Учебники / Pediatric Sinusitis and Sinus Surgery Younis 2006
.pdfHow to Set Up a Sinus Center |
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ANCILLARY SERVICES
In general, whether onsite or contracted out, ancillary services including laboratory, radiology, pathology, and pharmaceutical services should be made available in accordance with the patient’s needs and the types and volume of procedures and surgery performed in the sinus center. The services provided should be supervised by personnel qualified in these respective areas. If the supervisor is the otolaryngologist, he or she should be qualified to assume the professional, organizational, and administrative responsibility for the quality of the service rendered.
All ancillary services located in the sinus center must meet the standards issued by the Occupational Safety and Health Administration (OSHA) and promulgated under the Clinical Laboratory Improvement Act (CLIA), as well as other applicable state and federal standards. Ancillary services can be an integral part of the sinus center.
Allergy Testing and Treatment
Allergy testing and treatment are excellent ancillary services which dovetail very well with sinonasal disease. In vivo and in vitro allergy testing may be a part of the sinus and rhinology practice, in both pediatric and adult settings. Allergy skin testing is a valuable diagnostic tool, the results of which can facilitate enhanced environmental avoidance techniques as well as immunotherapy if indicated for a particular patient. In addition, the rationale for otolaryngologists playing a more active role in allergy care cannot be understated given the atopic associations in otitis media, otitis externa, Me´nie`re’s disease, recurrent upper respiratory tract infections, rhinosinusitis, and asthma.
Generally screening can be accomplished with 10 to 15 allergens; full testing usually requires 40 or more antigens. The Academy of Otolaryngic Allergy is an excellent resource for training and certification in order to provide optimal and comprehensive allergy care for your patient. Diagnosis and management of allergy is an integral part of managing children, especially with sinonasal and other pathology.
Diagnostic Imaging Services
Diagnostic imaging services include, but are not limited, to radiography, fluoroscopy, CAT scans, MRI, ultrasound, and nuclear medicine. The sinus center will likely utilize CAT scanning more than any other modality, including its use as it relates to image-guided sinus surgery, and should be an integral part of the sinus center. Diagnostic imaging should be performed by qualified, certified staff and interpreted by a qualified practitioner. Complete patient records should be maintained in a readily accessible location in the sinus center. This allows for comprehensive patient evaluation and
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enhances the patient experience by providing an effective onsite radiographic test eliminating the need to go to another radiology facility or hospital. In addition, one is able to obtain the CT scan at any time for immediate review in determining whether or not further antibiotic treatment or other management is indicated. Having a CAT scanner onsite makes for a more complete, convenient, and efficient patient experience. In addition, this is a favorable ancillary revenue source where one can be reimbursed for performing the technical component of the study. Depending on the medicolegal environment where one practices, one might choose to interpret one’s own CAT scans and obtain reimbursement for both the technical and diagnostic component, or one might outsource the interpretation of the CAT scan to a radiology practice. In addition, given the fact that sinus disease and rhinology often represent a large portion of one’s practice, the CAT scanner can be well-utilized and supported by two or more otolaryngologists. Other studies including non-contrast head, temporal bone, and soft tissue studies of the head and neck are also frequently necessary, thereby maintaining efficiency of the scanner.
Laboratory and Pathology
Other ancillary services that might be considered in the setting of a sinus center or ambulatory surgery facility include chemical pathology and histopathology testing. Practices should comply with federal and state regulations. Routine laboratory testing, cytology, and histopathology are usually contracted out based on the patient’s insurance obligations.
OFFICE ADMINISTRATION
Policies and Procedures
Develop simple written policies and procedures to ensure the provision of safe and quality medical and surgical care. One must be able to inform patients, respond to their needs, and assure consistent personnel performance to maintain a high quality sinus center. The policies and procedures should include an emergency care and transfer plan, medical record maintenance and security, surgical services and invasive procedures, maintenance of surgical and anesthesia equipment as well as a structured infection control policy, organizational structure and job description and a clear delineation of patient rights.
