Is a CT scan of the sinuses medically necessary for a patient with postnasal drip, gagging, and choking?

CT Scan of the Sinuses is NOT Medically Necessary for This Patient

Based on current clinical practice guidelines, a CT scan of the sinuses (CPT 70486) is not medically indicated for this 62-year-old patient presenting with postnasal drip, gagging, and choking without cardinal symptoms of chronic rhinosinusitis. 1, 2

Why CT Imaging is Not Indicated

Absence of Cardinal CRS Symptoms

• The patient lacks the defining symptoms of chronic rhinosinusitis: no nasal congestion, no facial pain/pressure, no purulent nasal drainage, and reports an "excellent sense of smell" 3, 2
• The American Academy of Otolaryngology-Head and Neck Surgery explicitly states that CT scan is not medically necessary for patients with chronic halitosis and postnasal drip without cardinal symptoms of chronic rhinosinusitis 1
• The physician's own endoscopic examination documented "normal examination without turbinate hypertrophy, masses, septal deformity or synechiae; the superior, inferior, and middle meati are clear; no masses or ulcers; the sphenoethmoidal recess is clear and normal; no drainage" 1, 2

Guidelines Require Direct Visualization First

• The American College of Radiology mandates that direct visualization via anterior rhinoscopy or nasal endoscopy must be performed before any imaging is considered 1
• CT scan would only be appropriate if endoscopy reveals mucosal inflammation, purulent drainage, polyps, or other objective findings suggestive of chronic rhinosinusitis 1
• In this case, the endoscopy was completely normal, making CT imaging unnecessary 1, 2

High Risk of Misleading Findings

Incidental Abnormalities in Asymptomatic Patients

• Studies demonstrate high rates (18-82%) of incidental sinus abnormalities in asymptomatic individuals undergoing head CTs 3, 2
• In asymptomatic children, 50% had sinus CT scans consistent with sinusitis, and haziness (a radiological sign for sinusitis) was present in 52-75% 3
• CT findings correlate poorly with symptoms in chronic sinusitis, and approximately 30% of asymptomatic adults show mucosal changes on CT 4, 5
• Ordering sinus CT for non-specific symptoms without clear sinus-related complaints leads to unnecessary radiation exposure and potentially misleading incidental findings 2

Alternative Etiology Already Identified

Reflux as Primary Cause

• The patient's history explicitly states he was "treated for reflux before with medication and that did not help," but the physician notes "we may not try that again" 1, 2
• The physician's plan appropriately considers swallow study and esophagram if CT is normal, suggesting awareness that this may be an aerodigestive issue rather than sinus disease 1
• Medical management, including optimization of GERD treatment and trial of allergy nasal sprays, should be exhausted before considering advanced imaging 1
• The patient reports allergies as a child, yet there is no documentation of allergy testing or trial of allergy medications, which should be addressed first 2

Appropriate Next Steps

What Should Be Done Instead

• Optimize GERD treatment: The patient's previous reflux treatment was inadequate; this should be revisited with appropriate acid suppression therapy 1
• Trial of allergy nasal sprays: Allergic rhinitis has not been adequately addressed as a potential cause of postnasal drip 2
• Consider swallow study/esophagram: Given the gagging and choking symptoms with normal nasal endoscopy, these studies are more appropriate for evaluating dysphagia and aspiration risk 1
• Laryngoscopy: To evaluate for laryngopharyngeal reflux, which commonly causes throat clearing and postnasal drip sensation 1

When CT Would Be Indicated

Specific Criteria for Imaging

• CT becomes medically necessary only if nasal endoscopy reveals objective mucosal inflammation, purulent drainage, or polyps 1
• CT is indicated if the patient develops cardinal symptoms of chronic rhinosinusitis (nasal congestion, facial pressure/pain, purulent drainage) that persist despite appropriate medical therapy 1, 6
• CT with contrast or MRI is indicated if orbital or intracranial complications are suspected 3
• The European Position Paper on Rhinosinusitis (EPOS 2020) recommends CT after failure of appropriate medical treatment in patients with persistent symptoms and abnormal endoscopy 3, 6

Critical Pitfall to Avoid

The physician documented "no abnormalities are present to suggest an etiology for his severe choking, throat clearing and postnasal drip" on endoscopy, which actually argues AGAINST sinus CT rather than for it. 1, 2 Normal endoscopy in the absence of cardinal sinus symptoms means the problem lies elsewhere—likely in the laryngopharynx or esophagus—making sinus imaging both unnecessary and unlikely to change management.