulse oximetry (risk of hypoxia and cardiac arrhythmia). ENT specialist procedure.

Endoscopic surgical management

Endoscopic sphenopalatine artery ligation (ESPAL) or anterior/posterior ethmoid artery ligation for refractory cases. Angioembolisation by interventional radiology is an alternative.

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Anticoagulant management during epistaxis: Do not routinely discontinue anticoagulants for simple anterior epistaxis. For severe/recurrent bleeds, consult the prescribing physician. INR should be checked in patients on warfarin — target INR 2.0–3.0 (or 2.5–3.5 for mechanical valves). For DOACs, timing of last dose is critical — do not reverse without haematology advice.

Disorders of Smell & Nasal Tumours

Disorders of Smell (Dysosmia)

Olfactory dysfunction is broadly classified as quantitative (hyposmia — reduced; anosmia — absent; hyperosmia — enhanced) or qualitative (parosmia — distorted perception; phantosmia — olfactory hallucination). In Australia, post-viral olfactory loss (including post-COVID-19) is now the most common cause, followed by CRSwNP and post-traumatic olfactory dysfunction.

Common Aetiologies

Mechanism	Causes	Typical Presentation
Conductive (transport)	Allergic rhinitis, CRS, nasal polyps, septal deviation, turbinate hypertrophy	Bilateral smell loss; improves when obstruction relieved (e.g., decongestant trial)
Sensorineural (epithelial)	Post-viral (SARS-CoV-2, influenza, parainfluenza), toxic exposure (smoking, industrial chemicals), medications (intranasal zinc, methotrexate)	Acute onset following URI; may recover over 6–12 months; parosmia common during recovery
Neural (central)	Head trauma, neurodegenerative disease (Parkinson's, Alzheimer's), intracranial tumours (olfactory groove meningioma, frontal lobe glioma), epilepsy (uncinate fits)	Gradual or sudden onset; may be unilateral; associated neurological signs

Investigation and Management

Bedside testing: Assess each nostril separately using coffee, peppermint, or vanilla; standardised tools include the Sniffin' Sticks test or University of Pennsylvania Smell Identification Test (UPSIT) — available through ENT and neurology clinics
Nasal endoscopy: Evaluate for polyps, masses, or mucosal disease
MRI brain (with gadolinium): Indicated for unilateral anosmia, suspected intracranial pathology, or post-traumatic loss with focal neurological signs
Post-viral olfactory training: Sniff 4 essential oils (rose, eucalyptus, lemon, clove) for 20 seconds each, twice daily, for ≥ 12 weeks. Evidence supports modest improvement in olfactory scores. Free resources available through Fifth Sense (UK) and adapted by ASCIA
Intranasal corticosteroids: May benefit conductive and some post-viral cases; high-volume sinonasal rinses with budesonide (off-label) used by ENT for CRS-related hyposmia
Alpha-lipoic acid (600 mg PO OD): Limited evidence for post-viral anosmia; may be trialled for 3 months

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Post-COVID-19 olfactory dysfunction: Affects 40–65% of SARS-CoV-2 infections in the acute phase; 5–10% have persistent symptoms beyond 12 months. Most recover within 6 months. Olfactory training is the best-supported intervention. Intranasal corticosteroid sprays have not shown consistent benefit in RCTs for post-COVID anosmia specifically.

Nasal Tumours

Primary sinonasal tumours are rare, accounting for < 1% of all malignancies in Australia. Benign tumours are more common than malignant. A high index of suspicion is required as early symptoms are non-specific.

Benign Tumours

Tumour	Key Features	Management
Inverting papilloma	Most common benign sinonasal tumour. Unilateral nasal obstruction, arises from lateral nasal wall. 5–15% malignant transformation to SCC.	Complete surgical excision (wide local excision via ESS). Long-term endoscopic follow-up essential.
Haemangioma	Red/blue mass on septum (capillary) or lateral wall (venous/cavernous). Recurrent epistaxis.	Surgical excision or laser ablation.
Ossifying fibroma	Slow-growing bony tumour of the mandible or maxilla; may extend into sinuses.	Surgical excision.
Juvenile nasopharyngeal angiofibroma (JNA)	Highly vascular tumour in adolescent males. Unilateral nasal obstruction + recurrent profuse epistaxis. CT/MRI shows characteristic bowing of posterior maxillary wall.	Pre-operative angioembolisation + surgical resection. Refer to paediatric ENT or skull-base centre.

