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A radical maxillary sinusotomy, also known as an antrostomy, is a surgical procedure that involves creating an opening into the maxillary sinus to facilitate access for treatment. This specific procedure, referred to as the Caldwell-Luc operation, is performed to remove antrochoanal polyps, which are abnormal growths that originate in the maxillary sinus. The procedure begins with an incision made in the oral cavity, specifically over the canine tooth, extending towards the first premolar. This approach allows the surgeon to access the maxillary sinus effectively while minimizing external incisions. The use of electrocautery aids in the dissection through the soft tissue and periosteum, ensuring that the surrounding structures, such as the infraorbital nerve, are preserved. Once the maxillary sinus is accessed through the canine fossa, the opening is enlarged to allow for adequate drainage and removal of any pathological tissue. The procedure is comprehensive, as it not only addresses the polyps but also involves obtaining specimens for culture and sensitivity testing, which is crucial for diagnosing any underlying infections. The irrigation of the maxillary sinus is performed to clear any debris and ensure a clean surgical field. This procedure is particularly indicated for patients experiencing nasal obstruction and related complications due to the presence of antrochoanal polyps, which can lead to further issues such as serous otitis media if left untreated.
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The radical maxillary sinusotomy (Caldwell-Luc procedure) with removal of antrochoanal polyps is indicated for patients presenting with specific symptoms and conditions related to the maxillary sinus. The following are the primary indications for this procedure:
The procedure for a radical maxillary sinusotomy with removal of antrochoanal polyps involves several detailed steps to ensure effective access and treatment:
After the radical maxillary sinusotomy with removal of antrochoanal polyps, patients can expect specific post-procedure care and considerations. It is important to monitor for any signs of complications, such as excessive bleeding or infection. Patients may experience some discomfort and swelling in the area of the incision, which can be managed with prescribed pain relief medications. Follow-up appointments are essential to assess healing and ensure that the sinus is draining properly. Patients are typically advised to avoid strenuous activities and to follow any specific instructions regarding nasal care and hygiene to promote recovery. Additionally, the results of the culture and sensitivity tests will guide any necessary antibiotic therapy to address any identified infections.
| Short Descr | EXPLORE SINUS REMOVE POLYPS | Medium Descr | SINUSOT MAX ANTRT RAD W/RMVL ANTROCH POLYPS | Long Descr | Sinusotomy, maxillary (antrotomy); radical (Caldwell-Luc) with removal of antrochoanal polyps | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 1 - 150% payment adjustment for bilateral procedures applies. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 1 - Statutory payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P5E - Ambulatory procedures - other | MUE | 1 | CCS Clinical Classification | 33 - Other OR therapeutic procedures on nose, mouth and pharynx |
| 50 | Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | GC | This service has been performed in part by a resident under the direction of a teaching physician | GW | Service not related to the hospice patient's terminal condition | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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| 2011-01-01 | Changed | Short description changed. |
| Pre-1990 | Added | Code added. |
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