TNRF2: Ear, nose and throat

Overview

Adenoidectomy is the surgical removal of the adenoid for reasons which include impaired breathing through the nose, chronic infections, or recurrent earaches.

Thresholds and eligibility 

These recommendations apply to children aged 18 or under.

Adjuvant adenoidectomy should not be routinely performed in children undergoing grommet insertion for the treatment of otitis media with effusion.

Adjuvant adenoidectomy for the treatment of glue ear should only be offered when one or more of the following clinical criteria are met:

• The child has persistent and / or frequent nasal obstruction which is contributed to by adenoidal hypertrophy (enlargement).
• The child is undergoing surgery for re-insertion of grommets due to recurrence of previously surgically treated otitis media with effusion.
• The child is undergoing grommet surgery for treatment of recurrent acute otitis media.

This guidance only refers to children undergoing adenoidectomy for the treatment of glue ear and should not be applied to other conditions where adenoidectomy should continue to be routinely funded:

• As part of treatment for obstructive sleep apnoea or sleep disordered breathing in children (e.g., as part of adenotonsillectomy).
• As part of the treatment of chronic rhinosinusitis in children.
• For persistent nasal obstruction in children and adults with adenoidal hypertrophy.
• In preparation for speech surgery in conjunction with the cleft surgery team.

Patients should be encouraged to stop smoking prior to treatment, if applicable.

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment.  

However, if the patients does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.

Overview

Bone-anchored hearing devices are implantable devices that stimulate the inner ear through the bone. The tiny device is implanted in the mastoid bone, located behind the ear, on the affected side.

Thresholds and eligibility 

This service and any applications are managed by NHS England.

Resources

Treatments not routinely published policy (TNRF2)

Additional information

This service and any applications are managed by NHS England.

Overview

Bone-anchored hearing devices are implantable devices that stimulate the inner ear through the bone. The tiny device is implanted in the mastoid bone, located behind the ear, on the affected side.

Thresholds and eligibility 

There is insufficient evidence to justify the use of bilateral bone anchored hearing aids (i.e., one on each side).

Resources

Treatments not routinely published policy (TNRF2)

Additional information

There is insufficient evidence to justify the use of bilateral bone anchored hearing aids (i.e., one on each side). 

Overview

A cochlear implant is a small, complex electronic device that can help to provide a sense of sound to a person who is profoundly deaf or severely hard-of-hearing. The implant consists of an external portion that sits behind the ear and a second portion that is surgically placed under the skin.

Thresholds and eligibility 

This service and any applications are managed by NHS England.

Resources

Treatments not routinely published policy (TNRF2)

Additional information

This service and any applications are managed by NHS England.

Overview

Grommets are tiny tubes inserted into the eardrum. They allow air to pass through the eardrum, keeping the air pressure on either side equal. The surgeon makes a tiny hole in the eardrum and inserts the grommet into the hole.

Thresholds and eligibility 

The NHS should only commission this surgery for the treatment of glue ear in children when the criteria set out by the NICE guidelines are met:

• All children must have had a specialist audiology and ENT assessment.
• Persistent bilateral otitis media with effusion over a period of 3 months.
• Hearing level in the better ear of 25-30dbHL or worse averaged at 0.5, 1, 2, & 4kHz.
• Exceptionally, healthcare professionals should consider surgical intervention in children with persistent bilateral OME with a hearing loss less than 25-30dbHL where the impact of the hearing loss on a child’s developmental, social, or educational status is judged to be significant.
• Healthcare professionals should also consider surgical intervention in children who cannot undergo standard assessment of hearing thresholds where there is clinical and tympanographic evidence of persistent glue ear and where the impact of the hearing loss on a child’s developmental, social, or educational status is judged to be significant.
• The guidance is different for children with Down’s Syndrome and Cleft Palate, these children may be offered grommets after a specialist MDT assessment in line with NICE guidance.
• It is also good practice to ensure glue ear has not resolved once a date of surgery has been agreed, with tympanometry as a minimum.

The risks to surgery are generally low, but the most common is persistent ear discharge (10-20%) and this can require treatment with antibiotic eardrops and water precautions.