Malignant Tumours

Tumour	Prevalence	Key Features	Management
Squamous cell carcinoma (SCC)	Most common sinonasal malignancy (~50–60%)	Unilateral nasal obstruction, epistaxis, facial pain, cheek swelling. Associated with hardwood dust (occupational), nickel, leather dust.	Surgery + adjuvant radiotherapy. MDT at tertiary centre.
Adenoid cystic carcinoma	10–15% of sinonasal malignancies	Slow-growing; perineural invasion (V2, V3) is hallmark. Late recurrence (10–20 years).	Surgery + radiotherapy. Lifelong surveillance.
Esthesioneuroblastoma (olfactory neuroblastoma)	Rare (~3–5%)	Arises from olfactory epithelium at skull base. Unilateral nasal obstruction, epistaxis, anosmia. Bimodal age distribution (young adults + 50–60 years).	Craniofacial resection + radiotherapy ± chemotherapy. Kadish staging.
Mucosal melanoma	Rare (~3–5%)	Darkly pigmented (or amelanotic) mass. Aggressive with early metastasis.	Surgery + immunotherapy (checkpoint inhibitors). Refer melanoma MDT.
Non-Hodgkin lymphoma (NHL)	~5–10%	NK/T-cell lymphoma (nasal-type) — more common in Asian/Indigenous Australian populations. Midline destructive lesion, "lethal midline granuloma".	Chemoradiotherapy. Refer haematology MDT.

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Urgent referral criteria for suspected sinonasal malignancy (2-week wait): Any adult (> 40 years) with unilateral nasal obstruction + epistaxis; new unilateral cranial nerve palsy (especially V1, V2, VI); non-healing nasal septal ulcer; expanding facial mass; persistent bloody nasal discharge unresponsive to standard management. Arrange CT ± MRI of sinuses and refer to ENT with head-and-neck oncology expertise.

Staging and Imaging

CT sinuses (non-contrast): First-line for suspected structural/mass lesion; demonstrates bony erosion, involvement of orbit/skull base
MRI with gadolinium: Superior for soft-tissue characterisation, intracranial extension, perineural spread, and orbital involvement. Essential for staging
PET-CT: For staging of malignant sinonasal tumours; assesses regional and distant metastases
Biopsy: Must be performed under ENT guidance (endoscopic); avoid blind biopsy due to risk of bleeding and incomplete sampling. JNA is typically not biopsied (imaging diagnosis) due to haemorrhage risk.

Investigations

Investigations for nasal disorders should be guided by clinical context. The majority of acute presentations (viral rhinitis, simple anterior epistaxis) require no laboratory or imaging workup.

GP — In Clinic Anterior rhinoscopy Visualisation of anterior nasal cavity using speculum and headlight. Identifies septal deviation, polyps, mucosal oedema, discharge character, bleeding points. No special equipment beyond ENT set.

GP — In Clinic Nasal endoscopy (flexible) Some GP practices with ENT interest; more commonly performed by ENT specialists. MBS item 106 (specialist). Direct visualisation of middle meatus, osteomeatal complex, and posterior nasal cavity.

GP — In Clinic Skin prick testing (SPT) Available in allergist clinics and some GP practices with allergy training. Battery includes HDM, grasses, moulds, pet dander, cockroach. Results in 15–20 minutes. MBS item 71030 (specialist/allergist).

GP — Pathology Serum-specific IgE (RAST/CAP) In-vitro allergen-specific IgE testing. Useful when SPT contraindicated (severe dermatographism, cannot stop antihistamines). Available through major labs (Sullivan Nicolaides, Douglass Hanly Moir, Pathology QLD). MBS item 71131.

GP — Pathology Nasal swab — microscopy, culture, sensitivities For refractory sinusitis, suspected CA-MRSA, or suspected diphtheria/other atypical infection. Essential in ATSI remote communities with high MRSA prevalence. Available through all major Australian pathology providers.

GP — Pathology FBC, coagulation profile (INR, APTT, fibrinogen) For recurrent epistaxis, suspected bleeding diathesis, thrombocytopenia, or anticoagulant monitoring. Bulk-billed at all Australian pathology labs.

Imaging — Referral CT sinuses (non-contrast) Gold standard for chronic rhinosinusitis diagnosis and surgical planning. Identifies mucosal thickening, polyps, bony erosion, anatomical variants. Available at most radiology practices. MBS item 56001.

Imaging — Referral MRI brain/sinuses with gadolinium For suspected intracranial extension, perineural spread, or olfactory groove pathology. Available at major radiology centres and hospitals. MBS item 63090.

Specialist Nasal biopsy (endoscopic-guided) For suspected malignancy, granulomatous disease (GPA, sarcoidosis), or atypical infection. Performed by ENT specialist. Histopathology via anatomical pathology.

Specialist β-2 transferrin assay (CSF confirmation) For suspected CSF rhinorrhoea. Collected in sterile container, sent to reference laboratory (e.g., PathWest WA, SA Pathology). High sensitivity and specificity for CSF.

Empirical Therapy

Empirical treatment decisions are guided by clinical presentation and likelihood of aetiology. Most acute nasal complaints are managed symptomatically before diagnostic confirmation.

Viral rhinosinusitis (common cold)

Paracetamol/ibuprofen PRN; saline irrigation; intranasal oxymetazoline × 3–5 days max

Self-limiting 7–10 days

No antibiotics. Avoid oral decongestants > 5 days (rhinitis medicamentosa risk).

Acute bacterial sinusitis (mild–moderate)

Amoxicillin 500 mg PO TDS

5–7 days

Add INCS (mometasone/fluticasone). If β-lactam allergy: doxycycline 200 mg day 1 then 100 mg OD. If atypical: add clarithromycin 500 mg BD.

Acute bacterial sinusitis (severe / high-risk)

Amoxicillin–clavulanate 875/125 mg PO BD

7–10 days

Consider IV if systemic signs (fever > 39°C, periorbital oedema, neurological symptoms). CT to exclude orbital/intracranial complications.

Allergic rhinitis (first presentation)

INCS (mometasone 200 µg/day or fluticasone 200 µg/day) + oral non-sedating antihistamine PRN

Ongoing / seasonal

Counsel on correct spray technique. Add SLIT/SCIT if inadequate response after 4–8 weeks. Refer allergy/immunology.

Anterior epistaxis (simple)

First aid (lean forward, compress 10–15 min) → silver nitrate cautery if visible bleeding point

Single event

Naseptin® cream (chlorhexidine + neomycin) BD to affected nostril for 10 days to promote mucosal healing. Check BP; review anticoagulants.

Nasal polyps — initial management

INCS (mometasone 200 µg BD or fluticasone 200 µg BD) + short course prednisolone 25–50 mg OD × 5–7 days

INCS ≥ 12 weeks; oral steroids for flare only

Refer ENT if no improvement. Check for AERD (aspirin sensitivity). Assess asthma control concurrently.

Monitoring

Allergic rhinitis: Review at 4–8 weeks after initiating INCS; assess symptom control (ARIA classification), nasal obstruction severity, impact on sleep/work/asthma. Step down if well controlled; step up (add antihistamine, combination spray, or refer for immunotherapy) if persistent.
Acute bacterial sinusitis: Review at 48–72 hours if no improvement or worsening; consider alternative antibiotic or imaging. Repeat review at 7 days to confirm resolution.
Chronic rhinosinusitis: Assess at 3-monthly intervals using validated symptom scores (SNOT-22). CT at baseline and post-operatively. Monitor for polyp recurrence after ESS.
Nasal polyps on dupilumab: Monitor at 16 weeks (first assessment point), then 6-monthly. Assess SNOT-22, NPS (Nasal Polyp Score), olfaction, asthma control (if concurrent), and eosinophil count.
Recurrent epistaxis: Monitor haemoglobin if frequent bleeds. Review anticoagulant appropriateness. Screen for hereditary haemorrhagic telangiectasia (HHT) if recurrent nosebleeds with telangiectasia and family history (Curacao criteria).
Post-surgical (ESS): Endoscopic surveillance at 2 weeks, 6 weeks, 3 months, 6 months, and 12 months post-surgery, then annually if CRSwNP. Ongoing INCS is mandatory.
Sinonasal malignancy post-treatment: Clinical examination + nasal endoscopy every 3 months for 2 years, then every 6 months for 3 years, then annually. CT/MRI per oncology protocol.

Special Populations

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Pregnancy

Rhinitis of pregnancy: Affects up to 30% of pregnant women due to hormonal mucosal congestion. Diagnosis of exclusion (no allergen triggers, onset in 2nd/3rd trimester).

Safe medications: Saline irrigation is first-line. Budesonide nasal spray (Rhinocort Aqua®) is Category B1 in pregnancy — preferred INCS. Loratadine or cetirizine are the preferred oral antihistamines (Category B1).

Avoid: Pseudoephedrine (Category B2 — teratogenic in animal studies; use only if benefit outweighs risk). Oxymetazoline nasal spray — avoid chronic use.

Epistaxis may be more common in pregnancy due to hypervolaemia and mucosal congestion. Silver nitrate cautery is safe.

