Endoscopic Sinus Surgery, Pediatric

Clinical Indicators
Endoscopic Sinus Surgery, Pediatric

Procedure	CPT	FUD
*Endoscopy with ethmoidectomy, partial (anterior)	31254	0
Endoscopy with ethmoidectomy, total (anterior & posterior)	31255	0
*Endoscopy with maxillary antrostomy	31256	0
Endoscopy with maxillary antrostomy and removal of tissue
from maxillary sinus	31267	0
Endoscopy with frontal sinus exploration, with or without
removal of tissue from sinus	31276	0
Endoscopy with sphenoidotomy	31287	0
Endoscopy with sphenoidotomy & removal of tissue
from sphenoid sinus	31288	0
Endoscopy with repair of cerebrospinal fluid leak, ethmoid region	31290	10
Endoscopy with repair of cerebrospinal fluid leak, sphenoid region	31291	10
Endoscopy with medial or inferior orbital wall decompression	31292	10
Endoscopy with medial and inferior orbital wall decompression	31293	10
Endoscopy with medial or inferior orbital wall decompression
with optic nerve decompression	31294	10

Indications

1. History. . . one or more required

a)	Failure of medical management for chronic sinus pathology, in addition to other disorders: Allergy Day care exposure Gastro-esophageal reflux contributing to rhinosinusitis Adenoiditis and/or obstructive adenoid hypertrophy Cystic fibrosis Immotile cilia syndrome Immune deficiency disorders (The history must include specific symptoms and findings obtained by the otolaryngologist. A historical diagnosis labeled "sinusitis" by the patient or a unsubstantiated symptoms alone is not sufficient documentation to establish this as a chronic illness). Chronic Disease is defined as sinusitis of greater than 12 weeks duration that includes: Nasal congestion Rhinorrhea Headaches or facial pain Irritability Frequent cough Post-nasal discharge Halitosis Clinically significant recurrent sinusitis is defined as 4 or more episodes of acute sinusitis per year, each lasting greater than 10 days, and there is absence of symptoms between episodes (without antibiotic therapy). Adenoidectomy should be performed a minimum of three months prior to performing pediatric sinus surgery for any of the above indications
b)	Complete nasal obstruction caused by the following: Cystic fibrosis Allergic fungal sinusitis Antrochoanal polyps Other causes of nasal polyps
c)	Intracranial complications
d)	Cavernous sinus thrombosis
e)	Mucocoeles and mucupyocoeles
f)	Subperiosteal or orbital abscess
g)	Traumatic injury to optic canal (decompression)
h)	Dacryocystitis from rhinosinusitis
i)	Allergic or invasive fungal rhinosinusitis
j)	Meningocephaloceles
k)	Cerebrospinal fluid leaks
l)	Tumors of the nasal cavity or sinuses

2. Physical Examination... required

a)	Complete anterior and posterior nasal examination (rhinoscopy after mucosal decongestion), as possible for patient's age
b)	Nasal endoscopic examination, obtained following medical therapy -- optional

3. Tests

a)	For surgical planning, coronal CT scan is required in all cases following medical therapy.
b)	Complete axial CT scan... recommended in cases with complex disease.
c)	Culture and sensitivity - optional.
d)	Allergy testing.

4. Optimal Medical Therapy: prior to obtaining sinus CT scan, prior to nasal endoscopy, and prior to surgery

a)	Evaluation and management for all medical conditions listed above
b)	Treatment of rhinitis medicamentosa, when present
c)	Parental education of environmental irritants including environmental or secondhand tobacco smoke
d)	Antibiotic therapy consisting of four to six consecutive weeks of appropriate antibiotic drugs.
e)	Appropriate topical and/or systemic steroids when indicated.

5. Surgical Procedure and Findings:

a)	Must be compatible with clinical status, CT findings, and nasal endoscopic findings that is, only patients with significant persistent sinus symptoms and pathology should undergo surgery.
b)	Extensive sinus surgery is occasionally indicated in the pediatric age group. An anterior ethmoidectomy is often all that is required. Maxillary antrostomy may be indicated in some cases.

Postoperative Observations
1. Bleeding, eyelid ecchymosis; notify surgeon
2. Pain- severe headache; notify surgeon
3. Follow-up endoscopy under anesthesia may be indicated
4. Vision- if there is loss of double vision, notify surgeon immediately
5. Swelling - is there evidence of facial edema? If hematoma, notify surgeon
6. Mental status - is patient alert and oriented? If not, notify surgeon

Associated ICD-9 Diagnostic Codes

160.2	M-Neoplasm, Maxillae sinus
160.3	M-Neoplasm, Ethmoid sinus
160.4	M-Neoplasm, Frontal sinus
160.5	M-Neoplasm, Sphenoid sinus
194.3	M-Neoplasm, Pituitary gland
212.0	B-Neoplasm, Nasal cavity/sinus
231.8	CA in situ, Respiratory system NEC
235.9	UB-Neoplasm, Respiratory system NOS
349.81	Cerebrospinal fluid rhinorrhea
376.01	Orbital cellulitis, abscess
461.1	Acute frontal sinusitis
471.1	Polypoid sinus degeneration
471.8	Nasal sinus polyp NEC
473.0	Chronic maxillary sinusitis
473.1	Chronic frontal sinusitis
473.2	Chronic ethmoidal sinusitis
473.3	Chronic sphenoidal sinusitis
473.8	Chronic sinusitis NEC; pansinusitis
478.1	Cyst or mucocoele of sinus
242.00	Graves disease/exophthalmopathy without thyrotoxicosis
242.01	Graves disease/exophthalmopathy with thyrotoxicosis
376.32	Orbital hemorrhage
376.33	Orbital edema
921.2	Contusion of orbital tissues

Additional Information
Assistant Surgeon -- N
Supply Charges -- N

Anesthesia Code(s)
00160

Patient Information

Endoscopic sinus surgery is performed through an intranasal approach. The decision regarding the appropriate sinuses for treatment depends on radiographic and endoscopic findings combined with the patient's clinical status following appropriate medical evaluation and therapy. This surgery is performed only after it has been determined that comprehensive medical management has been unsuccessful. Surgical risks in the pediatric age group include post-operative bleeding, orbital complications (visual impairment), intracranial extension (brain damage or infection), persistent or recurrent nasal obstruction due to failure to manage polyps, recurrent nasal or sinus infections, and the possibility of interference with facial growth patterns.

Important Notice

The Clinical Indicators for Otolaryngology--Head and Neck Surgery are guidelines only. In no sense do they represent a standard of care. The applicability of an indicator for a procedure, and/or of the process or outcome criteria, must be determined by the responsible physician in light of all the circumstances presented by the individual patient. Adherence to these guidelines will not ensure successful treatment in every situation. The American Academy of Otolaryngology-Head and Neck Surgery, Inc. emphasizes that these clinical indicators should not be deemed inclusive of all proper treatment decisions or methods of care, nor exclusive of other treatment decisions or methods of care reasonably directed to obtaining the same results.