Lancashire Clinical Commissioning Groups (CCGs)

Policies for the Commissioning of Healthcare

Chronic Rhinosinusitis Surgery Policy

 

 Introduction

This document is part of a suite of policies that the CCG uses to drive its commissioning of healthcare. Each policy in that suite is a separate public document in its own right, but will be applied with reference to other policies in that suite.

          

1         Policy          

1.1      The CCG will commission surgical procedures for Chronic Rhinosinusitis (CRS) when the following criteria are satisfied:         

1.1.1   A clinical diagnosis of CRS has been made (as set out in RCS/ENT-UK Commissioning guidance¹) and patient still has moderate/ severe symptoms after a 3-month trial of intranasal steroids and nasal saline irrigation.

AND

1.1.2   for patients with bilateral nasal polyps there has been no improvement in symptoms 4 weeks after a trial of 5-10 days of oral steroids (0.5mg/kg to a max of 60 mg)

OR

1.1.3   Patient has nasal symptoms with an unclear diagnosis in primary care

OR

1.1.4   Any patient with unilateral symptoms or clinical findings, orbital, or neurological features should be referred urgently / via 2-week wait depending on local pathways.          

1.2      The CCG commissions endoscopic sinus surgery when the following criteria are met:

For Chronic Rhinosinusitis

1.2.1   A diagnosis of CRS has been confirmed from clinical history and nasal endoscopy and / or CT scan

AND

1.2.2   Disease-specific symptom patient reported outcome measure confirms moderate to severe symptoms e.g. Sinonasal Outcome Test (SNOT-22) after trial of appropriate medical therapy (including counselling on technique and compliance) as outlined in RCS/ENT-UK commissioning guidance ‘Recommended secondary care pathway’.

AND

1.2.3   Pre-operative CT sinus scan has been performed and confirms presence of CRS. Note: a CT sinus scan does not necessarily need to be repeated if performed sooner in the patient’s pathway.

AND

1.2.4   Patient and clinician have undertaken appropriate shared decision-making consultation regarding undergoing surgery including discussion of risks and benefits of surgical intervention.          

For Recurrent acute sinusitis

1.2.5   In patients with recurrent acute sinusitis, nasal examination is likely to be relatively normal. Ideally, the diagnosis should be confirmed during an acute attack if possible, by nasal endoscopy and/or a CT sinus scan.          

1.3      Endoscopic sinus surgery is routinely funded in any of the following circumstances:          

1.3.1   Any suspected or confirmed neoplasia

OR

1.3.2   Emergency presentations with complications of sinusitis (e.g. orbital abscess, subdural or intracranial abscess)

OR

1.3.3   Patients with immunodeficiency

OR

1.3.4   Fungal Sinusitis

OR

1.3.5   Patients with conditions such as Primary Ciliary Dyskinesia, Cystic Fibrosis or NSAID-Eosinophilic Respiratory Disease (NSAID-ERD, Samter’sTriad Aspirin Sensitivity, Asthma)

OR

1.3.6   Treatment with topical and / or oral steroids contra-indicated.

OR

1.3.7   As part of surgical access or dissection to treat non-sinus disease (e.g. pituitary surgery, orbital decompression for eye disease, nasolacrimal surgery).

OR

1.4      Exceptionality has been demonstrated in accordance with section 9 below.

          

2         Scope and definitions          

2.1      This policy is based on the CCGs Statement of Principles for Commissioning of Healthcare (version in force on the date on which this policy is adopted).       

2.2     Chronic rhinosinusitis (CRS) is defined as inflammation (swelling) of the nasal sinuses that lasts longer than 12 weeks. The sinuses are mucus secreting, air filled cavities in the face and head that drain into the nose; their normal function may be disrupted by environmental, infectious or inflammatory conditions which damage the epithelial lining and disturb the balance of the natural microbial community².

Patients report a number of symptoms including nasal blockage, discharge, alteration to smell, and facial pressure or pain. They often have a relapsing course, with recurrence after treatment commonplace³.          

2.5     The CCG recognises that a patient may have certain features, such as

• having chronic rhinosinusitis or recurrent bouts of acute sinusitis
• wishing to have a service provided for sinusitis,
• being advised that they are clinically suitable for surgical intervention for chronic rhinosinusitis, and
• be distressed by the fact that that they may not meet the criteria specified in this commissioning policy. 

Such features place the patient within the group to whom this policy applies and do not make them exceptions to it.                     

2.7     This Policy is based on the Evidence-Based Interventions Guidance List 2,

2C Surgical intervention for chronic rhinosinusitis ².

          

3         Appropriate Healthcare        

3.1      The purpose of surgical intervention for chronic rhinosinusitis is normally to relieve the symptoms caused by the condition, namely nasal blockage, discharge, alteration to smell, and facial pressure or pain.     

3.2      The CCG regards the achievement of this purpose as according with the Principle of Appropriateness.  Therefore this policy does not rely on the principle of appropriateness.  Nevertheless if a patient is considered exceptional in relation to the principles on which the policy does rely, the CCG may consider the principle of appropriateness in the particular circumstances of the patient in question when considering an application to provide funding.

          

4         Effective Healthcare        

4.1      This policy is based on based on the Principle of Effectiveness.  The effective treatment is detailed in the NICE Clinical Knowledge Summary – Sinusitis³.  First-line treatment is with appropriate medical therapy, which should include intranasal steroids and nasal saline irrigation. In the case of CRS with Nasal Polyps a trial of a short course of oral steroids should also be considered³. 

