Medical Policy

 

Subject: Ultrasound for the Evaluation of Paranasal Sinuses
Document #: RAD.00012 Publish Date:    04/25/2018
Status: Reviewed Last Review Date:    03/22/2018

Description/Scope

 

This document addresses the use of ultrasound for the evaluation of paranasal sinuses as a diagnostic procedure intended to determine the presence of sinus fluid in clinical cases of sinusitis. Ultrasound is also proposed for use in demonstrating mucosal wall thickening, focal soft tissue masses, and complex collections in the paranasal sinuses.

 

Position Statement

Investigational and Not Medically Necessary:

Paranasal sinus ultrasound is considered investigational and not medically necessary for all indications.

Rationale

 

The American Academy of Allergy, Asthma and Immunology (AAAAI) published parameters for the diagnosis and management of sinusitis. These parameters state that computed tomography is the preferred imaging technique for preoperative evaluation of the paranasal sinuses and that ultrasonography has "limited utility, but may be applicable in pregnant women and for determining the amount of retained secretions" (Slavin, 2005).

The American College of Radiology (ACR) published Appropriateness Criteria® (2012) for sinusitis in the pediatric population. The routine use of imaging of the paranasal sinuses in children with acute bacterial sinusitis without complications is not recommended. These criteria suggest that computed tomography (CT) is the most appropriate imaging modality for persistent, recurrent or chronic sinusitis. Ultrasound is not addressed by the ACR Appropriateness Criteria.

In 2013, the American Academy of Pediatrics (AAP) updated their Clinical Practice Guidelines for the management of sinusitis. These guidelines note that the diagnosis of acute bacterial sinusitis is made when a child with an acute upper respiratory tract infection presents with persistent illness, worsening course, or severe onset (concurrent fever and purulent nasal discharge for at least 3 consecutive days). The guidelines also state that clinicians should not obtain imaging studies such as x-rays, CT, magnetic resonance imaging (MRI) or ultrasound to distinguish acute bacterial sinusitis from viral upper respiratory infection.

Reider and colleagues (2003) systematically reviewed the evidence supporting the use of various imaging studies in the diagnosis of acute sinusitis. In the 1980s and 1990s, ultrasound was studied, noting a great variability in test performance as supported by a systematic evidence review by Varonen and colleagues (2000). Reider notes that “since the cost of this procedure (ultrasound) is similar to that of a sinus CT, ultrasound is not indicated in the diagnostic evaluation of the sinuses.” This review concluded, “Accurate diagnosis of acute sinusitis in both children and adults depends on the history and clinical examination of the patient.”

A group of 25 physicians from five national medical societies including the AAAAI, the American Academy of Otolaryngic Allergy (AAOA), the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF), the American College of Allergy, Asthma and Immunology (ACAAI), and the American Rhinologic Society (ARS) collaborated to design the first clinical trial guidelines for researchers working to find the most effective treatments for rhinosinusitis. A key component of this Rhinosinusitis Initiative guidance includes a recommendation of scoring instruments for symptoms, radiographs, endoscopic testing, and quality of life assessment. As it relates to imaging recommendations, in “an acutely infected sinus caused by bacterial or fungal infection showing thickening of the mucosa (reflecting edematous tissue of the paranasal sinuses), conventional radiography is adequate for the diagnosis of clinically uncomplicated acute sinusitis” (Meltzer, 2006).

In 2015 the AAO-HNS (Rosenfeld, 2015) updated their Clinical Practice Guideline for adult sinusitis. Their recommendation is that clinicians should not obtain imaging for adults (18 years or older) who meet the diagnostic criteria for acute rhinosinusitis, unless there is a complication or another diagnosis is suspected. The guideline does not specifically address ultrasound, however their recommendation is clear in stating “Recommendation (against imaging) based on diagnostic studies with minor limitations and a preponderance of benefit over harm for not obtaining imaging” and “radiographic imaging of the paranasal sinuses is unnecessary for diagnosis in patients who already meet clinical diagnostic criteria.”

Background/Overview

 

Sinusitis, also known as rhinosinusitis, is one of the most common health care problems in the United States, with evidence that it is increasing in prevalence and incidence with 37 million Americans affected annually. Because acute sinusitis may be caused by bacterial infection, individuals with compatible symptoms frequently receive antibiotics. Acute bacterial rhinosinusitis is the fifth most common reason for outpatient antibiotic prescription. Complications of acute bacterial rhinosinusitis (ABRS) may include orbital, intracranial, or soft tissue involvement. Therefore, accurate initial diagnosis of the condition is of major importance. Alternative diagnoses may include malignancy and other noninfectious causes of facial pain. Radiographic imaging as an accurate diagnostic tool may be particularly important in individuals with modifying factors or comorbidities that predispose to complications, including diabetes, immune compromised state, or a past history of facial trauma or surgery.

