Description
Computed tomography (CT) primarily provides information about bony structures but may also be useful in evaluating soft tissue masses. It can help document the extent of facial bone fractures, facial infections, and abscesses, and can aid in diagnosing salivary stones.

Additionally, CT may be useful in characterizing and identifying tumor extent in the face and may be used in the assessment of chronic osteomyelitis.

CT scans can provide more detailed information about the anatomy and abnormalities of the paranasal sinuses than plain films. A CT scan provides greater definition of the sinuses and is more sensitive than plain radiography for detecting sinus pathology, especially within the sphenoid and ethmoid sinuses. CT scan findings can be nonspecific, however, and should not be used routinely in the diagnosis of acute sinusitis. The primary role of CT scans is to aid in the diagnosis and management of recurrent and chronic sinusitis, or to define the anatomy of the sinuses prior to surgery.

Anosmia — Nonstructural causes of anosmia include post viral symptoms, medications (Amitriptyline, Enalapril, Nifedipine, Propranolol, Penicillamine, Sumatriptan, Cisplatin, Trifluoperazine, Propylthiouracil). These should be considered prior to advanced imaging to look for a structural cause. Anosmia and dysgeusia have been reported as common early symptoms in patients with COVID-19, occurring in greater than 80 percent of patients. For isolated anosmia, imaging is typically not needed once the diagnosis of COVID has been made given the high association. As such, COVID testing should be done prior to imaging (Geyer, 2008; Lechien, 2020; Saniasiaya, 2020).

Suspected Osteonecrosis of the Jaw — CT can characterize the extension of the lesions and in detecting cortical involvement. MRI should be reserved for those patients who have soft tissue extension of the disease (Phal, 2007).

OVERVIEW:
Don’t order sinus computed tomography (CT) or indiscriminately prescribe antibiotics for uncomplicated acute rhinosinusitis (AAAAI, 2012). Viral infections cause the majority of acute rhinosinusitis and only 0.5 percent to 2 percent progress to bacterial infections. Most acute rhinosinusitis resolves without treatment in two weeks. Uncomplicated acute rhinosinusitis is generally diagnosed clinically and does not require a sinus CT scan or other imaging. Antibiotics are not recommended for patients with uncomplicated acute rhinosinusitis who have mild illness and assurance of follow-up. If a decision is made to treat, amoxicillin should be first-line antibiotic treatment for most acute rhinosinusitis.

CT instead of MRI — MRI allows better differentiation of soft tissue structures within the sinuses. It is used occasionally in cases of suspected tumors or fungal sinusitis. Otherwise, MRI has no advantages over CT scanning in the evaluation of sinusitis. Disadvantages of MRI include high false-positive findings, poor bony imaging, and higher cost. MRI scans take considerably longer to accomplish than CT scans and may be difficult to obtain in patients who are claustrophobic.

Policy 
A single authorization for CPT codes 70486, 70487, 70488 or 76380 includes imaging of the entire maxillofacial area, including face and sinuses. Multiple authorizations are not required.

INDICATIONS FOR SINUS & MAXILLOFACIAL CT

Rhinosinusitis^1-5

• Clinical suspicion of fungal infection^6,7
• Clinical suspicion of complications,⁸ such as
  • Preseptal, orbital, or intracranial infection9
  • Osteomyelitis
  • Cavernous sinus thrombosis
• Acute ( < 4 weeks) or subacute (4 – 12 weeks) sinusitis (viral or bacterial)
  • Not responding to medical management including 2 or more courses of antibiotics at least 5 days each course
• Note: Imaging may be indicated in those predisposed to complications, including diabetes, immune-compromised state, or a history of facial trauma or surgery.
• Recurrent acute rhinosinusitis with 4 or more annual episodes without persistent symptoms in between and is a possible surgical candidate
• Chronic recurrent sinusitis ( > 12 weeks) not responding to medical management*, is a possible surgical candidate, and with at least two of the following:
  • Mucopurulent discharge
  • Nasal obstruction and congestion
  • Facial pain, pressure, and fullness
  • Decreased or absent sense of smell
• *Note: Medical management for chronic sinusitis includes nasal saline irrigation and/or topical intranasal steroids. In chronic sinusitis, repeat imaging is not necessary unless clinical signs or symptoms have changed. 
• Allergic Rhinitis — Sinus imaging usually not indicated unless there are signs of complicated infection, signs of neoplasm, or persistence of symptoms/chronic rhinosinusitis despite treatment (including antihistamines) and is a possible surgical candidate¹⁰
• If suspected as a cause of poorly controlled asthma (endoscopic sinus surgery improves outcomes)¹¹
• To evaluate in the setting of unilateral nasal polyps or obstruction (to evaluate for a potential neoplasm)³