Performance Improvement Program
The sinus center should establish and maintain a performance improvement program, which should assess both process and clinical outcomes of the practice to improve the quality of care. This typically includes peer review.
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The scope and breadth of the program should reflect the size of the practice and the sinus center as well as the level of anesthesia used and the complexity of services performed.
CONCLUSION
The creation of a sinus center with the understanding that it will function as a ‘‘center of excellence’’ requires much preparation. The organizational requirements are listed in detail in the chapter. A thorough understanding of the issues pertaining to coding and reimbursement are critical to the success of the center. Credentialing, satisfying OSHA requirements, and knowledge of the legal ramifications including malpractice issues are essential requirements for a successful ‘‘Sinus Center of Excellence.’’
Index
AA-HNS (Academy of Otolaryngologyhead and Neck Surgery), policy for IGS, 192
ABRS (acute bacterial rhinosinusitis), 142
diagnosis of, 143
SAHP treatment guidelines, 153 Academy of Otolaryngology-head and
Neck Surgery (AA-HNS), policy for IGS, 191
Acute bacterial rhinosinusitis (ABRS), 142
diagnosis of, 143
SAHP treatment guidelines, 153 Acute exacerbation of chronic
rhinosinusitis, 143 Acute rhinosinusitis
adjuvant therapies, 156 antihistamines and, 157 antimicrobial management of, 151 decongestants and, 157 humidification, 156
mucolytic agents, 157 nasal saline irrigations, 156 nasal steroids, 158
surgery for, 158
treatment overview, 149–150 vaccinations, 158
Acute sinusitis, corticosteroids and, 107 Adenoid facies, 147
Adenoid hypertrophy, 24 vs. sinusitis, 217
Adenoid size
and rhinosinusitis, 220 and sinusitis, 220
Adenoidectomy, 173 and sinusitis, 219
Adenoiditis, 146, 165, 167 Adenoids, 218
role in sinusitis, 217–222 Adenotonsillar hypertrophy, 24 Adult sinusitis
anatomy, 47–48 microbiology, 49–51 pathophysiology, 48–49
vs. pediatric sinusitis, 47–61 Allergens, allergic rhinitis and, 104 Allergic diathesis, pediatric patients
with, 79 Allergic rhinitis, 99
asthma and, 57
in children, effects of, 100 clinical presentation, 79–80 food hypersensitivity, 79 pathophysiology of, 78 sinusitis and, 79
Allergy
pediatric sinusitis and, 19 rhinosinusitis, 141, 146 symptoms, 78
Amoxicillin, 149 Amoxicillin-clavulanate, 149 Anatomic abnormalities
adenoid size, 219–220
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[Anatomic abnormalities] rhinosinusitis, 147
Anterior ethmoid cavity, 207 Antibiotics, for rhinosinusitis, 149 Antihistamines, for acute rhinosinusitis,
108, 157 Antimicrobials
for acute rhinosinusitis, 151 for chronic rhinosinusitis, 155
Antral lavage, 59 Apert’s syndrome, 13 Asthma, 81–83
clinical manifestations, 81 pathophysiological mechanisms, 82 pediatric sinusitis, 19
sinus disease and, 35 sinusitis and, 81–82
Atopy, 80
Bronchiectaisis and Kartagener’s
syndrome, 92
Caldwell-Luc procedure, 59 Cathotomy, 230
Cavernous sinus thrombosis, and sinusitis, 71
Cerebral spinal fluid leak, sphenoid, 228 Chondrocranium, fetal anatomy of , 3 Chronic rhinosinusitis (CRS), 142
adults, diagnosis of, 55, 144 antimicrobial management of, 155 bacteriologic studies of children with,
150 causes of, 50
Cilia, role in sinusitis, 166 Ciliary dyskinesia, 35 Ciliary dyskinesias, 18 Ciliary motility disorders, in