In rare cases (1-2%) a persistent hole in the eardrum may remain, and if this causes problems with recurrent infection, surgical repair may be required (however this is not normally done until around 8-10 years of age).

Patients should be encouraged to stop smoking prior to treatment, if applicable.

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment.  

However, if the patients does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.

Overview

Ear correction surgery, where the ears are pinned back, is known as pinnaplasty or otoplasty. The cosmetic surgery procedure is used to change the size or shape of the ears, or to pin them back if they stick out.

Thresholds and eligibility 

This procedure is not routinely funded for adults on cosmetic grounds.

Royal College of Surgeons Commissioning Guidance recommends Pinnaplasty for children aged 5-18.

NHS Surrey Heartlands will consider funding for children when:

• The child is aged between 5 and 18 years old.

AND

• The surgeon has defined the deformity to the ear(s) as severe enough to require surgical correction.

AND

• The child has clearly expressed concerns to the clinician which in their opinion or following a psychological assessment, it is considered that this is likely to be remedied through correction of the ear deformity.

Details of the child’s psychosocial concerns must be clearly described in the IFR application.

Note: there is no clinical evidence to suggest that the degree of prominence has a direct link to psychological distress. It is at the clinician’s discretion to treat due to prominence.

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment.  

However, if the patients does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.

Overview

Rhinoplasty, commonly called nose job, is a plastic surgery procedure for altering and reconstructing the nose.

Thresholds and eligibility 

NHS Surrey Heartlands will not routinely fund nasal surgery to correct the following three situations:

1. To stop snoring 
2. Cosmetic appearance of the nose 
3. For patients who are unhappy with the outcome of previous surgeries including immediate post-trauma corrections (whether provided by the NHS or private providers)

Rhinoplasty will be funded if the patient has: 

• Nasal deformity is secondary to congenital cleft lip and/or palate (NB: this should be managed by a specialist cleft team).

OR
 

• Chronic non-septal nasal airway obstruction from vestibular stenosis (collapsed internal valves), which may be due to trauma, disease, or congenital defect, when ALL of the following criteria are met: 
  • Prolonged, persistent obstructed nasal breathing
  • Physical examination confirming moderate to severe vestibular obstruction
  • Airway obstruction will not respond to Septoplasty alone
  • Nasal obstruction is causing significant symptoms (e.g., chronic rhinosinusitis, difficulty breathing)
  • Conservative management for 6 months or more failed to relieve symptoms
  • Patient suffers from severe or extreme obstruction of one or both nares
  • Note: Recommend use of Nasal Obstruction Symptom Evaluation (NOSE) Scale instrument (score 55 or more). 

OR 

• Significant distortion of external anatomy subsequent to recent trauma.
• Note: A humped or bent nose is not by itself sufficient evidence of injury.

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment.  

However, if the patients does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.

Overview

Septorhinoplasty is a deviated septum surgery and a traditional nose job at the same time. It is a type of cosmetic surgery to change the shape, size, and contour of the nose. It also treats a deviated nasal septum at the same time.

Thresholds and eligibility 

NHS Surrey Heartlands will not routinely fund nasal surgery to correct the following three situations:

• To stop snoring 
• Cosmetic appearance of the nose 
• For patients who are unhappy with the outcome of previous surgeries including immediate post-trauma corrections (whether provided by the NHS or private providers)

Septorhinoplasty will be funded if the patient meets the following two criteria: 

• Patient requires the procedure as an integral part of a medically necessary Septoplasty.

AND 

• Patient has gross nasal obstruction on the same side as the septal deviation, so that to correct the nasal obstruction the external skeleton will also need correction. 

Septoplasty will be funded if the patient has:

• Asymptomatic septal deformity that prevents access to other intranasal areas when such access is required to perform medical necessary surgical procedures (e.g., Ethmoidectomy).

OR 

• Patient has recurrent rhino-sinusitis due to a deviated septum not relieved by appropriate medical and antibiotic therapy after at least 6 months of medical therapy.