Pediatrics Rhinosinusitis^12,13

• Persistent or recurrent sinusitis not responding to treatment (primarily antibiotics, treatment may require a change of antibiotics)
• Suspicion of orbital or central nervous system involvement (e.g., swollen eye, proptosis, altered consciousness, seizures, nerve deficit)
• Clinical suspicion of a fungal infection (more common in immunocompromised children)

Deviated nasal septum, polyp, or other structural abnormality seen on imaging or direct visualization

• Causing significant airway obstruction AND
• Imaging is needed to plan surgery or determine if surgery is appropriate^14,15

Suspected sinonasal mass based on exam, nasal endoscopy, or prior imaging with contraindication to MRI or if bony involvement suspected^3,16,17

Refractory Asthma — These patients benefit from medical treatment and surgery together.^11,18,19

Anosmia or Dysosmia noted on objective testing, is persistent, of unknown origin and MRI cannot be performed^16,17,20,21

Suspected infection

• Osteomyelitis (after X-rays and MRI cannot be performed)²²
• Abscess based on clinical signs and symptoms of infection

Face mass^16,17,23

• Present on physical exam and remains non-diagnostic after X-ray or ultrasound is completed; OR
• Known or highly suspected head and neck cancer on examination¹⁶; OR
• Failed 2 weeks of treatment for suspected infectious adenopathy²⁴

Facial trauma^25-30

• Severe facial trauma
• Suspected facial bone fracture with indeterminate X-ray
• For further evaluation of a known fracture for treatment or surgical planning
• CSF (cerebrospinal fluid) rhinorrhea when looking to characterize a bony defect

Note: For CSF otorrhea should be a Temporal Bone CT; for intermittent leaks and complex cases, consider CT/MRI/Nuclear Cisternography. CSF fluid should always be confirmed with laboratory testing (Beta-2 transferrin assay).

Salivary gland

• Sialadenitis (infection and inflammation of the salivary glands) with indeterminate ultrasound, bilateral symptoms or concern for abscess³¹
• Suspected or known salivary gland stones^32-34

Granulomatosis with polyangiitis (Wegener’s granulomatosis) disease³⁵

Suspected Osteonecrosis of the Jaw³⁶

• Possible etiologies: Bisphosphonate treatment, dental procedures, Denosumab, radiation treatment

Lesion seen on X-ray or other study requiring further characterization (primary or secondary bone tumor, metabolic disorder)³⁷

Trigeminal neuralgia/neuropathy if MRI is contraindicated or cannot be performed (for evaluation of the extracranial nerve course)

• If atypical features (i.e., bilateral, hearing loss, dizziness/vertigo, visual changes, sensory loss, numbness, pain > 2 minutes, pain outside trigeminal nerve distribution, progression)^6,38

Pre-operative/procedural evaluation

• Pre-operative evaluation for a planned surgery or procedure

Post-operative/procedural evaluation

• When imaging, physical, or laboratory findings indicate surgical or procedural complications