rhinosinusitis, 148
Cleft palate, and sinus disease, 36 Common variable immune deficiency,
117–118
Computed tomography, for pediatric rhinosinusitis, 40
Concha bullosa, 24
Conchal sphenoid sinus, 11 Conjunctivitis, 116, 146 Corticosteroids, acute sinusitis and, 107 Cranipharyngioma, 197
Credentialing, of a sinus center, 253 Cyanotic heart disease, 35
Cystic fibrosis
anatomical abnormalities, 133 anesthesia, 133
antibacterial nasal sprays, 130 clinical manifestations, 84, 127–129 diagnosis, 129
dornase alfa, 130 epidemiology, 124 genetics, 124
hematological abnormalities, 133 IGS, 193
lung transplantation, 134 macrolides, 130
medical management, 129 nasal polypectomy, 86 nasal polyposis, 84, 126
pathophysiology, 83–84, 125–127 pediatric, 85
propofol, 134 rhinosinusitis and, 20 rhinosinusitis, 148 saline sprays, 129 sevoflurane, 134
sinusitis and, 19–20, 34, 83–86, 123–136 steroids, 129
surgical management of sinusitis, 131 survival trend, 124
systematic effects of, 127–129
Decongestants, 157
Dehiscences of Zuckerkandhl, 66 Dennie-Morgan lines, 80
Dornase alfa, in cystic fibrosis, 130 Dyskineisa, primary ciliary, 22
Endoscopic sinus surgery. See ESS. Endoscopy
in diagnosis of, sinusitis, 53 pediatric, 163–181
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Enteroviral infections, 116–117 Enzyme-linked immunosorbent assays
(ELISAs), 80
Eosinophils, in acute rhinosinusitis, 78, 81, 103, 170
Epidural abscess, as complications of sinusitis, 73–74
ESS (endoscopic sinus surgery) anatomical reference point, 202 anterior ethmoid cavity, 207, 208 bony crest of the antrostomy, 206 complications, 201
frontal sinusotomy, 212, 214 inferior ethmoidectomy, 208–209 inferior turbinate, 205 intranasal exposure, 204
meatal antrostomy, 206 medial floor of the orbit, 206 ostium seeker, 213
posterior choanal structures, 204, 205 posterior ethmoidectomy, 210, 210 sagittal dissection, 208
sinonasal disease, 201–204, 203–204 sphenoid sinus, 211
sphenoid sinusotomy, 211, 212 surgical technique, 203 triangular zone of safe entry, 209
Ethmoid opacification photo, 70 Ethmoid sinus
developmental anatomy of, 4–6 surgery for, 60
Fexofenadine, 158
Flunisolide, 106 Foramen cecum, 31 Frontal sinus
developmental anatomy of, 11–13 surgery for, 61
Frontal sinusotomy, 212, 214 Fungal ball with fungal mucin, 60
Gastroesophageal reflux disease clinical presentation, 87–88 pathophysiology, 86–87 pharmacologic therapy, 88–89
[Gastroesophageal reflux disease] rhinosinusitis and, 23
sinus disease and, 36, 86
Haller cells, 24 concha bullosa, 16
Haemophilus influenzae type B, 165 HIV, sinus disease, 37
Humidification, for acute rhinosinusitis, 156
Humoral immunity deficiencies, 148 rhinosinusitis, 148
Hyperplastic rhinosinusitis, 103
IgC subclass deficiencies, 119 IGS (image guided surgery)
craniopharyngioma (photo), 197 cystic fibrosis, 193
diseases that abut important structures, 192 electromagnetic systems, 190
electromagnetic vs. optical systems, 191
limitations of, 196 nasopharyngeal angiofibroma, 198
neurofibroma of sphenoid sinus, 194 optical systems, 189
pan-sinusitis, 194
patient registration for, 190 pediatric otolaryngology and, 191 periorbital and intraconal abscesses,
195
registration techniques, summary of, 191
revision sinus cases, 192
sinonasal or skull-base tumors, 193 system components, 188 technology, 188
tracking systems, 188 tracking systems, 189 tumor, 196
Image-guided pediatric sinus surgery, 187–198. See PESS. See also ESS.