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Paediatrics

Foreign body: Common in children 1–5 years. Unilateral, foul-smelling, purulent or bloody discharge. Do not probe blindly — refer to ED/ENT for removal under direct vision.

Adenoid hypertrophy: Major cause of nasal obstruction in children. Mouth breathing, snoring, hyponasal speech. Assess for obstructive sleep apnoea (OSA). Adenoidectomy ± tonsillectomy if significant.

Allergic rhinitis: Uncommon < 2 years; increases in school-age children. First-line: INCS (mometasone approved ≥ 3 years; fluticasone approved ≥ 4 years). Cetirizine liquid ≥ 1 year; loratadine syrup ≥ 2 years.

Nasal polyps in children: Consider cystic fibrosis (sweat test) and primary ciliary dyskinesia (nasal NO, genetic testing) if bilateral polyps.

Intranasal decongestants (oxymetazoline) should be avoided in children < 6 years due to risk of systemic absorption and CNS depression. Antibiotic dosing for sinusitis uses weight-based calculations.

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Elderly

Posterior epistaxis: More common in elderly patients and more difficult to manage. Hypertension, anticoagulants (warfarin, DOACs, aspirin, clopidogrel), and mucosal atrophy are contributing factors. Lower threshold for ENT referral and admission.

Nasal polyposis: AERD triad may present for the first time in later life. Careful NSAID history required.

Sinonasal malignancy: Peak incidence 55–65 years. Any new unilateral nasal symptom should raise suspicion. Urgent CT + ENT referral.

Elderly patients may have atrophic rhinitis (ozaena) — dry, crusted nasal mucosa with foul smell. Managed with saline irrigation and topical emollients. Antihistamines with anticholinergic properties should be avoided (confusion, urinary retention risk).

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Renal Impairment

Amoxicillin: Dose reduction required in eGFR < 30 (see drug card above). Amoxicillin–clavulanate: reduce dose if eGFR < 30.

Fexofenadine: Reduce to 60 mg OD if eGFR 10–50. Primarily renally excreted.

INCS: No dose adjustment needed — negligible systemic absorption.

Patients on dialysis with CRS may have altered mucosal immunity. Consider nasal swab cultures for CA-MRSA if recurrent sinusitis in the context of vascular access devices.

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Hepatic Impairment

Coagulopathy: Hepatic impairment predisposes to epistaxis due to reduced clotting factor synthesis and thrombocytopenia. Check INR, APTT, platelets. Consider vitamin K 10 mg IV if INR elevated.

Antibiotics: Amoxicillin–clavulanate: risk of cholestatic hepatitis; use amoxicillin alone if mild liver disease. Doxycycline: no significant hepatic dose adjustment.

INCS are safe in hepatic impairment. Loratadine and cetirizine should be used with caution in severe hepatic failure (reduced clearance).

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Immunocompromised

Expanded differential: Invasive fungal sinusitis (Aspergillus, Mucorales — especially in uncontrolled diabetes/DKA or neutropenia), atypical mycobacteria, CMV, HSV. This is an ENT/emergency.

Invasive fungal sinusitis: Presents with facial pain, fever, black eschar on nasal endoscopy, rapid orbital/cranial invasion. Requires emergency surgical debridement + IV antifungals (liposomal amphotericin B). Mortality 50–80%.

HIV: CRS is more common and severe. Low threshold for nasal swab (bacterial, fungal, AFB). Consider granulomatous disease (GPA, sarcoidosis).

Wegener's granulomatosis (GPA) commonly presents with ENT manifestations — saddle-nose deformity, septal perforation, bloody nasal crusting. c-ANCA/PR3 testing should be performed in patients with refractory CRS and systemic features.

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander Health Considerations

Nasal and sinus disease disproportionately affects Aboriginal and Torres Strait Islander Australians, particularly those living in remote and very remote communities. Otitis media with effusion (OME) and upper respiratory tract infections are among the most common childhood conditions, and chronic rhinosinusitis in adults is frequently complicated by CA-MRSA colonisation and recurrent antibiotic-resistant infections.

Prevalence

Chronic rhinosinusitis and allergic rhinitis are 1.5–2 times more prevalent in ATSI populations compared with non-Indigenous Australians. Childhood URTIs and nasal carriage of Staphylococcus aureus (including CA-MRSA) are significantly higher in remote communities.

CA-MRSA and refractory sinusitis

Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) nasal carriage rates in some remote NT and WA communities exceed 30%. Empirical antibiotic regimens for sinusitis must consider local antibiograms. Refractory cases require nasal swab for MC&S. Decolonisation with mupirocin nasal ointment (5 days) + chlorhexidine wash may be required.