COMBINATION OF STUDIES WITH SINUS & MAXILLOFACIAL CT

Sinus CT/Chest CT

• Granulomatosis with polyangiitis (Wegener’s granulomatosis) disease (GPA)³⁹

References  

1. Abdel Razek AAK, Mukherji S. Imaging of sialadenitis. Neuroradiol J. 2017;30(3):205-215. doi:10.1177/1971400916682752
2. Abuabara A. Cerebrospinal fluid rhinorrhoea: diagnosis and management. Med Oral Patol Oral Cir Bucal. 2007;12(5):E397-400.
3. Allis TJ, Leopold DA. Smell and taste disorders. Facial Plast Surg Clin North Am. 2012 Feb; 20(1):93-111.
4. American Academy of Allergy, Asthma & Immunology (AAAAI). Choosing Wisely® - Five Things Physicians and Patients Should Question. http://www.choosingwisely.org/clinician-lists/american-academy-allergy-asthma-immunology-uncomplicated-acute-rhinosinusitis/. Published 2012.
5. American College of Radiology (ACR). ACR Appropriateness Criteria® Cranial Neuropathy. 2017.
6. https://acsearch.acr.org/docs/69509/Narrative.
7. American College of Radiology (ACR). ACR Appropriateness Criteria® Head Trauma. 2015.
8. American College of Radiology (ACR). ACR Appropriateness Criteria® - Major Blunt Trauma, Variant 3. 2019.
9. Andreu-Arasa VC, Chapman MN, et al. Craniofacial Manifestations of Systemic Disorders: CT and MRI Imaging Findings and Imaging Approach. Radiographics. 2018; 38(3).
10. Borges A, Casselman J. Imaging the trigeminal nerve. Eur J Radiol. 2010;74(2):323-340. doi:10.1016/j.ejrad.2010.02.006
11. Brook I, Brusch JL. Chronic Sinusitis Questions & Answers. Medscape. 2019 Jul. https://emedicine.medscape.com/article/232791-questions-and-answers
12. Chiarella SE, Grammer LC. Immune deficiency in chronic rhinosinusitis: Screening and treatment. Expert Rev Clin Immunol. 2017 Feb; 13(2):117-23. Epub 2016 Aug 18.
13. Dankbaar JW, van Bemmel AJ, Pameijer FA. Imaging findings of the orbital and intracranial complications of acute bacterial rhinosinusitis. Insights Imaging. 2015; 6(5):509-518.
14. De Lucas EZ, Martinez JF, Ribate DR, et al. Analysis of the findings on paranasal sinuses and chest computed tomography in patients with severe asthma. Euro Respiratory J. 2018; 52: PA677.
15. Decker JR, Meen EK, Kern RC, Chandra RK. Cost effectiveness of magnetic resonance imaging in the workup of the dysosmia patient. International Forum of Allergy & Rhinology. 2013;3(1):56-61. doi:10.1002/alr.21066
16. Echo A, Troy JS, Hollier LH. Frontal sinus fractures. Semin Plast Surg. 2010; 24(4):375-382. http://doi.org/10.1055/s-0030-1269766. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3324222/.
17. Gadodia A, Bhalla AS, Sharma R, et al. Bilateral parotid swelling: A radiological review. Dentomaxillofac Radiol. October 2011; 40(7):403-414. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3528147/.
18. Geyer M, Nilssen E. Evidence-based management of a patient with anosmia. Clin Otolaryngol. 2008; 33(5).
19. Haynes J, Arnold KR, Aguirre-Oskins C, Chandra S. Evaluation of neck masses in adults. Am Fam Physician. 2015;91(10):698-706.
20. Jang A-S. The role of rhinosinusitis in severe asthma. Korean J Intern Med. 2013 Nov; 28(6):646-51.
21. Kalia V, Kalra G, et al. CT Scan as an essential tool in diagnosis of non-radiopaque sialoliths.
22. J Maxillofac Oral Surg. 2015 Mar; 14(Suppl 1):240-4.
23. Kaplan A. Canadian guidelines for chronic rhinosinusitis: Clinical summary. Can Fam Physician. 2013; 59(12):1275-1281. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3860922/.
24. Kastner J, Simmen D, Netuka D, et al. Orbital and intracranial complications of acute and chronic rhinosinusitis. 2014. In: Chang C, Incaudo G, Gershwin M. (eds) Diseases of the Sinuses. Springer, New York, NY.
25. Kirsch CFE, Bykowski J, Aulino JM, et al. ACR Appropriateness Criteria® Sinonasal Disease. J Am Coll Radiol. 2017;14(11S):S550-S559. doi:10.1016/j.jacr.2017.08.041
26. Koeller KK. Radiologic features of sinonasal tumors. Head and Neck Pathol. 2016;10(1):1-12. doi:10.1007/s12105-016-0686-9
27. Lechien JR, Chiesa-Estomba CM, De Siati DR, et al. Olfactory and gustatory dysfunctions as a clinical presentation of mild-to-moderate forms of the coronavirus disease (COVID-19): a multicenter European study. Eur Arch Otorhinolaryngol. 2020;277(8):2251-2261. doi:10.1007/s00405-020-05965-1