          

5         Cost Effectiveness          

5.1      The CCG considers that any treatment which is not effective cannot be cost-effective and therefore treatment outside of the policy criteria may not accord with the Principle of Cost Effectiveness

          

6         Ethics          

6.1      The CCG does not call into question the ethics of surgical intervention for chronic rhinosinusitis and therefore this policy does not rely on the Principle of Ethics.   Nevertheless if a patient is considered exceptional in relation to the principles on which the policy does rely, the CCG may consider whether the treatment is likely to raise ethical concerns in this patient when considering an application to provide funding.

          

7         Affordability         

7.1      The CCG does not call into question the affordability of surgical intervention for chronic rhinosinusitis and therefore this policy does not rely on the Principle of Affordability.  Nevertheless if a patient is considered exceptional in relation to the principles on which the policy does rely, the CCG may consider whether the treatment is likely to be affordable in this patient when considering an application to provide funding.

          

8         Exceptions          

8.1      The CCG will consider exceptions to this policy in accordance with the Policy for Considering Applications for Exceptionality to Commissioning Policies.          

8.2      In the event of inconsistency, this policy will take precedence over any non-mandatory NICE guidance in driving decisions of this CCG.  A circumstance in which a patient satisfies NICE guidance but does not satisfy the criteria in this policy does not amount to exceptionality.

          

9         Force          

9.1      This policy remains in force until it is superseded by a revised policy or by mandatory NICE guidance relating to this intervention, or to alternative treatments for the same condition.          

9.2     In the event of NICE guidance referenced in this policy being superseded by new NICE guidance, then:

• If the new NICE guidance has mandatory status, then that NICE guidance will supersede this policy with effect from the date on which it becomes mandatory.
• If the new NICE guidance does not have mandatory status, then the CCG will aspire to review and update this policy accordingly.  However, until the CCG adopts a revised policy, this policy will remain in force and any references in it to NICE guidance will remain valid as far as the decisions of this CCG are concerned.

          

10       References

• RCS Commissioning Guide: Chronic Rhinosinusitis. 2016: https://www.rcseng.ac.uk/standards-and-research/commissioning/commissioningguides/topics/
• Evidence-Based Interventions List 2 Guidance.  Academy of Medial Royal Colleges.  November 2020.
• NICE Clinical Knowledge Summary – Sinusitis: https://cks.nice.org.uk/sinusitis

 

Appendix 1: Associated OPCS codes 

The codes applicable to this policy are: 

OPCS Codes

Y76.1 Functional endoscopic sinus surgery

Y76.2 Functional endoscopic nasal surgery

E12.1 Ligation of maxillary artery using sublabial approach

E12.2 Drainage of maxillary antrum using sublabial approach

E12.3 Irrigation of maxillary antrum using sublabial approach

E12.4 Transantral neurectomy of vidian nerve using sublabial approach

E12.8 Other specified operations on maxillary antrum using sublabial approach

E12.9 Unspecified operations on maxillary antrum using sublabial approach

E13.1 Drainage of maxillary antrum NEC

E13.2 Excision of lesion of maxillary antrum

E13.3 Intranasal antrostomy

E13.4 Biopsy of lesion of maxillary antrum

E13.5 Closure of fistula between maxillary antrum and mouth

E13.6 Puncture of maxillary antrum

E13.7 Neurectomy of vidian nerve NEC

E13.8 Other specified other operations on maxillary antrum

E13.9 Unspecified other operations on maxillary antrum

E14.1 External frontoethmoidectomy

E14.2 Intranasal ethmoidectomy

E14.3 External ethmoidectomy

E14.4 Transantral ethmoidectomy

E14.5 Bone flap to frontal sinus

E14.6 Trephine of frontal sinus

E14.7 Median drainage of frontal sinus

E14.8 Other specified operations on frontal sinus

E14.9 Unspecified operations on frontal sinus

E15.1 Drainage of sphenoid sinus

E15.2 Puncture of sphenoid sinus

E15.3 Repair of sphenoidal sinus

E15.4 Excision of lesion of sphenoid sinus

E15.8 Other specified operations on sphenoid sinus

E15.9 Unspecified operations on sphenoid sinus

E16.1 Frontal sinus osteoplasty

E16.2 Drainage of frontal sinus NEC

E16.8 Other specified other operations on frontal sinus

E16.9 Unspecified other operations on frontal sinus

E17.1 Excision of nasal sinus NEC

E17.2 Excision of lesion of nasal sinus NEC

E17.3 Biopsy of lesion of nasal sinus NEC

E17.4 Lateral rhinotomy into nasal sinus NEC

E17.8 Other specified operations on unspecified nasal sinus

E17.9 Unspecified operations on unspecified nasal sinus

E08.1 Polypectomy of internal nose

Diagnosis Codes 

J32.0 Chronic maxillary sinusitis

J32.1 Chronic frontal sinusitis

J32.2 Chronic ethmoidal sinusitis

J32.3 Chronic sphenoidal sinusitis

J32.4 Chronic pansinusitis

J32.8 Other chronic sinusitis

J32.9 Chronic sinusitis, unspecified

J33.0 Polyp of nasal cavity

J33.1 Polypoid sinus degeneration

J33.8 Other polyp of sinus

J33.9 Nasal polyp, unspecified

 

Date of adoption   2021

Date for review…2024