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

   1. Septal deviation causing continuous nasal airway obstruction resulting in nasal breathing difficulty not responding to appropriate medical therapy; 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 related to a septal deformity; or 
   4. 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  

   5. When done in association with cleft palate repair. 

   Aetna considers septoplasty experimental and investigational for all other indications.

2. 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. Nasal airway obstruction is causing significant symptoms (e.g., chronic rhinosinusitis, difficulty breathing), and
      2. Photos demonstrate an external nasal deformity, and
      3. There is an average 50 % or greater obstruction of nares (e.g., 50 % obstruction of both nares, or 75 % obstruction of one nare and 25 % obstruction of other nare, or 100 % obstruction of one nare), documented by endoscopy, CT scan or other appropriate imaging modality, and
      4. Obstructive symptoms persist despite conservative management for three months or greater, which includes, where appropriate, nasal steroids or immunotherapy; and
      5. Airway obstruction will not respond to septoplasty and turbinectomy alone.

      Documentation of these criteria should include:

      1. Results of nasal endoscopy, CT or other appropriate imaging modality documenting degree of nasal obstruction; and
      2. If there is an external nasal deformity, preoperative photographs showing the standard 4-way view – base of nose, anterior posterior (AP), and right and left lateral views; and
      3. 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
      4. Documentation of duration and degree of symptoms related to nasal obstruction, such as chronic rhinosinusitis, mouth breathing, etc.; and

      5. Documentation of results of conservative management of symptoms.

   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.

Note: See CPB 031 - Cosmetic Surgery for details on exceptions to the cosmetic surgery exclusion.  In addition, please check benefit plan descriptions for details. 

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 overutilization 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 which 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 two 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 three passageways (the superior, middle and inferior meati) by the projection of the four 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 three 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 one 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 reobstruction due to improper healing and scarring, creating intranasal synechiae.

There are four 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 (1998) has noted that the following findings are useful in assessing the need for septoplasty.

1. History - one or more required

   1. Nasal airway obstruction or difficult nasal breathing causing any of the following: mouth breathing, snoring, sleep apnea or recurrent sinus infections.
   2. Frequent nosebleeds.
   3. Atypical facial pain of nasal origin.  Positive response to topical anesthetic, where deformed septum contacts a turbinate, supports but may not prove septal cause.

   4. Asymptomatic deformity that prevents surgical access to other intranasal areas, i.e., ethmoidectomy.

2. Physical Examination - all appropriate findings required

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

   5. Description of nasopharynx, oropharynx, hypopharynx and larynx if purpose of surgery is to prevent sleep apnea or snoring

The AAO-HNS 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 two to four 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 ten percent 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 (Nose Bleed)

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.