28. Lohrmann C, Uhl M, Warnatz K, Kotter E, Ghanem N, Langer M. Sinonasal computed tomography in patients with Wegener’s granulomatosis. J Comput Assist Tomogr. 2006;30(1):122-125. doi:10.1097/01.rct.0000191134.67674.c6
29. Mantur M, Łukaszewicz-Zając M, Mroczko B, et al. Cerebrospinal fluid leakage—Reliable diagnostic methods. Clinica Chimica Acta. 2011;412(11-12):837-840. doi:10.1016/j.cca.2011.02.017
30. Oh JW, Kim SH, Whang K. Traumatic cerebrospinal fluid leak: Diagnosis and management. Korean J Neurotrauma. 2017; 13(2):63-67.
31. Pakalniskis MG, Berg AD, Policeni BA, et al. The many faces of granulomatosis with polyangiitis: A review of the head and neck imaging manifestations. Am J Roentgenol. 2015; 205:W619-W629.
32. Phal PM, Myall RW, Assael LA, et al. Weissman JL. Imaging findings of bisphosphonate-associated osteonecrosis of the jaws. Am J Neuroradiol. 2007; 28:1139–45.
33. Pincus DJ, Armstrong MB, Thaller SR. Osteomyelitis of the Craniofacial Skeleton. Semin Plast Surg. 2009; 23(2):73-79. http://doi.org/10.1055/s-0029-1214159. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2884909/.
34. Policeni B, Corey AS, Burns J, et al. American College of Radiology (ACR) Appropriateness Criteria. Expert Panel on Neurologic Imaging: Cranial neuropathy. https://acsearch.acr.org/docs/69509/Narrative/. Published 2017.
35. Poorey VK, Gupta N. Endoscopic and computed tomographic evaluation of influence of nasal septal deviation on lateral wall of nose and its relation to sinus diseases. Indian J Otolaryngol Head Neck Surg. 2014 Sep; 66(3):330-335.
36. Popovic KS, Kocar M. Imaging findings in bisphosphonate-induced osteonecrosis of the jaws. Radiol Oncol. 2010; 44(4):215–219.
37. Ragab S, Scadding GK. Treatment of chronic rhinosinusitis and its effects on asthma. Eur Respir J. 2006 Jul; 28(1):68-74.
38. Raju NS, Ishwar P, Banerjee R. Role of multislice computed tomography and three-dimensional rendering in the evaluation of maxillofacial injuries. J Oral Maxillofac Radiol. 2017; 5:67-73.
39. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. American Academy of Otolaryngology-Head and Neck Surgery. Clinical Practice Guideline (update): Adult sinusitis. Otolaryngol Head Neck Surg. 2015; 152(2 Suppl):S1-39.
40. Sahay S, Gera K, Bhargava SK, et al. Occurrence and impact of sinusitis in patients with asthma
41. and/or allergic rhinitis. J Asthma. 2016; 53(6):635-643. doi: 10.3109/02770903.2015.1091005.
42. Saniasiaya J, Islam MA, Abdullah B. Prevalence of olfactory dysfunction in coronavirus disease 2019 (COVID-19): a meta-analysis of 27,492 patients. Laryngoscope. 2021;131(4):865-878. doi:10.1002/lary.29286
43. Sedaghat AR, Kieff DA, Bergmark RW, et al. Radiographic evaluation of nasal septal deviation from computed tomography correlates poorly with physical exam findings. Int Forum Allergy Rhinol. 2015 Mar; 5(3):258-62.
44. Setzen G, Ferguson BJ, Han JK, et al. Clinical Consensus Statement: Appropriate Use of Computed Tomography for Paranasal Sinus Disease. Otolaryngol Head Neck Surg. 2012 Nov; 147(5):808-16. Epub 2012 Oct 10.
45. Silveira MLC, Anselmo-Lima WT, Faria FM, et al. Impact of early detection of acute invasive fungal rhinosinusitis in immunocompromised patients. BMC Infect Dis. 2019; 19:310.
46. Tekes A, Palasis S, Durand DJ, et al. ACR Appropriateness Criteria® Sinusitis–Child. https://acsearch.acr.org/docs/69442/Narrative/. Revised 2018.
47. Terraz S, Poletti PA, et al. How reliable is sonography in the assessment of sialolithiasis? Am J Roentgenol. 2013; 201(1):W104-W109.
48. Varshney H, Varshney J, Biswas S. Importance of CT scan of paranasal sinuses in the evaluation of the anatomical findings in patients suffering from sinonasal polyposis. Indian J Otolaryngol Head Neck Surg. 2016 Jun; 68(2): 167–172. Published online 2015 Feb 4. doi: 10.1007/s12070-015-0827-6
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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 non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

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