Access to specialist care

ENT specialist services are largely concentrated in major cities. Remote communities may rely on visiting ENT surgeons (RFDS, Outreach programs) with wait times of 3–12 months. Telehealth (MBS items 99200–99215) is increasingly used for ENT triage. Patient-assisted travel schemes (PATS) are available through state/territory health departments.

Environmental factors

Overcrowded housing, indoor wood-fire smoke exposure, and dusty environments in central and northern Australia exacerbate nasal mucosal inflammation and increase respiratory infection transmission. Social determinants of health (housing, water quality, employment) are upstream factors requiring whole-of-government responses.

Cultural safety in ENT examination

Nasal endoscopy and anterior rhinoscopy may require cultural sensitivity, particularly for women in some communities (preference for female practitioners). Health practitioners should use Aboriginal Health Workers (AHWs) and Aboriginal Community Controlled Health Organisations (ACCHOs) as intermediaries for education, consent, and follow-up coordination.

Epistaxis management

Epistaxis first-aid education is essential in communities where access to healthcare is delayed. Train AHWs and community members in basic anterior compression technique. Ensure communities have access to nasal tampons (Merocel®) in first-aid kits. Review anticoagulant use proactively in elderly community members.

⚠️

Clinical alert: Any ATSI patient with chronic nasal symptoms, non-healing nasal septal ulcer, or progressive midline nasal destruction must be urgently assessed for nasal NK/T-cell lymphoma (nasal-type), which has a higher prevalence in some Indigenous populations. This tumour can mimic GPA ("lethal midline granuloma"). Urgent biopsy + haematology referral is essential.

📚 References

1. Bousquet J, Khaltaev N, Cruz AA, et al. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update (in collaboration with the World Health Organization, GA²LEN and AllerGen). Allergy. 2008;63 Suppl 86:8–160.
2. Chow AW, Benninger MS, Brook I, et al. IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults. Clin Infect Dis. 2012;54(8):e72–e112.
3. Fokkens WJ, Lund VJ, Hopkins C, et al. European Position Paper on Rhinosinusitis and Nasal Polyps 2020 (EPOS 2020). Rhinology. 2020;58 Suppl S29:1–464.
4. Australasian Society of Clinical Immunology and Allergy (ASCIA). ASCIA Guide to Allergic Rhinitis and Hay Fever. Sydney: ASCIA; 2023. Available at: https://www.allergy.org.au
5. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Ear and hearing health. Canberra: AIHW; 2023.
6. Kilty SJ, Brown D, Engels K, et al. Management of epistaxis: A practical approach. Can Fam Physician. 2021;67(9):667–672.
7. Royal Australian College of General Practitioners (RACGP). Red Book: Guidelines for Preventive Activities in General Practice. 9th ed. Melbourne: RACGP; 2018.
8. Hummel T, Whitcroft KL, Andrews P, et al. Position paper on olfactory dysfunction. Rhinology. 2017;54 Suppl 26:1–30.
9. Bachert C, Han JK, Desrosiers M, et al. Efficacy and safety of dupilumab in patients with severe chronic rhinosinusitis with nasal polyps (LIBERTY NP SINUS-24 and LIBERTY NP SINUS-52): results from two multicentre, randomised, double-blind, placebo-controlled, parallel-group phase 3 trials. Lancet. 2019;394(10209):1638–1650.
10. Tong MCF, Sih T, Hopkins C, et al. Prevalence and economic burden of chronic rhinosinusitis in the Asia-Pacific region. Allergy. 2021;76(5):1429–1439.
11. Antimicrobial Guidelines eTG complete [Internet]. Melbourne: Therapeutic Guidelines Limited; 2024. Chapter: Upper respiratory tract infections — Sinusitis.
12. Australian Commission on Safety and Quality in Health Care (ACSQHC). National Safety and Quality Health Service Standards. 2nd ed. Sydney: ACSQHC; 2021.
13. National Health and Medical Research Council (NHMRC). Australian Guidelines for the Prevention and Control of Infection in Healthcare. Canberra: NHMRC; 2019.
14. RHDAustralia (a program of Menzies School of Health Research). CARPA Standard Treatment Manual: A Clinical Manual for Primary Health Care. 8th ed. Alice Springs: RHDAustralia; 2022.

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

for PBS-listed medicines at participating pharmacies.

Cultural safety

Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.

Medication adherence

Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.

Specific conditions

Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.

Referral pathways

Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).