Sinus Treatment Guidelines Updated

NEW YORK, NY (November 2009) -- “Guidelines for the Treatment of Nasal Obstruction and Chronic Rhinosinusitis" are a tool for both the practicing physician and the patient who wants more education about the condition.  They were prepared by Steven D. Schaefer, MD, FACS, professor & chair of Otolaryngology-Head & Neck Surgery at The New York Eye and Ear Infirmary

Guidelines for the Treatment of Nasal Obstruction and Chronic Rhinosinusitis

Procedure

Disorder

Criteria for Surgery / Comments

Septoplasty (cpt #30520)

  1. nasal obstruction.
  2. frequent and intractable epistaxis.
  3. inability to inspect or visualize sinuses or posterior nose(impaired access to operative site).
  4. intractable facial pain due to septal deviation.
  5. benign or malignant tumors of septum or nose.
  6. nasal obstruction and non-allergic rhinitis/sinusitis.
  1. CT scan correlates poorly with functional obstruction of nose.  Therefore, CT may be useful to only confirm the clinical diagnosis;     b)when available,                      rhinometry provides           objective information;
  2. prior trial of nasal steroids, immuno- therapy  or decongestants by either PCP or ENT;
  3. chronic problem;
  4. trauma with nasal obstruction.
  5. prior attempts of nasal packing or cauterization.
  6. positive response to topical anesthetic.
  7. no response to allergic management or septum obstructing the sinus outflow.

Ethmoidectomy (cpt# 31200, 31201, 31205, 31254, 31255)

  1. nasal polyposis with obstruction of sinuses or nose.
  2. complication of sinusitis.
  3. mucocele or mucopyocele.
  4. invasive or allergic fungal sinusitis.
  5. benign or malignant tumors.
  6. CSF rhinorrhea
  7. sinusitis refractive to medical management (antibiotics/and steroids).
  8. orbital decompression for thyroid eye disease.
  1. a) CT scan evidence of sinus or nasal obstruction. 
    b) nasal endoscopy.
  2. a) prior or current history of subperiosteal orbital abscess or cellulitis;
    b) brain abscess, intracranial event.
  3. a) CT scan evidence.
  4. a) CT scan evidence;
    b) nasal endoscopy.
  5. a) CT scan evidence;
    b) nasal endoscopy;
    c) biopsy.
  6. a) imaging or CSF chemistry documentation.
  7. a) chronic sinusitis >12wks duration of symptoms including facial pain/ pressure, facial congestion/ fullness, nasal obstruction, purulent nasal discharge, headache;
    b) recurrent acute >4 episodes per year, each episode lasting >7days without intervening signs or symptoms; symptoms including facial pain/ pressure, facial congestion/ fullness, nasal obstruction, purulent nasal discharge, headache, fever;
    c) minimal ethmoid disease should be treated by partial ethmoidectomy;
    d) in acutely ill patients, CT should be obtained 1-2 weeks after completing 3 weeks of antibiotics.  If patient is not responding to antibiotics, CT scan during the acute illness is appropriate.
  8. eye consultation.

Maxillary antrostomy (CPT# 31020, 31256, 31267)

  1. nasal polyposis with obstruction of sinuses or nose.
  2. complication of sinusitis.
  3. mucopyocele.
  4. invasive or allergic fungal sinusitis.
  5. benign or malignant tumors.
  6. sinusitis refractive to medical management (antibiotic/and steroids).
  7. prevention of maxillary sinusitis in orbital decompression
  1. a) CT scan evidence of sinus or nasal obstruction;
    b) nasal endoscopy.
  2. a) prior or current history of subperiosteal orbital abscess or cellulitis;
    b) brain abscess, intracranial event.
  3. a) CT scan evidence.
  4. a) CT scan evidence;
    b) nasal endoscopy.
  5. a) CT scan evidence;
    b) nasal endoscopy.
    c) biopsy.
  6. a) imaging documentation.
    b) chronic sinusitis >12wks duration of symptoms including facial pain/pressure, facial congestion/fullness, nasal obstruction, purulent nasal discharge, headache;
    c) recurrent acute >4 episodes per year, each episode lasting >7days without intervening signs or symptoms; symptoms including facial pain/pressure, facial congestion/fullness, nasal obstruction, purulent nasal discharge, headache, fever;
    d) minimal ethmoid disease should be treated by partial ethmoidectomy;
    e) in acutely ill patients, CT should be obtained 1-2 weeks after completing 3 weeks of antibiotics.  If patient is not responding to antibiotics, CT scan during the acute illness is appropriate.

