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Aetna Aetna
Clinical Policy Bulletin:
Septoplasty and Rhinoplasty
Number: 0005


Policy

  1. Aetna considers septoplasty medically necessary when any of the following clinical criteria is met:

    1. Asymptomatic septal deformity that prevents access to other intranasal areas when such access is required to perform medical necessary surgical procedures (e.g., ethmoidectomy); or  
    2. Documented recurrent sinusitis felt to be due to a deviated septum not relieved by appropriate medical and antibiotic therapy; or
    3. Recurrent epistaxis (nosebleeds) related to a septal deformity; or 
    4. Septal deviation causing continuous nasal airway obstruction resulting in nasal breathing difficulty not responding to 4 or more weeks of appropriate medical therapy; or  
    5. When done in association with cleft palate repair. 

    Aetna considers septoplasty experimental and investigational for all other indications (e.g., allergic rhinitis) because its effectiveness other than the ones listed above has not been established.

  2. Aetna considers extracorporeal septoplasty medically necessary for initial correction of an extremely deviated nasal septum that can not adequately be corrected with an intranasal approach, for members who meet criteria for septoplasty listed above.  Extracorporeal septoplasty for revision of deviated septum is considered experimental and investigational because its effectiveness for this indication has not been established.

  3. Aetna considers rhinoplasty a cosmetic surgical procedure.

    Rhinoplasty may be considered medically necessary only in the following limited circumstances:

    1. When it is being performed to correct a nasal deformity secondary to congenital cleft lip and/or palate;
    2. Upon individual case review, to correct chronic non-septal nasal airway obstruction from vestibular stenosis (collapsed internal valves) due to trauma, disease, or congenital defect, when all of the following criteria are met:

      1. Prolonged, persistent obstructed nasal breathing; and
      2. Physical examination confirming moderate to severe vestibular obstruction; and 
      3. Airway obstruction will not respond to septoplasty and turbinectomy alone; and
      4. Nasal airway obstruction is causing significant symptoms (e.g., chronic rhinosinusitis, difficulty breathing); and
      5. Obstructive symptoms persist despite conservative management for 4 weeks or greater, which includes, where appropriate, nasal steroids or immunotherapy; and
      6. Photographs demonstrate an external nasal deformity; and 
      7. There is significant obstruction of one or both nares), documented by nasal endoscopy, computed tomography (CT) scan or other appropriate imaging modality.

      Documentation of these criteria should include:

      1. Documentation of duration and degree of symptoms related to nasal obstruction, such as chronic rhinosinusitis, mouth breathing, etc.; and
      2. Documentation of results of conservative management of symptoms;  and
      3. If there is an external nasal deformity, pre-operative photographs showing the standard 4-way view: anterior-posterior, right and left lateral views, and base of nose (also known as worm's eye view confirming vestibular stenosis; this view is from the bottom of nasal septum pointing upwards); and
      4. Relevant history of accidental or surgical trauma, congenital defect, or disease (e.g., Wegener’s granulomatosis, choanal atresia, nasal malignancy, abscess, septal infection with saddle deformity, or congenital deformity); and
      5. Results of nasal endoscopy, CT or other appropriate imaging modality documenting degree of nasal obstruction.
    3. When rhinoplasty for nasal airway obstruction is performed as an integral part of a medically necessary septoplasty and there is documentation of gross nasal obstruction on the same side as the septal deviation.

    Aetna considers rhinoplasty cosmetic for all other indications.

  4. Aetna considers nasal valve suspension for the repair of nasal valve collapse experimental and investigational because its effectiveness has not been established.

Note: See CPB 0031 - Cosmetic Surgery for details on exceptions to the cosmetic surgery exclusion.  In addition, please check benefit plan descriptions for details. 



Background

Nasal septoplasty is a procedure to correct anatomic deformity or deviation of the nasal septum.  Its purpose is to restore the structure facilitating proper nasal function.  Cosmetic enhancement, if any, is incidental.  Because the septum is deviated in most adults, the potential exists for over-utilization of septoplasty in asymptomatic individuals.  The primary indication for surgical treatment of a deviated septum is nasal airway obstruction.  Corrective surgery also is done to treat recurrent epistaxis associated with the septal deviation or sinusitis in which the deviation has a contributory role, and, occasionally, is necessary to gain access to another region such as the sphenoid, sella turcica or pituitary gland.  In addition, septoplasty may be performed in response to an injury (nasal trauma) or in conjunction with cleft palate repair.  Note: Under many Aetna plans, surgery to correct deformity due to an injury is covered when it is performed in the calendar year of the accident that causes the injury or in the next calendar year.  After this time period has elapsed, covered surgery is contingent on the need for functional improvement, i.e., the other specific indications for surgery would apply.  Please check benefit plan descriptions for details.

The nose is essentially a respiratory organ that provides a passageway for incoming and outgoing air.  The internal nose is comprised of 2 nasal cavities (nostrils) through which air enters and passes posteriorly to the nasopharynx; it is separated in the middle by the septum which is composed of cartilage, anteriorly and bone, posteriorly.  The nasal cavity is an irregularly shaped space extending from the bony palate that separates the nose and mouth cavities upward to the frontal ethmoid and sphenoid bones of the cranial cavity.  Each nasal cavity is divided into 3 passageways (the superior, middle and inferior meati) by the projection of the 4 nasal turbinates (inferior, middle, superior and supreme) from the lateral walls of the internal nose.  The inferior turbinate is a separate bone, while the other 3 are part of the ethmoid bone.  The turbinates greatly increase the surface area of the mucous membrane over which air travels as it passes through the nasal passages and into the nasopharynx, serving to improve humidification of inspired air.

The vestibule of the nostril is lined with skin containing nasal hairs and some sebaceous and sweat glands.  The nose is lined with respiratory mucosa except for the skin in the vestibule and the olfactory epithelium.  Mucus secreted by the mucosa is carried back to the nasopharynx by the cilia of the mucosa.  The nasal mucosa is extremely vascular, which makes it appear redder than the oral mucosa.