Image-guided surgery. See IGS. See also PESS.
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Immune deficiency disorders major primary, 115
pediatric sinusitis and, 113–121 screening for, 119–121
Immune dysfunction
clinical presentation, 89–90 laboratory analyses, 89–90 pathophysiology, 88–89 sinusitis and, 88–89
Immunodeficiency, and sinus disease, 37 Immunoglobulin deficiency, and sinus
disease, 36
Immunologic defects, rhinosinusitis and, 21–22
Immunologic testing, children with recurrent infections, 120
Inferior ethmoidectomy, 208–209 Inferior turbinate, ESS and, 205 Informed consent, sinus center, 251, 252 Insta Trak (GE Medical), 189 Intracerebral abscess, complication of
sinusitis, 72
Intracranial complications of sinusitis, 71–72
Intraorbital injury, sphenoid, 229
Juvenile nasalpharyngeal angiofibroma, 195, 226
Kartagener disease, 35, 91
Klinefelter syndrome, 13
LandmarX , (Medtronic), 189 Lateral nasal wall, developmental
anatomy 3–5
Left nasal cavity, anatomy of, 9 Loratadine, 259
Macillary sinus hypoplasia Macrolides, cystic fibrosis, 130 Magnetic resonance imaging, pediatric
rhinosinusitis, 40 Maxillary sinus
Index
[Maxillary sinus] aspirate, 169
developmental anatomy of, 6–10 irrigation of, 59
measurements at, 7
Meatal antrostomy, in ESS, 206 Medicolegal issues, in the sinus center,
251
Meningitis, as complications of sinusitis, 74–75
Microdebrider, 175, 228
Mucocele, as complication of sinusitis, 67
Mucociliary dysfunction, 145, 166 Mucolytic agents, in acute rhinosinusitis,
157 Mucoperichondiral graft, 228
Mucopurulent rhinorrhea, 84–87, 168 Mucormycosis, sinus disease, 37 Mycobacterium infection, sinus disease,
37
Nasal edema, allergic rhinitis and, 103 Nasal polyp(s), 5, 203–204
cystic fibrosis, 84
Nasal polypectomy, in cystic fibrosis, 86 Nasal polyposis, 20–21, 124, 126
in cystic fibrosis, 126
Nasal saline irrigations, for acute rhinosinusitis, 156
Nasal steroids, for acute rhinosinusitis, 158
Nasolacrimal duct stenosis, 201 Nasopharyngeal angiofibroma, 198 Neurofibroma of sphenoid sinus, 194 Nose, embryology of, 1–3
Occupational Safety and Health Administration (OSHA), 254
Ondontogenic sinusitis, 54 Onodi cells, 16, 225–226, 232 Optic nerve injury, sphenoid, 229
Orbital cellulitis, as complications of sinusitis, 68
Osteomeatal obstruction, 145
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Osteomyelitis, as complications of sinusitis, 67–68
Ostia, obstruction of, 17, 165 Ostiomeatal complex (OMC), 166
in infants, 30 obstruction, 77 Ostium seeker, 213
Otitis media
clinical presentation, 93 microbiology, 93 pathophysiology, 92–93 sinusitis and, 92
Pan-sinusitis, 194
Paradoxical middle turbinates, 24 Paranasal sinuses
drainage of, 16 function, of, 17 operations for, 58
Pediatric allergy, sinusitis and, 99–108 Pediatric endoscopic sinus surgery. See
PESS. See also ESS. Pediatric rhinosinusitis
allergy and, 19 asthma and, 19
computed tomography, 40 definition of, 164
diagnostic workup for, 29–41 laboratory investigations, 39 magnetic resonance imaging, 40 pathophysiology and etiology of, 15–
25
physical examination, 38 radiographic evaluation, 39, 40 ultrasound, 41
Pediatric sinusitis comorbidities, 77–93 complications of, 65–75 extracranial complications, 66 intracranial complications, 66
tonsils and adenoids in, 217–221 PESS
complications of, 180 indication (possible), 176 indications (absolute), 175 instrumentation, 175
[PESS ]