Caldwell Luc (CPT # 31020, 31032)

  1. antrochonal polyp.
  2. odontogenic sinusitis.
  3. fungal sinusitis.
  4. orbital decompression for thyroid eye disease
  5. internal maxillary artery ligatio
  6. tumor
  1. CT documentation of pathology. In acutely ill patients, CT should be obtained 1-2 weeks after completing 3 weeks of antibiotics.  If patient is not responding to antibiotics, CT scan during the acute illness is appropriate.
  2. eye consultation.
  3. epistaxis resistant to nasal packing, or cautery.

Frontal sinustomy (CPT #31276)

  1. frontal sinus polyposis.
  2. frontal sinusitis.
  3. tumor involving or extending to frontal sinus.
  1. a) CT documentation
    b) endoscopic evidence of frontal sinus involvement
  2. a) acute infection not responding to medical management
    b) CT documentation.In acutely ill patients, CT should be obtained 1-2 weeks after completing 3 weeks of antibiotics.  If patient is not responding to antibiotics, CT scan during the acute illness is appropriate.
  3. a) CT documentation; endoscopic evidence of frontal sinus involvement.

Frontal sinus trephination (CPT # 31070)

  1. frontal sinus polyposis.
  2. frontal sinus mucosal thickening.
  1. a) see frontal sinusotomy;
    b) acute infection not responding to medical management.

External fronto-ethmoidectomy(CPT # 31075)

  1. frontal sinus polyposis
  2. frontal sinusitis
  3. tumor involving or extending to frontal sinus
  1. a) CT documentation;
    b) endoscopic evidence of frontal sinus involvement
  2. a) acute infection not responding to medical management;
    c) CT documentation.
  3. a) CT documentation
    b) endoscopic evidence of frontal sinus involvement.

Osteoplastic flap with fat obliteration (CPT # 31080, 31081, 31084, 31085, 31086, 31087)

  1. frontal sinus polyposis.
  2. frontal sinusitis, with or without mucocele.
  3. tumor involving or extending to frontal sinus.
  4. frontal sinus trauma.
  5. tumors
  6. CSF rhinorrhea
  7. trauma
  1. a) CT documentation
    b) endoscopic evidence of frontal sinus involvement.
  2. a) acute infection not responding to medical management;
    b) CT documentation.
  3. a) CT documentation

Sphenoidotomy (CPT # 31050, 31287, 31288)

  1. nasal polyposis with obstruction of sinuses or nose.
  2. complication of sinusitis.
  3. chronic mucocele or mucopyocele.
  4. invasive or allergic fungal sinusitis.
  5. benign or malignant tumors.
  6. CSF rhinorrhea.
  7. sinusitis refractive to medical management.
  8. pituitary access.
  9. optic nerve decompression.
  1. a) CT scan evidence of sinus or nasal obstruction; 
    b) nasal endoscopy.
  2. a) prior or current history of subperiosteal orbital abscess or cellulitis;
    b) brain abscess, intracranial event.
  3. a) CT scan evidence.
  4. a) CT scan evidence;
    b) nasal endoscopy.
  5. a) CT scan evidence;
    b) nasal endoscopy;
    c) biopsy.
  6. a) imaging or CSF chemistry documentation.
  7. a) chronic sinusitis >12wks duration symptoms including facial pain/pressure, facial congestion/fullness, nasal obstruction, purulent nasal discharge, headache;
    b) recurrent acute >4 episodes per year, each episode lasting >7days without intervening signs or symptoms; symptoms including facial pain/pressure, facial congestion/fullness, nasal obstruction, purulent nasal discharge, headache, fever
    c) minimal ethmoid disease should be treated by partial ethmoidectomy;
    d) in acutely ill patients, CT should be obtained 1-2 weeks after completing 3 weeks of antibiotics.  If patient is not responding to antibiotics, CT scan during the acute illness is appropriate.
  8. documented pituitary tumor.
  9. optic nerve decompression.

Turbinectomy (reduction in size or repositioning of inferior turbinate) cpt # 30130, 30140

  1. nasal airway obstruction.
  2. access to nose or sinuses.
  3. for graft.
  1. failure of steroids and/or decongestants and/or immunotherapy.
  2. inferior turbinate obstructing access for primary surgical process.
  3. use of turbinate for grafting in CSF rhinorrhea, septal perforation.

Anterior cranial fossa skull base resection/ and related sinuses (CPT# 61580, 61581, 61582, 61583, 61584, 61600, 61601)

  1. Carcinoma of sinuses
  2. Benign tumor of sinuses.
  1. biopsy or CT documentation.

Septal perforation repair (CPT# 30630)

  1. epistaxis
  2. nasal crusting or whistling
  1. second opinion required for perforations greater than 2.0cm.

 

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