The blood supply to the nose is from the external and internal carotid arteries.  One of the terminal divisions of the external carotid artery, the internal maxillary artery and its terminal branch, the sphenopalatine artery, supply blood to most of the posterior nasal septum and lateral wall of the nose.  Blood is supplied to the anterior superior part of the septum and lateral wall by the internal carotid system which includes the anterior ethmoid artery.

A number of techniques can be used to straighten and thin a displaced or deviated septum.  In the most common procedure, an incision is made through the mucosa and perichondrium (on 1 side) just behind the mucocutaneous junction.  The mucoperichondrium and the mucoperiosteum are elevated on that side.  The cartilage is then cut through at the site of the original incision.  Similar mucoperichondrial and periosteal flaps are elevated on the opposite side until the septal cartilage and bones are freed of all soft tissue attachments.  The obstructing pieces of cartilage or bone or both are removed or placed in a better position by reshaping through marsupialization.

In one approach, submucous resection, almost all the framework of the septum, except a strut at the top and in the front (caudal and dorsal struts), is removed.  In other techniques, an effort is made to excise as little cartilage and bone as possible.  The obstruction is corrected by shaving off the thickened cartilage and braking its spring, leaving the septum thinned and straightened.  When the inferior edge of the cartilage is dislocated and appears in one vestibule rather than in the midline, an incision through the entire membranous collumella just in front of the cartilage affords an end-on view of the free edge of the cartilage.

The potential complications of septoplasty include septal perforation; failure to completely improve breathing due to swollen membranes as is seen in allergic patients; post-operative bleeding; nasal crusting; and re-obstruction due to improper healing and scarring, creating intranasal synechiae.

There are 4 pairs of paranasal sinuses, frontal, maxillary, ethmoidal and sphenoidal.  Sinuses are mucous membrane-lined cavities in the facial bones that drain into the nasal cavities through openings in grooves (the meati) between the turbinates.  Although it has been purported that sinuses serve to lighten the weight of the skull and give the voice its resonance and timbre, much of their function is unknown.

The American Academy of Otolaryngology Head and Neck Surgery (AAOHNS, 1998) has noted that the following findings are useful in assessing the need for septoplasty.

  1. History - one or more required

    1. Asymptomatic deformity that prevents surgical access to other intranasal areas, i.e., ethmoidectomy.
    2. Atypical facial pain of nasal origin.  Positive response to topical anesthetic, where deformed septum contacts a turbinate, supports but may not prove septal cause.
    3. Frequent nosebleeds.
    4. Nasal airway obstruction or difficult nasal breathing causing any of the following: mouth breathing, snoring, sleep apnea or recurrent sinus infections.
       
  2. Physical Examination - all appropriate findings required

    1. Description of complete anterior and posterior nasal examination.
    2. Description of nasopharynx, oropharynx, hypopharynx and larynx if purpose of surgery is to prevent sleep apnea or snoring.
    3. Document absence of nasal polyps, tumors, turbinate hypertrophy or other causes of obstruction unless their removal is part of the proposed surgery.
    4. Identification of known or suspected bleeding site if the purpose of surgery is to control epistaxis.
    5. Identification of sinus that is recurrently infected if the purpose of surgery is to control disease.

The AAOHNS states that objective testing (e.g., CT scan) is optional in assessing the need for septoplasty.

Septal Deviation:

Septal deviation may occur during the birth process, but even when the septum is straight at birth, it is likely to become deformed or deviated from the midline as a person ages; often there is no history of injury to account for the change.  Frequently there are no symptoms associated with a deviated septum.  A significantly deviated septum can be seen, upon examination, to be inclined or bent to one side (sometimes an S-shaped curve blocks both sides) and the airway is greatly reduced.  The obstruction may be anterior (cartilaginous) or posterior (bony) or cartilaginous and bony.  Sometimes the anterior end of the septal cartilage is dislocated into one nasal vestibule, causing moderate to severe degrees of nasal obstruction.  In the presence of symptoms, the position and degree of any deviations, dislocations, and spurs should be noted on a diagram of the septum.  Under such conditions, septal reconstruction or submucous resection is appropriate to relieve the nasal obstruction.  Such surgery is not ordinarily intended to correct headache or reduce nasal mucous discharge.

Except for nasal obstruction, other symptoms resulting from septal malformations are not well defined.  While headaches are found in some patients who have a septal spur impinging on the inferior turbinate, the possibility of coincidence in patients who have both head pain and septal deformity is great and careful evaluation is required before a causal relationship is suggested.

Symptoms of sinusitis may be influenced by a deviated septum that obstructs a sinus opening, and sometimes nosebleeds are produced as a result of air currents drying the mucosa that covers the deflected septum.

Nasal Obstruction:

Nasal obstruction can be caused by changes in the tissue of the nasal cavity, septum, or turbinates; disease of the nasal vestibule; or tumors of the nasal cavity; it can be temporary or fixed.  Obstructive sensations can be associated with the physiologic process known as the nasal cycle, i.e., the physiologic alteration of congestion and decongestion of the nasal turbinates.  This phenomenon, present in about 80 % of the population, means that breathing at any time may be more difficult on one side, but the sides will switch after 2 to 4 hours.  Because of the nasal cycle, total nasal resistance or breathing through both nares remains somewhat constant without producing symptoms of total nasal airway obstruction.  Another normal physiologic occurrence is positional nasal airway obstruction, i.e., when a person lies on one side, that dependent side tends to feel obstructed.

A very common cause of nasal obstruction is allergic rhinitis; this usually can be determined by a patient’s history and clearly requires medical, not surgical, management.  Mechanical obstruction due to septal deformity or hypertrophic turbinates is one of several nonallergic causes.