Paranasal sinus ultrasound has been proposed as a convenient office-based diagnostic tool to confirm the diagnosis of clinical sinusitis. Ultrasound is a painless non-invasive diagnostic procedure, which uses a water-soluble gel as an interface between the ultrasound applicator and the skin. The ultrasound applicator is applied to the area on the face where the sinuses are located, including the nose and the cheekbones. High frequency sound waves produce the image of the internal structures, and the physician or radiologist interprets the data. No risks have been identified with ultrasound evaluation of the paranasal sinuses, but the accuracy of the ultrasound is dependent largely on the examiner’s skills.

Sinus involvement is common in documented viral upper respiratory infections, making it impossible to distinguish ABRS from viral rhinosinusitis based solely on imaging studies. Clinical criteria may be comparable to diagnostic accuracy of sinus radiography, and radiography is not cost effective regardless of baseline sinusitis prevalence. When a complication of acute rhinosinusitis or an alternative diagnosis is suspected, imaging studies may be obtained. It is important to note that sensitivity and specificity for ethmoid and frontal sinusitis are lower on plain film radiography. Additional radiology becomes important when complications or recurrent or chronic rhinosinusitis is suspected. CT scan of the paranasal sinuses is an alternative choice that is preferred when a complication of acute rhinosinusitis is suspected as it improves visualization of the paranasal sinus anatomy, including soft tissue changes, and bone structure. In recurrent rhinosinusitis, CT scanning may help explain anatomic blockage of the frontal maxillary sinuses (sinuses around the eyes). Complicated rhinosinusitis, with suspected orbital, intracranial, or deep facial extension based on severe headache, proptosis, cranial nerve palsies, or facial swelling, may be evaluated with iodine contrast-enhanced CT or gadolinium-based MRI to identify extra-sinus extension or involvement.

Definitions

Acute bacterial rhinosinusitis (ABRS): Acute rhinosinusitis that is caused by, or is presumed to be caused by, bacterial infection. Signs or symptoms are present for 10 days or more beyond the onset of upper respiratory symptoms or worsen within ten days after an initial improvement (double worsening).

Diagnostic ultrasound: A non-invasive type of imaging that uses high-frequency sound waves.

Paranasal sinus: The mucosal lined, air-filled cavities in the skull bones adjacent to and communicating with the nasal cavity.

Recurrent acute rhinosinusitis: Four or more acute episodes of ABRS per year, without persistent symptoms between episodes.

Sinusitis: Also known as rhinosinusitis, sinusitis is the symptomatic inflammation of the paranasal sinuses and nasal cavity. Typically sinusitis is characterized by up to 4 weeks of purulent nasal drainage accompanied by nasal obstruction, facial pain-pressure-fullness, or both.

Viral rhinosinusitis (VRS): An acute rhinosinusitis that is caused by, or is presumed to be caused by, viral infection. Signs or symptoms are present less than ten days and the symptoms are not worsening.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services are Investigational and Not Medically Necessary:
For the following procedure code for all indications, or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

HCPCS

 

S9024

Paranasal sinus ultrasound

 

 

ICD-10 Diagnosis

 

 

All diagnoses

References

Peer Reviewed Publications:

