Endoscopic Sinus Surgery is Medically Indicated for This Patient
Yes, endoscopic maxillary antrostomy (CPT 31267) and endoscopic total ethmoidectomy (CPT 31255) are medically indicated for this patient who has failed appropriate medical therapy and demonstrates persistent chronic ethmoid sinusitis on CT imaging. 1
Rationale for Surgical Intervention
This patient meets the established criteria for functional endoscopic sinus surgery (FESS):
- Objective CT evidence of disease: Mild bilateral ethmoid chronic sinusitis documented on imaging 1
- Failed appropriate medical therapy: The patient has completed trials of antibiotics, systemic steroids, intranasal corticosteroids (Flonase), antihistamine nasal spray (Azelastine), and saline irrigation—representing comprehensive first-line medical management 1
- Persistent symptoms: Ongoing headaches, head/eye pressure, and purulent drainage (green/yellow mucus) for weeks post-septoplasty indicate active disease 2
- Post-surgical complications: Symptoms began 1 week after initial surgery, suggesting either incomplete resolution of underlying disease or development of new pathology in the ethmoid sinuses 2
Why Ethmoid Surgery is Critical
The ethmoid sinuses are the primary source of maxillary sinus disease in most cases:
- Ethmoid disease drives maxillary pathology: The frontal and maxillary sinuses are "subordinate cavities" where disease typically originates in the anterior ethmoid region and spreads secondarily 3, 4
- Ostiomeatal complex obstruction: All cases of chronic maxillary sinusitis are associated with anatomical variations or pathological abnormalities in the ostiomeatal area (anterior ethmoid complex) 4
- Incomplete initial surgery: The patient's prior septoplasty and turbinate reduction did not address the ethmoid disease, which is now the likely source of persistent symptoms 2, 5
Specific Surgical Approach Justified
Total Ethmoidectomy (CPT 31255)
- Addresses the primary disease source: Since CT shows bilateral ethmoid chronic sinusitis, complete ethmoidectomy removes diseased ethmoid cells and prevents recurrence from residual disease 2, 3
- Prevents secondary maxillary involvement: By treating the ethmoid disease, you prevent continued drainage and infection of the maxillary sinus 3, 4
Maxillary Antrostomy (CPT 31267)
- Restores natural drainage: Creates adequate ventilation and drainage through the natural ostium rather than relying on inferior meatal fenestration 3
- Allows direct visualization: Permits assessment of maxillary sinus mucosa and identification of any retained disease or foreign material 5, 6
- Facilitates postoperative care: A patent antrostomy enables office-based endoscopic management if needed 6
Common Pitfalls to Avoid
Do not perform maxillary antrostomy alone without addressing the ethmoid disease—this is a leading cause of surgical failure, as the underlying ethmoid pathology will continue to cause maxillary sinus problems 5, 4
Ensure complete ethmoidectomy: Incomplete resection of ethmoid cells leads to persistence of infection, mucus impaction, or development of new disease 2
Verify adequate uncinate process removal: If the uncinate is retained, functional drainage from the maxillary sinus remains impaired, and mucus continues to collect in the middle meatus 2
Expected Outcomes
Recent evidence demonstrates that endoscopic sinus surgery resolves chronic sinusitis with ethmoid involvement in nearly all cases when appropriately performed 7. The combination of ethmoidectomy and maxillary antrostomy addresses both the primary disease source (ethmoids) and secondary involvement (maxillary sinus), providing the best chance for long-term resolution 3, 6.
Postoperative Considerations
Continue medical management after surgery, including: