Clinical Indicators: Ethmoidectomy

1. History (one or more required)
   1. Failure of optimal medical management (describe) for acute or
      chronic ethmoid sinusitis.
   2. Multiple or recurrent nasal polyps causing obstruction.
   3. Impaired sense of smell.
   4. CSF leak/encephalocele (31290 should include the ethmoidectomy)
   5. Orbital thyroid disease
   6. Trauma resulting in ethmoid scarring or orbital/optic nerve injury
2. Physical Examination
   1. Complete anterior and posterior (if possible) nasal examination required.
      1. Anterior rhinoscopy with speculum
      2. Endoscopy
   2. Neurologic, ophthalmologic and/or pulmonary evaluation may be required in cases of extensive sinus involvement.
3. Tests
   1. Sinus imaging–describe (required)
      1. Unilateral ethmoid opacification, symptomatic or asymptomatic, consistent with Chronic Rhinosinusitis without Nasal Polyposis (CRSsNP), Chronic Rhinosinusitis with Nasal Polyposis (CRSwNP), fungus ball, neoplasm, polyp, etc
      2. Complications of ethmoiditis, including orbital or cranial extension of ethmoiditis evident on radiographs
      3. Ethmoid mucocele;
      4. Frontal sinus disease, in which ethmoidectomy may be needed to access the frontal sinusNote: In cases of Chronic Rhinosinusitis (CRS), imaging studies
         are generally obtained after optimal medical therapy. Based
         on the clinical situation (i.e. concern for extrasinus
         complications or neoplasm) early or emergent imaging may be
         required to confirm a diagnosis. Sinus MRI with/without
         contrast may be obtained for cases with concern for skull base
         and/or orbital erosion/invasion, such as cases where CT scan
         imaging is concerning, or in cases of possible neoplasm,
         mucocele, and concern for intracranial or intraorbital infection.

          

   2. Endoscopically guided culture and sensitivity – optional,
      describe results.

Postoperative Observations

1. Immediate postoperative inspection:
   1. Bleeding, eyelid ecchymosis–how managed? Surgeon notified?
   2. Pain–severe headache; notify physician.
   3. Packing–is it in desired location?
   4. Vision–if there is loss or double vision, notify surgeon immediately.
   5. Swelling–is there evidence of facial edema? If hematoma, how managed? Surgeon notified
   6. Mental status-is patient alert and oriented?
2. Postoperative Care:
   1. Endoscopy for debridement and assessment as clinically warranted
   2. Additional optimal therapy (including saline irrigations, topical nasal steroids, antibiotics may be necessary)
   3. Coordination of care with other physicians

Outcome Review

1. Within One Month
   1. Healing–Did patient require treatment for bleeding or infection? Is surgical site healing satisfactorily? Has nonabsorbable packing been removed if used?
   2. Pathology–Does the pathology report indicate need for further treatment and if so, how managed?
   3. Are there any indicators for CSF rhinorrhea?
2. Beyond One Month
   1. Presenting problem–Is it (see history) improved?
   2. Airway–Is there evidence of airway obstruction due to polyps or nasal crusting?
   3. Mucosa – Does sinus mucosa appear edematous or exhibit polypoid inflammation?
   4. Are there any indicators for post-operative complications, including CSF rhinorrhea?
   5. Mucus – Are there any mucinous secretions present?

Associated ICD-10-CM Diagnostic Codes (Representative, but not all-inclusive codes)

• J01.20 Acute ethmoidal sinusitis, unspecified
• J01.21 Acute recurrent ethmoidal sinusitis
• J33.8 Other polyp of sinus
• J32.2 Chronic ethmoidal sinusitis
• C31.1 Ethmoid (sinus) neoplasm, malignant, primary
• C78.39 Ethmoid (sinus) neoplasm, malignant, secondary
• D02.3 Ethmoid (sinus) neoplasm, Ca in situ
• D38.5 Ethmoid (sinus) neoplasm, uncertain behavior
• D49.1 Ethmoid (sinus) neoplasm, unspecified behavior
• C41.0 Ethmoid bone or labyrinth neoplasm, malignant, primary
• C79.51 Ethmoid bone or labyrinth neoplasm, malignant, secondary
• D16.4 Ethmoid bone or labyrinth neoplasm, benign
• D48.0 Ethmoid bone or labyrinth neoplasm, uncertain behavior
• D49.2 Ethmoid bone or labyrinth neoplasm, unspecified behavior
• J89.8 Other specified respiratory disorders

Additional Information

Assistant Surgeon — N

Patient Information

Ethmoidectomy is performed through either an external (facial), transantral (maxillary sinus), or intranasal (endoscopic) approach. The decision regarding the best approach to the ethmoid sinus depends on certain technical considerations best decided by the surgeon. This surgery is performed only after it has been determined that medical management has been unsuccessful (i.e. in cases of chronic rhinosinusitis) or may not be indicated (i.e. malignancy, cerebrospinal fluid leak, etc.). Surgery, medical management, and failure to treat ethmoid disease all have similar risks. They include orbital complications (visual impairment), intra-cranial extension (brain damage or infection), persistent or recurrent nasal obstruction due to failure to manage polyps, and recurrent nasal infections.

Important Disclaimer Notice (Updated 8/7/14)

Clinical indicators for otolaryngology serve as a checklist for practitioners and a quality care review tool for clinical departments. The American Academy of Otolaryngology—Head and Neck Surgery, Inc. and Foundation (AAO-HNS/F) Clinical Indicators are intended as suggestions, not rules, and should be modified by users when deemed medically necessary. In no sense do they represent a standard of care. The applicability of an indicator for a procedure must be determined by the responsible physician in light of all the circumstances presented by the individual patient. Adherence to these clinical indicators will not ensure successful treatment in every situation. The AAO-HNS/F 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. The AAO-HNS/F is not responsible for treatment decisions or care provided by individual physicians. Clinical indicators are not intended to and should not be treated as legal, medical, or business advice.

CPT five-digit codes, nomenclature and other data are copyright 2014 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein.

Updated January 2015

© 2014 American Academy of Otolaryngology-Head and Neck Surgery.