In order to treat nasal obstruction appropriately, accurate diagnosis of its cause is essential.  Evaluation should include quantification and qualification of the symptoms, determination of the site and cause of obstruction, and determination of any predisposing factors.  The history should answer the questions of the duration of obstruction, any precipitating events such as trauma, are symptoms continuous or intermittent, unilateral or bilateral, or do they alternate from side to side.  It is important to ascertain if symptoms are worse at certain times of the day or night, at certain times of the year, or in any position such as lying on one side, and also if they are provoked by environmental factors, allergens, irritants or dietary factors.

Along with a full ear, nose and throat examination, a systematic evaluation of the nasal cavity, the paranasal sinuses, and nasopharynx should be performed.  In addition to rhinoscopy using a head mirror or fiberoptic headlight, flexible fiberoptic and rigid Hopkins rod endoscopy are important tools in diagnosing a variety of pathologies and anatomic abnormalities.

While obstructive symptoms associated with septal deviation usually occur on the affected side, paradoxically, a patient with a significant septal deviation may complain of obstruction on the apparently nonobstructed side.  This can occur when a septal deviation has been present for years but the patient is unaware of the deformity since he can breathe comfortably from the other side.  Under these circumstances when a major septal deviation causes enlargement of one nasal passage at the expense of the other, the inferior and sometimes the middle turbinate in the enlarged passage undergo compensatory mucosal hypertrophy so that the total airflow resistance of the nose remains pretty normal.  However, if the nasal cycle becomes more pronounced for any reason or even a mild degree of allergic or vasomotor rhinitis is acquired, then the symptoms will be noted primarily in the enlarged side rather than in the anatomically narrowed one since the hypertrophied turbinates on the enlarged side swell considerably more from any stimulus than do the relatively atrophic ones on the narrow side.

Permanent enlargement of the turbinates, particularly the inferior turbinate, may result from a long-standing allergic rhinitis and low-grade inflammation.  The turbinate loses most of its normal ability to expand and to shrink, resulting in continuous nasal obstruction.  Nose drops, antihistamines and allergic desensitization will not relieve such obstruction.  Treatment options include steroid nasal sprays, injection of a sclerosing solution beneath the mucosa of the turbinate and submucosal electrocoagulation; however, in some cases, successful treatment is possible only by submucous resection of the turbinate itself.

At the extreme, nasal airway obstruction can lead to pulmonary pathology because the protective functions of the nose (humidification, heating and filtering) cannot occur.  Asthma and bronchitis may worsen as a result of nasal obstruction.  As noted previously, septal reconstruction or submucous resection is appropriate to relieve nasal obstruction that is definitively caused by a deviated septum.

Sinusitis:

Sinusitis means an inflammatory change in the mucosa of a sinus.  Definite signs and symptoms are produced by this pathology.  Uncomplicated acute sinusitis is usually apparent clinically and imaging studies are unnecessary.  However, plain films may be helpful in equivocal cases, and computed tomography (CT) now plays a role in the evaluation of patients with chronic sinusitis who are under consideration for endoscopic sinus surgery (ESS).  CT, especially the coronal plane view, facilitates accurate definition of regional anatomy and extent of disease.  It is currently the modality of choice in the evaluation of the paranasal sinuses because of this ability to optimally display bone, soft tissues and air. In selected patients with complications of sinusitis, magnetic resonance imaging (MRI) may be useful since its multiplanar imaging capability reveals any extension of sinus infection into the orbit and adjacent brain, especially in cases of aggressive fungal infection.  However, authorities recommend that MRI should not precede CT because CT better displays the complex bony anatomy of the paranasal sinuses, orbits and skull base.

Although the paranasal sinuses often have been implicated as the underlying cause of nasal obstruction or other problems such as headaches, fever of unknown origin, cough, chronic dyspepsia and other upper respiratory or gastrointestinal symptoms, in  actuality, probably only 10 % of patients who consult an otolaryngologist because of “sinus trouble” have sinusitis.  Allergy evaluation is a useful part of the workup for chronic sinusitis.

Treatment of acute sinusitis is medical, directed at relief of pain, shrinkage of the nasal mucosa and control of infection; such conservative treatment is effective in 90 % of patients.  When a subacute infection persists, antral irrigation and/or antral puncture may be indicated and short term corticosteroids may be helpful.  Inadequate treatment of the acute or subacute phase or recurrent attacks can lead to irreversible tissue changes in the membranes lining one or more of the paranasal sinuses, i.e., chronic suppurative sinusitis.  Frequently surgery is required for this condition with removal of all diseased soft tissue and bone, adequate postoperative drainage, and obliteration of the preexisting sinus cavity where possible.  Although a specific technique is used for each sinus, the aim of any procedure used is to eradicate the infection but to leave contiguous structures normal.

When sinusitis is influenced by a deviated septum that occludes a sinus ostium, septoplasty may be warranted.

Epistaxis (NoseBleed):

The most common cause of nosebleed is trauma such as picking a crust off the nasal septum or excessive drying of the nasal mucosa.  Bleeding from the posterior half of the nose, however, is  more likely to be caused by a splitting of a sclerotic blood vessel and is more common in hypertensive patients.  Anterior nosebleeds are easy to treat by aspirating the blood clots, applying topical epinephrine and cauterizing the bleeding point.  Prolonged packing of both sides of the nose may be necessary to allow healing in some patients.  Because it is often impossible to see the exact bleeding site in posterior nosebleeds, treatment is more difficult.  Bleeding must be controlled by compression of the bleeding vessel with a postnasal pack for 48 to 96 hours, arterial ligation or transpalatal injection of saline solution into the greater palatine foramen.  Usually operative procedures on the nasal septum are not required for the control of nosebleeds; however, sometimes when projecting parts of the septum are traumatized by the drying effect of inspired air and impede visualization of the area of the nose posterior to the deviation, then septoplasty may be indicated to visualize the area for purposes of cautery and control.