  1. Bhattacharyya N. Clinical and symptom criteria for the accurate diagnosis of chronic rhinosinusitis. Laryngoscope. 2006; 116(7 Pt 2 Suppl 110):1-22.
  2. Engels EA, Terrin N, Barza M, Lau J. Meta-analysis of diagnostic tests for acute sinusitis. J Clin Epidemiol. 2000; 53(8):852-862.
  3. Haapaniemi J. Comparison of ultrasound and x-ray maxillary sinus findings in school-aged children. Ear, Nose, Throat J. 1997; 76(2):102-106.
  4. Ioannidis JP, Lau J. Technical report: Evidence for the diagnosis and treatment of acute uncomplicated sinusitis in children: A systemic overview. Pediatrics. 2001; 108(3):1-8.
  5. Karantanas AH, Sandris V. Maxillary sinus inflammatory disease: Ultrasound compared to computed tomography. Computerized Med Imag and Graph. 1997; 21(4):233-241.
  6. Kronemer KA, McAlister WH. Sinusitis and its imaging in the pediatric population. Pediatr Radiol. 1997; 27(11):837-846.
  7. Laine K, Maatta T, Varonen H, et al. Diagnosing acute maxillary sinusitis in primary care: A comparison of ultrasound, clinical examination and radiography. Rhinology. 1998; 36(1):2-6.
  8. Meltzer EO, Hamilos DL, Hadley JA, et al. Rhinosinusitis: developing guidance for clinical trials. J Allergy Clin Immunol. 2006 Nov; 118(5 Suppl):S17-61.
  9. Reider JM, Nashelsky J, Neher J. Clinical inquiries. Do imaging studies aid diagnosis of acute sinusitis? J Fam Pract. 2003 Jul; 52(7):565-567.
  10. Slavin RG. Nasal polyps and sinusitis. JAMA, 1997; 278(22):1849-1854.
  11. Varonen H, Kunnamo I, Savolainen S, et al. Treatment of acute rhinosinusitis diagnosed by clinical criteria or ultrasound in primary care. A placebo-controlled randomised trial. Scand J Prim Health Care. 2003; 21(2):121-126.
  12. Varonen H, Makela M, Savolainen S, et al. Comparison of ultrasound, radiolography, and clinical examination in the diagnosis of acute maxillary sinusitis: a systematic review. Journal of Clinical Epidemiology. 2000; 53(9):940-948.
  13. Vento SI, Ertama LO, Hytonen ML, Malberg CH. A-mode ultrasound in the diagnosis of chronic polypous sinusitis. Acta Otolyarngol. 1999; 119(8):916-920.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Academy of Pediatrics. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics. 2013; 132(1):e262-e280. Available at: http://pediatrics.aappublications.org/content/132/1/e262.full.pdf+html?sid=11550711-49b2-4f54-a208-9144a5d96bed. Accessed on February 20, 2018.
  2. American College of Radiology. ACR Appropriateness Criteria. Sinusitis—Child (2012) Available at: http://www.acr.org/Quality-Safety/Appropriateness-Criteria. Accessed on February 20, 2018.
  3. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg. 2015; 152(2 Suppl):S1-39.
  4. Slavin RG, Spector SL, Bernstein IL, et al. The diagnosis and management of sinusitis: A practice parameter update. J Allergy Clin Immunol 2005; 116(6 Suppl):S13-47.
Websites for Additional Information
  1. American Academy of Allergy, Asthma & Immunology (AAAAI). Available at: http://www.aaaai.org/. Accessed on February 20, 2018.
  2. American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS). Fact sheet: 20 questions about your sinuses. Available at: http://www.entnet.org/HealthInformation/sinuses.cfm. Accessed on February 20, 2018.
  3. American Rhinologic Society (ARS). Sinusitis FAQ’s. Available at: http://www.american-rhinologic.org/patientinfo.sinusitisqa.phtml. Accessed on February 20, 2018.
  4. National Library of Medicine (NLM). National Institute of Allergy and Infectious Diseases (NIAID). Sinusitis. Available at: http://www.nlm.nih.gov/medlineplus/sinusitis.html. Accessed on February 20, 2018.
Index

 

Paranasal Sinus Ultrasound

 

Document History
     

Status

Date

Action

Reviewed

03/22/2018

Medical Policy & Technology Assessment Committee (MPTAC) review. The document header wording updated from “Current Effective Date” to “Publish Date.” Updated Rationale and References sections.

Reviewed

05/04/2017

MPTAC review.

Reviewed

05/05/2016

MPTAC review. Removed ICD-9 codes from Coding section.

Reviewed

05/07/2015

MPTAC review. Updated Rationale and References.

Reviewed

05/15/2014

MPTAC review. Updated Rationale and References.

Reviewed

05/09/2013

MPTAC review. Updated Rationale and References.

Reviewed

05/10/2012

MPTAC review. Updated Rationale, Background/Overview, and References.

Reviewed

05/19/2011

MPTAC review. Updated Rationale and References.

Reviewed

05/13/2010

MPTAC review. Updated Rationale and References.

Reviewed

05/21/2009

MPTAC review. Updated References and Web Sites.

Reviewed

05/15/2008

MPTAC review. Updated Rationale, Background, Definitions, and References.

 

02/21/2008

The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." This change was approved at the November 29, 2007 MPTAC meeting.

Reviewed

05/17/2007

MPTAC review. Rationale and References updated.

Revised

06/08/2006

MPTAC review. Revision based on minor change to position statement. No change to position stance. 

Revised

07/14/2005

MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.

Pre-Merger Organizations

Last Review Date

Document Number

Title

Anthem, Inc.

 

10/28/2004

RAD.00012

Ultrasound for the Evaluation of Paranasal Sinuses

WellPoint Health Networks, Inc.

04/28/2005

4.03.01

Ultrasound for the Evaluation of the Paranasal Sinuses