Description:
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.

Policy:
Ultrasound in the evaluation of paranasal sinuses is considered INVESTIGATIONAL.

Policy Guidelines:
There is no specific CPT code for ultrasound of the paranasal sinuses. However, there is a HCPCS code that describes this procedure (S9024).

Benefit Application
BlueCard/National Account Issues
State or federal mandates (e.g., FEP) may dictate that all devices approved by the U.S. Food and Drug Administration (FDA) may not be considered investigational and, thus, these devices may be assessed only on the basis of their medical necessity.

Rationale
The diagnosis and management of disorders of the paranasal sinuses are the typical focus of a general otolaryngologist’s practice. While most cases can be managed empirically, imaging of the sinuses may be required for equivocal or atypical presentations. Imaging options include plain film radiography, computed tomography (CT), magnetic resonance imaging (MRI) or ultrasonography, with CT scans considered the gold standard. Ultrasonography has been proposed as a convenient office-based alternative, with the added advantage of low radiation exposure and a better discriminator between mucosal thickening and fluid retention. However, a review of the English language literature did not identify any published studies that adequately explored the diagnostic capabilities of ultrasonography in comparison to other imaging options. For example, in a 1997 study, Haapaniemi and colleagues performed plain film radiography and ultrasound of the maxillary sinus on a series of 663 unselected school children ages 7 to 14 years old. (1) The plain film radiograph was considered the gold standard, and sinusitis was suggested if marked mucosal thickening or the presence of a fluid level or cyst was present. On ultrasonography, the presence of a back wall echo was considered an abnormal finding, suggesting chronic sinusitis. Discrepancies between the 2 studies occurred in 74 studies; the presence of a back wall echo on ultrasonography predicted positive X-ray finding with a sensitivity of 69 percent, while a negative ultrasonography predicted the absence of chronic sinusitis with a specificity of 98 percent. However, the results of these studies were not correlated with the children’s symptoms, and, considering that the interpretation of plain film X-rays, particularly the evaluation of mucosal thickening, has been controversial, this outcome is important. Other studies have reported the findings of ultrasonography of the paranasal sinuses in either asymptomatic patients (2) or those with known sinusitis (3), two groups that do not mimic its proposed clinical application.

References:

1. Haapaniemi J. Comparison of ultrasound and x-ray maxillary sinus findings in school-aged children. Ear Nose Throat J 1997;76(2):102-6.
2. Savolainen S, Eskelin M, Jousimies-Somer H et al. Radiological findings in the maxillary sinuses of symptomless young men. Acta Otolaryngol Supp 1997; 529:153-7.
3. Vento SI, Ertama LO, Hytonen ML et al. A-mode ultrasound in the diagnosis of chronic polyposis sinusitis. Acta Otolaryngol 1999;119(8):916-20.
4. American Academy of Pediatrics. Clinical practice guideline: management of sinusitis. Pediatrics 2001:108(3):798-808.
5. American Academy of Allergy, Asthma and Immunology. Parameters for the diagnosis and management of sinusitis. Ann Allergy Asthma Immunol 1997;102(6 Pt 2):S107-44.
6. McAlister WH, Parker BR, Kushner DC et al. Sinusitis in the pediatric population. American College of Radiology. ACR Appropriateness Criteria. Radiology 2000;215(suppl):811-8

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

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