Nasal Packing:

The practice of nasal packing following septoplasty was based on a desire to prevent post-operative complications such as bleeding, septal hematoma, and adhesion formation.  However, it was since found that not only is nasal packing ineffective in this regard, it can actually cause these complications.  In a prospective, randomized, comparison study, Awan and Iqbal (2008) compared nasal packing versus no packing after septoplasty (n = 88).  These investigators examined the incidence of a variety of post-operative signs and symptoms in patients (15 years of age and older), who did (n = 44) and did not (n = 44) undergo nasal packing following septoplasty.  They found that patients who underwent packing experienced significantly more post-operative pain, headache, epiphora, dysphagia, and sleep disturbance on the night of surgery.  Oral and nasal examinations 7 days post-operatively revealed no significant difference between the 2 groups in the incidence of bleeding, septal hematoma, adhesion formation, and local infection.  Finally, subjects in the packing group reported a moderate-to-high level of pain during removal of the packing.  These findings confirmed that nasal packing after septoplasty is not only unnecessary, it is actually a source of patient discomfort and other signs and symptoms.

Furthermore, Dubin and Pletcher (2009) stated that although it appears intuitive that packing may prevent or decrease the incidence of complications following septoplasty, evidence supporting this assertion is limited at best.  In addition, certain types of nasal packing have been demonstrated to increase post-operative pain and have been implicated as a causative factor of catastrophic complications, such as toxic shock.  With limited evidence to suggest a beneficial effect and a potential for deleterious side-effects, the routine use of post-operative packing following septoplasty should be questioned.

Banglawala et al (2013) stated that nasal packing is routinely used after septoplasty because it is believed to decrease risk of post-operative bleeding, hematomas, and adhesions.  Multiple studies have shown, however, that there are numerous complications associated with nasal packing.  These investigators performed a meta-analysis on the existing literature to evaluate the role of nasal packing after septoplasty.  Two independent reviewers conducted a literature search using EMBASE, OVID, Medline, PubMed, Google scholar, Cochrane Library, and reference list review from 1966 to August 2010 to identify studies assessing nasal packing after septoplasty.  All papers were reviewed for study design, results, and were assigned an Oxford level of evidence grade, Detsky score, and Methodological Index for Nonrandomized Studies (MINORS) score.  A total of 16 papers were identified that met the inclusion criteria; 11 papers were randomized control trials, 3 were prospective, and 2 were retrospective studies.  Nasal packing did not show benefit in reducing post-operative bleeding, hematomas, septal perforations, adhesions, or residual deviated nasal septum.  There was, however, an increase in post-operative infections.  Two studies using fibrin products as nasal packing showed a decreased bleeding rate.  The authors concluded that nasal packing after septoplasty does not show any post-operative benefits.  Fibrin products showed a possibility of decreasing post-operative bleeding.  They stated that routine use of nasal packing after septoplasty is not warranted.

Extracorporeal Septoplasty:

Extracorporeal septoplasty (ECS) is a radical solution for extreme deviations of the septum.  This approach entails resection, extracorporeal straightening, and re-implantation of the nasal septum (Baumann, 2010).

Often, the deviation of the nasal septum is one component of a larger nasal deformity. The deformity may involve the nasal tip, dorsum, and nasal bones.  An intranasal approach to such deformities may not be adequate.  In these situations, an open septorhinoplasty approach is best.  Extracorporeal septoplasty is a technique that has been described to address these severe cases (Fettman et al, 2009).  This technique involves removing the entire nasal septum and straightening the septum using various techniques, followed by reimplantation.  Often, the external nose appears twisted in addition to symptomatic nasal obstruction, and extracorporeal septoplasty may help to correct this deformity as well.

Matulic and Skitarelic (2004) stated that rhinoplasty is often thought of as the most challenging of all esthetic procedures.  Irregularities of nasal tip implicate decreasing of nasal function and are generally regarded as an unattractive facial feature.  The combined operative techniques, which required ECS, incorporation of cartilage disc graft and onlay graft were performed in 19 patients.  Among the 19 patients, 15 had procedure of primary rhinoplasty and in 4 of them secondary or revised rhinoplasty was made.  Indications for this operative technique were in patients with boxy nasal tip, bifid nasal tip, lateral alar tethering with extremely fat or thin nose skin.  The authors emphasized that this technique is very successful with an acceptable percentage of post-operative complications.  The technique is method of choice for reconstruction of extreme nasal tip irregularities where the usual reconstruction technique does not give satisfactory results.

Gubisch (2005) described a technique of extracorporeal septal reconstruction to correct the markedly deviated nasal septum.  Retrospective medical charts of 2,119 patients undergoing ECS from January 1, 1981, through July 31, 2004, by the author in a tertiary care facial plastic surgery center were reviewed.  The primary outcome measures included surgical complications, revision rate, and the surgeon's subjective determination of functional and esthetic outcomes.  Of the 2,119 patients, 2 cohorts were available for review.  From January 1, 1981, to July 31, 1987, the author performed the operation on 459 patients.  Fifty-seven complications (12 %) occurred, with irregular contour of the dorsum or saddling noted in 38 (8 %).  Twenty patients (4 %) elected to have revision septoplasty.  From January 1, 1996, to December 31, 1996, the author supervised residents performing ECS in 108 patients.  Fourteen post-operative complications (13 %) occurred, with dorsal irregularity noted in 12 (11 %).  Eight patients (7 %) elected to have revision septoplasty.  The authors concluded that ECS is an important surgical option for the correction of the markedly deviated nasal septum.  Fixation of the straightened and re-planted septum at the nasal spine and dorsal septum border with the upper lateral cartilages is essential.  Spreader grafts for stabilization of the internal nasal valve and dorsal onlay grafts to prevent dorsal irregularity are strongly encouraged.