intraoperative nasal examination, 177 limited approach, 178
outcomes and pitfalls, 179 postoperative follow-up, 179 preoperative preparations, 175 procedure, 176–177 technique, 175
Physical examination, pediatric rhinosinusitis, 38
Polypectomy, 241
Posterior chonal structures, ESS, 205 Posterior ethmoid sinus, 210 Postseptal inflammation, as
complication of sinusitis, 69–70 Presellar sphenoid sinus, 11
Preseptal cellulitis, as complication of sinusitis, 68–69
Primary ciliary dsyskinesia clinical presentation, 90–91 pathophysiology, 90–91 rhinosinusitis and, 22 sinusitis and, 90–91
Primary immune deficiencies associated with sinusitis, 116–120
Primary immunodeficiency (PID), pediatric sinusitis and, 113 Propofol, cystic fibrosis and, 134
Radioactive allergosorbent test (RAST), 80
and atopy, 80
Radiology
in diagnosis of sinusitis, 53 in diagnosis of pediatric
rhinosinusitis, 40 Registration, definition of, 190 Retrobulbar hematoma, 229
sphenoid, 230 Rhinitis
classification of, 57 treatment plan for, 58
Rhinosinsusitis
allergic rhinitis, clinical association with, 105–106
allergy and, 141, 146
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[Rhinosinsusitis] amoxicillin, 149
amoxicillin-clavulanate, 149 anatomic abnormalities, 147 antibiotics, 149 antihistamine, 108
antimicrobial management of, 151– 154
categories of, 167
ciliary motility disorders, 148 clinical presentation, 143 cystic fibrosis and, 20, 148 definition of, 15, 142–143 diagnosis of, 144, 167
environmental factors and, 24, 148– 149
functional endoscopic sinus surgery (FESS), 19
gastroesophageal reflux disease, 23 humoral immunity deficiencies, 148 immunologic defects, 21–22 incidence of, 18
medical treatment, 141–159 microbiology of, 150–151 pathophysiology of, 102, 145 predisposing factors, 141 primary ciliary dyskinesia, 22 vs. rhinitis, 15
surgical management, in children, 173 treatment, 106
upper respiratory infection (URI), 141, 145–146
upper respiratory infections
Sagittal dissection, 208
SAHP (Sinus and Allergy Health Partnerships) treatment guidelines, for ABRS, 153
Saline sprays, for cystic fibrosis, 129 Second-look endoscopy, 179 Selective IgA deficiency, 118
Sellar sphenoid sinus, 11 Septoplasty, 172, 177
Sevoflurane, for cystic fibrosis, 134 Sinonasal or skull-base tumors, 193 Sinus aspiration, 169
Sinus center
embryology of, 239–242
allergy testing and treatment, 255 ancillary services, 255
coding and billing, 242, 248 account follow-up, 249 appeals, 249
charge entry, 249 claim submission, 249 line item reporting, 248
office-based procedures, 245–246 payment posting, 24
procedure codes and RVUs, 250 reimbursement, 247, 250 surgical sinus procedures, 246 time of service (TOS), 249
credentialing organizations, 253 diagnostic imaging services, 255 functional areas, 237
informed consent, 251 laboratory and pathology, 256 medicolegal issues, 251 occupational safety and health
administration (OSHA), 254 office administration, 256 organizational considerations, 236–
237
reimbursement and insurance issues, 242–244
setting-up, 235–257 telephone triage, 238
Sinus disease asthma and, 35
chief complaint, 32 ciliary dyskinesia, 35 cleft palate, 36
cyanotic heart disease, 35 cystic fibrosis, 34
gastroesophageal reflux disease, 36 history, 32
HIV, 37 immunodeficiency, 37
immunoglobulin deficiency, 36 Kartagener disease, 35 mucomycosis, 37 mycobacterial infection, 37 T-cell dysfunction, 37