OR 

• Patient suffers from recurrent epistaxis (nosebleeds) related to a septal deformity.

OR 

• Patient suffers from continuous nasal airway obstruction resulting in nasal breathing difficulty due to obvious and severe septal deviation with no other cause for the patient’s apparent breathlessness (e.g., rhinitis, COPD).

OR 

• Patient requires this procedure with the association of cleft palate repair.

AND (in the case of open Septoplasty)

• Patient has an extremely deviated nasal septum that cannot be corrected adequately with an intranasal Septoplasty. 

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment.  

However, if the patients does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.

Overview

Septoplasty is a surgical procedure to straighten the bone and cartilage dividing the space between your two nostrils (septum).

Thresholds and eligibility 

NHS Surrey Heartlands will not routinely fund nasal surgery to correct the following three situations:

• To stop snoring 
• Cosmetic appearance of the nose 
• For patients who are unhappy with the outcome of previous surgeries including immediate post-trauma corrections (whether provided by the NHS or private providers)

Septorhinoplasty will be funded if the patient meets the following two criteria: 

• Patient requires the procedure as an integral part of a medically necessary Septoplasty.

AND 

• Patient has gross nasal obstruction on the same side as the septal deviation, so that to correct the nasal obstruction the external skeleton will also need correction. 

Septoplasty will be funded if the patient has:

• Asymptomatic septal deformity that prevents access to other intranasal areas when such access is required to perform medical necessary surgical procedures (e.g., Ethmoidectomy).

OR 

• Patient has recurrent rhino-sinusitis due to a deviated septum not relieved by appropriate medical and antibiotic therapy after at least 6 months of medical therapy.

OR 

• Patient suffers from recurrent epistaxis (nosebleeds) related to a septal deformity.

OR 

• Patient suffers from continuous nasal airway obstruction resulting in nasal breathing difficulty due to obvious and severe septal deviation with no other cause for the patient’s apparent breathlessness (e.g., rhinitis, COPD).

OR 

• Patient requires this procedure with the association of cleft palate repair.

AND (in the case of open Septoplasty)

• Patient has an extremely deviated nasal septum that cannot be corrected adequately with an intranasal Septoplasty. 

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment.  

However, if the patients does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.

Overview

Tonsillectomy is surgery to remove the tonsils.

Thresholds and eligibility 

The NHS should only commission this surgery for treatment of recurrent severe episodes of sore throat when the following criteria are met, as set out by the SIGN guidance, and supported by ENT UK commissioning guidance:

• Sore throats are due to acute tonsillitis.

AND

• The episodes are disabling and prevent normal functioning.

AND

• Seven or more, documented, clinically significant, adequately treated sore throats in the preceding year.

OR

• Five or more such episodes in each of the preceding two years.

OR

• Three or more such episodes in each of the preceding three years.

There are a number of medical conditions where episodes of tonsillitis can be damaging to health or tonsillectomy is required as part of the on-going management.

In these instances, tonsillectomy may be considered beneficial at a lower threshold than this guidance after specialist assessment:

• Acute and chronic renal disease resulting from acute bacterial tonsillitis.
• As part of the treatment of severe guttate psoriasis.
• Metabolic disorders where periods of reduced oral intake could be dangerous to health.
• PFAPA (Periodic fever, Apthous stomatitis, Pharyngitis, Cervical adenitis).
• Severe immune deficiency that would make episodes of recurrent tonsillitis dangerous.

Please note this guidance only relates to patients with recurrent tonsillitis.

This guidance should not be applied to other conditions where tonsillectomy should continue to be funded, these include:

• Obstructive Sleep Apnoea/Sleep disordered breathing in Children.
• Suspected Cancer (e.g., asymmetry of tonsils).
• Recurrent Quinsy (abscess next to tonsil).
• Emergency Presentations (e.g., treatment of parapharyngeal abscess).

It is important to note that national randomised control trial comparing surgery versus conservative management for recurrent tonsillitis in adults is underway.

This may warrant review of this guidance in the near future.

Patients should be encouraged to stop smoking prior to treatment, if applicable

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment.  

However, if the patients does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.