Most (2006) described a modified ECS technique and measured its effectiveness with a validated quality-of-life instrument.  Pre-operative and post-operative evaluation was performed using photographs and the Nasal Obstruction Symptoms Evaluation scale.  A total of 12 consecutive patients were enrolled.  No complications occurred.  All patients noted improved airway function post-operatively.  There was a significant improvement in mean Nasal Obstruction Symptoms Evaluation score post-operatively (76.6 versus 12.9; p < 0.01).  Examination of post-operative photographs revealed improved mid-vault and tip anatomy.  The authors concluded that the anterior septal reconstruction technique is effective in improving both nasal airway function and esthetics in patients with severe septo-nasal deviation.  The technique avoids the most common complication of standard ECS by preserving the dorsal strut of septal cartilage and its attachment to the nasal bones at the keystone area.

Kantas et al (2008) evaluated the effectiveness, indications, and contraindications of the ECS in treating a severely deviated nose.  A total of 64 patients operated on for esthetic correction of a severely deviated nose were studied.  Forty-six of them were first operations and 18 were revision cases.  The surgical procedure of choice was the closed technique.  Septal cartilage was prepared and then dislocated, followed by external alignment and re-implantation.  Hump reduction with lateral osteotomies and, occasionally, medial dislocation of nasal bones was carried out.  Cosmetic results were satisfactory in all first operation cases.  In 11 of the 18 revision cases, septal preparation was impossible; in 2, septal sagging was observed; and in 1, perforation was noted.  The authors concluded that ECS is an effective, safe, and reliable technique, especially for twisted noses undergoing surgery for the first time.  The authors stated, however, that ECS is strongly contraindicated in a revised deviated nose.

Jang and Kwon (2010) noted that secure fixation of the re-implanted septum is critical for successful long-term esthetic and functional outcomes following ECS.  These investigators described the results of their modified ECS technique.  This retrospective study involved 27 patients with a deviated nose who underwent the authors' modified ECS method in rhinoplasty between June 2006 and January 2009.  Anthropometric changes were assessed from pre-operative and post-operative facial photographs.  Patient satisfaction was evaluated, and nasal obstruction improvement was assessed on a visual analog scale.  Post-operative correction of the external nose deviation angle was statistically significant.  Twenty-four patients (89 %) were satisfied with the cosmetic outcome, and all 23 patients with moderate-to-severe pre-operative nasal obstruction were satisfied with the post-operative improved nasal breathing.  The authors concluded that their modified ECS fixation technique was easy to perform and effective in septorhinoplasty for severe septal deviation.

Nasal Valve Suspension:

Nasal valve collapse is a common cause of nasal airway obstruction.  Nasal valve suspension (NVS) is a surgical approach for nasal valve repair, which entails suspension of the valve to the orbital rim.  During NVS, an anchored suture is first attached to the orbital rim and then a suture is passed through the collapsed valve.  The suspension suture is then returned to the anchor site at the orbital rim and tied, resulting in a repaired nasal valve that supposedly allows for less obstructed airflow.  Modifications to this procedure or other types of suspensions, such as those using sutures tunneled within the facial soft tissue to an infra-orbital incision on each side of the nose, have also been reported.

In a non-randomized, pilot study, Paniello (1996) evaluated the safety and effectiveness of NVS for treating nasal valve collapse.  Subjects (12 men aged 38 to 73 years; mean age of 59.3 years) were patients with complaints of nasal airway obstruction, a positive Cottle maneuver, and clinical findings of nasal valve collapse.  Follow-up ranged from 1 to 20 months.  Main outcome measures were subjective self-assessment scores for nasal airflow were collected on a 10-point scale.  Anterior rhinomanometry, acoustic rhinometry, and photographic analysis provided objective data.  The procedure involves accessing the orbital rim by a trans-conjunctival incision, then passing sutures from the nose to this incision where they may be affixed to the orbital rim.  The collapsing tissue of the nasal valve is thus supported and collapse is prevented.  All patients reported immediate subjective improvement in their symptoms of nasal obstruction; this was reflected in their self-assessment scores.  The rhinomanometry showed reduced nasal resistance in 10 (83 %) of 12 patients.  The acoustic rhinometry showed an increase in minimum cross-sectional area (CSA) in 2 (33 %) of 6 patients, with the others remaining stable.  The photographic analysis revealed mild widening of the mid-third of the nose in 6 of 12 patients, although this was not of concern to the patients.  There were no major complications.  The authors concluded that NVS is a safe and effective procedure for treatment of nasal valve collapse.  These preliminary findings need to be validated by well-designed studies with larger sample size and longer follow-up.

Nuara and Mobley (2007) reviewed their experience with NVS in a cohort of patients with nasal valve collapse, including a subset of patients with facial paralysis.  The objectives were to determine patient satisfaction and complication rates after NVS.  A retrospective review of patients 18 years and older who had NVS from 2003 to 2006 with a follow-up of at least 1 month was performed.  Data were collected on diagnosis, surgical outcomes, complications, and treatments required.  Complications included adverse outcomes, infections, and the need for repeat surgery or treatments.  In 17 charts reviewed, 9 patients (53 %) had nasal valve collapse as a result of facial paralysis, and 8 (47 %) had previous nasal surgery.  Follow-up ranged from 1 to 30 months, with a mean of 16.5.  Moderate-to-complete resolution of obstruction was reported by 82 % of patients, or for 88 % of procedures.  Sustained relief was observed in 2 of 8 patients who had previous nasal surgery and 6 of 9 who had no previous nasal surgery (p = 0.1).  Infection occurred in 4 (24 %) patients and 5 (21 %) total suspensions and ranged from 1.5 to 7 months.  Six (35 %) patients experienced a loss of suspension at 6 to 22 months.  The authors concluded that NVS is a technically straightforward, relatively reversible procedure particularly useful in the patient with facial paralysis.  The efficacy is excellent in the short-term yet appears to diminish with time.

Andre and Vuyk (2008) described their experience with NVS for treating nasal valve insufficiency.  A total of 20 patients with nasal valve insufficiency underwent NVS (a total of 33 sides).  Patients were prospectively studied and their nasal patency was rated per side pre- and post-operatively, by subjective self-evaluation on a scale from 1 to 10.  Post-operatively 7 sides (21 %) were rated as unchanged, on 17 sides (52 %) the improvement was from 1 to 3 out of 10, and on 9 sides (27 %) 4 or more out of 10.  The average post-operative improvement for all sides was 2.3 out of 10.  In 5 patients (25 %) complications occurred, such as pain, inflammation and suborbital swelling, and 3 eventually underwent a re-exploration of the surgical area, resulting in a permanent scar in 1 patient.  The authors concluded that although NVS may be beneficial for some patients, based on their experience, they would not recommend this technique as first line treatment for nasal valve insufficiency.  In this series, these researchers found relatively limited improvement in most patients and a far higher complication rate compared with other nasal valve procedures they had experienced with in the past.

Spielmann et al (2009) evaluated the surgical treatment strategies for nasal valve collapse.  A systematic review of studies to treat nasal valve collapse, using surgical methods, from 1970 to 2008.  A search of EBM reviews, MEDLINE, and EMBASE was performed using the following search terms: "nasal valve collapse" and "alar collapse," "nasal valve insufficiency," "alar insufficiency," and "functional rhinoplasty".  The following outcome measures were sought: subjective symptom relief, cosmetic outcome, and objective measurements of nasal airway patency.  The following were inclusion criteria: at least 10 patients in each study, stated aim to improve airway obstruction, and a minimum of 1 month follow-up for every patient.  These investigators identified 98 papers, which were then retrieved and analyzed.  Of these, 43 met the inclusion criteria.  No randomized controlled trials exist; 1 trial presented level IIIb evidence, but all other studies were classed as level IV.  Seven authors present objective measurements of nasal airflow or CSA, and 4 authors presented validated outcome measures.  The authors concluded that a variety of focused surgical techniques were described to deal with nasal valve collapse.  They could find no randomized controlled trials on nasal valve surgery.  Research in nasal valve surgery is frequently driven by technical description of surgical technique rather than the establishment of evidence of long-term patient benefit.  They stated that although their understanding of the role of the nasal valve in the pathophysiology of nasal obstruction has improved vastly, the myriad of surgical techniques described perhaps reflects the uncertainty in choice of technique and in degree of patient benefit.

In a prospective pilot study, Kim et al (2011) evaluated the effect of septoplasty on the clinical course of allergic rhinitis by comparing (i) symptom change using the visual analog scale (VAS), (ii) change of the medication score, and (iii) improvement of the quality of life using a questionnaire.  A total of 62 patients who had undergone septoplasty and turbinoplasty for septal deviation and allergic rhinitis were enrolled in group A; 26 patients who had undergone only turbinoplasty for allergic rhinitis were enrolled in group B.  The VAS score, the Average Rescue Medication Score (ARMS), and the Rhinasthma Questionnaire for the quality of life were all obtained from each patient.  These parameters were compared before and after the surgery and between the groups.  Both groups showed significant improvement of the VAS score (p < 0.001).  When the change of VAS was compared between groups, there was a significant difference in group A only for nasal obstruction (p = 0.047).  Comparison of the ARMS between groups showed significant improvement in both groups after the surgery (p < 0.01).  However, there were no differences between the groups.  The Rhinasthma score of group A was significantly lowered after the surgery (56.4 +/- 13.2 to 34.1 +/- 12.3, p < 0.001).  The Rhinasthma score of group A was significantly lower than that of group B after the surgery (p = 0.004).  The authors concluded that this is the first research about the potential effect of septoplasty on the clinical course of allergic rhinitis.  They stated that further studies are needed to elucidate the mechanisms underlying these effects.

Antibiotic Prophylaxis in Septoplasty:

Ricci and D'Ascanio (2012) stated that antibiotic prophylaxis for surgical procedures is a common practice among otorhinolaryngologists.  Most American Rhinology Society members use antibiotics routinely in septoplasties, even though the need for this practice in rhinological surgery is controversial.  These investigators evaluated the necessity of antibiotic prophylaxis in septoplasties in relation to surgical outcome and post-operative complications.  In a prospective, randomized clinical trial these researchers evaluated 630 subjects who underwent septoplasty according to the technique already described by the authors.  Patients were divided into 3 groups: group A, no antibiotic prophylaxis; group B, antibiotics (cefazolin at 1.0 g i.v.) only at anesthetic induction; and group C, antibiotics both at anesthetic induction (cefazolin at 1.0 g i.v.) and post-operatively (oral amoxicillin at 1 g every 12 hours) for 7 days.  Pre- and post-operative patients' scores on the Nasal Obstruction Septoplasty Effectiveness (NOSE) questionnaire were compared to assess the improvement of nasal symptoms after surgery.  Post-operative pain, nasal bleeding, septal hematoma/abscess, fever, and nausea/vomiting were recorded.  Nasal endoscopy was performed 14 days post-operatively to quantify purulent rhinorrhea.  An improvement of post-operative nasal symptoms on the NOSE questionnaire was recorded with respect to pre-operative score.  No significant difference was found among the groups with regard to post-operative pain, fever, nausea/vomiting, and nasal bleeding.  No case of hematoma or septal abscess was noticed.  No significant difference in purulent nasal discharge was found among the groups.  The authors concluded that septal surgery with early removal of nasal packing is a clean-contaminated procedure and does not require routine antibiotic prophylaxis because of the low infection risk.

Karaman et al (2012) examined the effect of antibiotic prophylaxis and septoplasty on nasal flora.  These researchers included 115 consecutive patients who underwent septoplasty because of symptomatic nasal septal deviation.  Patients were divided into study and control groups.  Study patients received prophylactic parenteral sodium cefazoline twice-daily beginning intra-operatively and while the nasal packing remained in the nose for 48 hours, and expandable polyvinyl acetate (Merocel) packing covered with antibiotic ointment containing 0.2 % nitrofurazone was inserted into each nostril at the end of the operation.  Control patients received neither parenteral antibiotic prophylaxis nor antibiotic ointment around the Merocel packs.  Both groups received oral prophylactic cefuroxime axetil for 5 days after nasal packing was removed.  Nasal flora was determined pre-operatively, post-operatively when nasal packing was removed, and 3 months after surgery.  Study patients were compared to control patients at pack removal and 1 month after surgery.  The effect of antibiotic use in septoplasty on nasal flora was as follows: Increased isolation rate of gram-positive rods (p = 0.007), decreased methicillin-sensitive coagulase-negative staphylococci (p = 0.002).  Pre-operative and post-operative culture results at 3 months were compared.  The effect of septoplasty on nasal flora was as follows: Decreased coagulase-negative staphylococci (p = 0.05), decreased Klebsiella (p < 0.001), decreased gram-positive rods (p < 0.001), increased methicillin-sensitive Staphylococcus aureus (p < 0.001).   The authors concluded that septoplasty increases S. aureus colonization and decreases normal flora.  Antibiotics do not protect against S. aureus colonization and contribute to a decrease in normal flora.  They stated that antibiotics do not seem to confer benefit in terms of flora changes; studies investigating flora changes with a longer follow-up should be conducted.

Gioacchini et al (2013) noted that both systemic antibiotic therapy and nasal packing are used frequently in septoplasty.  Nevertheless, there is still great disagreement among authors around the real advantages with regard to the effectiveness of both of these procedures in septal surgery.  The aim of the present review was to evaluate the more recent data published on this topic.  One appropriate string was run on PubMed to retrieve articles dealing with the topics mentioned above.  A double cross-check was performed on citations and full-text articles found using the selected inclusion and exclusion criteria.  Overall, the articles analyzed by these researchers indicated the poor utility of routine antibiotic therapy and nasal packing during septoplasty, the latter procedure producing more complications than advantages.  The authors concluded that on the basis of the recent literature, the use of systemic antibiotic prophylaxis and nasal packing in septal surgery seems to be a non-rational procedure.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
Septoplasty:
CPT codes covered if selection criteria are met:
30520
30620
ICD-9 codes covered if selection criteria are met:
470 Deviated nasal septum [causing continuous nasal airway obstruction resulting in nasal breathing difficulty not responding to appropriate medical therapy]
473.0 - 473.9 Chronic sinusitis [due to deviated septum not relieved by appropriate medical and antibiotic therapy]
478.18 Other disease of nasal cavity and sinuses [significant nasal obstruction][after four or more weeks of conservative management when criteria are met]
738.0 Acquired deformity of nose [that prevents access to other intranasal areas when such access is required to perform medically necessary surgical procedures] [not covered for nasal valve collapse]
748.1 Other congenital anomalies of nose [deformity of septum]
749.00 - 749.04 Cleft palate
749.20 - 749.25 Cleft palate with cleft lip
754.0 Congenital musculoskeletal deformities of skull, face, and jaw [congenital deviated septum]
784.7 Epistaxis [related to septal deformity]
ICD-9 codes not covered for indications listed in the CPB:
477.0 - 477.9 Allergic rhinitis
Other ICD-9 codes related to the CPB:
905.0 Late effect of fracture of skull and face bones
Rhinoplasty:
CPT codes covered if selection criteria are met [limited circumstances only]:
30420
30435
30450
30460
30462
CPT codes not covered for indications listed in the CPB:
30400
30410
30430
30465
Other CPT codes related to the CPB:
30130
30140
31231 - 31235
31237 - 31294
70450
70460
70470
70486
70487
70488
ICD-9 codes covered if selection criteria are met:
478.19 Other disease of nasal cavity and sinuses [significant nasal obstruction][after four or more weeks of conservative management when criteria are met]
738.0 Acquired deformity of nose [individual case review see criteria]
748.0 Choanal atresia [individual case review see criteria]
748.1 Other congenital anomalies of nose [individual case review see criteria]
749.00 - 749.04 Cleft palate
749.20 - 749.25 Cleft palate with cleft lip
Other ICD-9 codes related to the CPB [relevant history for required documentation]:
147.3 Malignant neoplasm of nasopharynx, anterior wall
160.0 Malignant neoplasm of nasal cavities, middle ear, and accessory sinuses
160.2 - 160.5 Malignant neoplasm of maxillary, ethmoidal, frontal or sphenoidal sinuses
170.0 Malignant neoplasm of bones of skull and face, except mandible
172.3 Malignant melanoma of other and unspecified parts of face
173.3 Malignant neoplasm of skin of other and unspecified parts of face
195.0 Malignant neoplasm of head, face, and neck
210.7 Benign neoplasm of nasopharynx
212.0 Benign neoplasm of nasal cavities, middle ear, and accessory sinuses
213.0 Benign neoplasm of bones of skull and face
216.3 Benign neoplasm of skin of other and unspecified parts of face
232.3 Carcinoma in situ of skin of other and unspecified parts of face
446.4 Wegener's granulomatosis
472.0 Chronic rhinitis
682.0 Other cellulitis and abscess of face
873.20 - 873.39 Open wound of nose
906.0 Late effect of open wound of head, neck, and trunk
906.5 Late effect of burn of eye, face, head, and neck
941.05, 941.15, 941.25, 941.35, 941.45 Burn of nose (septum)
V10.02 Personal history of malignant neoplasm of other and unspecified oral cavity and pharynx
V10.22 Personal history of malignant neoplasm of nasal cavities, middle ear, and accessory sinuses
V10.82 Personal history of malignant melanoma of skin
V10.83 Personal history of malignant neoplasm of skin


The above policy is based on the following references:
  1. American Academy of Otolaryngology Head and Neck Surgery (AAOHNS). Septoplasty. Clinical Indicators Compendium. Alexandria, VA: AAOHNS; 1998.
  2. Doyle RL. Healthcare Management Guidelines. Vol. 1. 2nd Printing. Seattle, WA: Milliman and Robertson; September 1997.
  3. Schuller DE, Schleuning AJ. DeWeese and Saunders' Otolaryngology - Head and Neck Surgery. 8th ed. St. Louis, MO: Mosby; 1994:93-107, 123-133, 135-145.
  4. Meyerhoff WL, Rice DH. Otolaryngology- Head and Neck Surgery. Philadelphia, PA: W.B. Saunders Co; 1992:474.
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  6. Marshall, KG, Elhamy LA. Disorders of the nose and paranasal sinuses. Littleton, MA: PSG Publishing Co, Inc.; 1987:103.
  7. Godley FA, Nemeroff RF, Josephson JS. Current trends in rhinoplasty and the nasal airway. Med Clin North Am. 1993;77(3):643-656.
  8. Grossman ZD, Katz DS, et al. Sinusitis. In: Cost-Effective Diagnostic Imaging; The Clinician's Guide. St. Louis, MO: Mosby; 1995:376-377.
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  12. Bessonov SN. Rhinoplasty in cases of congenital upper cleft lips. Stomatologiia (Mosk). 2005;84(3):64-67.
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  14. Schwentner I, Dejakum K, Schmutzhard J, et al. Does nasal septal surgery improve quality of life? Acta Otolaryngol. 2006;126(7):752-757.
  15. Gurlek A, Fariz A, Aydogan H, et al. Effects of different corticosteroids on edema and ecchymosis in open rhinoplasty. Aesthetic Plast Surg. 2006;30(2):150-154.
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  18. Arosarena OA. Cleft lip and palate. Otolaryngol Clin North Am. 2007;40(1):27-60, vi.
  19. Getz AE, Hwang PH. Endoscopic septoplasty. Curr Opin Otolaryngol Head Neck Surg. 2008;16(1):26-31.
  20. Koutsourelakis I, Georgoulopoulos G, Perraki E, et al. Randomised trial of nasal surgery for fixed nasal obstruction in obstructive sleep apnoea. Eur Respir J. 2008;31(1):110-117.
  21. Rhee JS, Arganbright JM, McMullin BT, Hannley M. Evidence supporting functional rhinoplasty or nasal valve repair: A 25-year systematic review. Otolaryngol Head Neck Surg. 2008;139(1):10-20.
  22. Awan MS, Iqbal M. Nasal packing after septoplasty: A randomized comparison of packing versus no packing in 88 patients. Ear Nose Throat J. 2008;87(11):624-627.
  23. Dubin MR, Pletcher SD. Postoperative packing after septoplasty: Is it necessary? Otolaryngol Clin North Am. 2009;42(2):279-285, viii-ix.
  24. Matulić Z, Skitarelić N. Reconstruction of nasal tip in combined technique of cartilage disc grafts and onlay graft. Lijec Vjesn. 2004;126(1-2):18-21.
  25. Gubisch W. Extracorporeal septoplasty for the markedly deviated septum. Arch Facial Plast Surg. 2005;7(4):218-226.
  26. Most CP. Anterior septal reconstruction: Outcomes after a modified extracorporeal septoplasty technique. Arch Facial Plast Surg. 2006;8(3):202-207.
  27. Kantas I, Balatsouras DG, Papadakis CE, et al. Aesthetic reconstruction of a crooked nose via extracorporeal septoplasty. J Otolaryngol Head Neck Surg. 2008;37(2):154-159.
  28. Baumann I. Septoplasty update. Laryngorhinootologie. 2010;89(6):373-384.
  29. Jang YJ, Kwon M. Modified extracorporeal septoplasty technique in rhinoplasty for severely deviated noses. Ann Otol Rhinol Laryngol. 2010;119(5):331-335.
  30. Fettman N, Sanford T, Sindwani R. Surgical management of the deviated septum: Techniques in septoplasty. Otolaryngol Clin North Am. 2009;42(2):241-252.
  31. Paniello RC. Nasal valve suspension. An effective treatment for nasal valve collapse. Arch Otolaryngol Head Neck Surg. 1996;122(12):1342-1346.
  32. Nuara MJ, Mobley SR. Nasal valve suspension revisited. Laryngoscope. 2007;117(12):2100-2106.
  33. André RF, Vuyk HD. Nasal valve surgery; our experience with the valve suspension technique. Rhinology. 2008;46(1):66-69.
  34. Spielmann PM, White PS, Hussain SS. Surgical techniques for the treatment of nasal valve collapse: A systematic review. Laryngoscope. 2009;119(7):1281-1290.
  35. Moore M, Eccles R. Objective evidence for the efficacy of surgical management of the deviated septum as a treatment for chronic nasal obstruction: A systematic review. Clin Otolaryngol. 2011;36(2):106-113.
  36. Kim YH, Kim BJ, Bang KH, et al. Septoplasty improves life quality related to allergy in patients with septal deviation and allergic rhinitis. Otolaryngol Head Neck Surg. 2011;145(6):910-914.
  37. Trimarchi M, Bellini C, Toma S, Bussi M. Back-and-forth endoscopic septoplasty: Analysis of the technique and outcomes. Int Forum Allergy Rhinol. 2012;2(1):40-44.
  38. Lawrence R. Pediatric septoplasy: A review of the literature. Int J Pediatr Otorhinolaryngol. 2012;76(8):1078-1081.
  39. Ricci G, D'Ascanio L. Antibiotics in septoplasty: Evidence or habit? Am J Rhinol Allergy. 2012;26(3):194-196.
  40. Karaman E, Alimoglu Y, Aygun G, et al. Effect of septoplasty and per-operative antibiotic prophylaxis on nasal flora. B-ENT. 2012;8(1):13-19.
  41. Banglawala SM, Gill M, Sommer DD, et al. Is nasal packing necessary after septoplasty? A meta-analysis. Int Forum Allergy Rhinol. 2013;3(5):418-424.
  42. Gioacchini FM, Alicandri-Ciufelli M, et al. The role of antibiotic therapy and nasal packing in septoplasty. Eur Arch Otorhinolaryngol. 2013 Jun 5. [Epub ahead of print]


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