Grommet insertion
The clinician proposing this intervention is not required to secure prior approval from the Armed Forces Health Commissioning team and can proceed with treatment if the criteria in the relevant policy are met.
A. Children – see evidence based interventions guidance: EBI – Grommets for glue ear in children
B. Adults
NHS England will fund grommets in adults with otitis media with effusion (OME) only in the following circumstances.
All adults must have had an ENT and specialist audiology assessment. Grommet insertion is only funded for adults with disabling conductive hearing loss due to middle ear effusions, who meet the following criteria:
- persistent bilateral otitis media with effusion (OME) documented over a period of 3 months (watchful waiting) with a hearing level in the better ear of 25–30 dBHL or worse averaged at 0.5, 1, 2 and 4 kHz (or equivalent dBA where dBHL not available); [during this time, auto inflation should be offered as part of self-care and purchased ‘over the counter’], plus investigation and treatment of underlying causes has been completed without improvement in hearing; or
- unilateral middle ear effusion where a post-nasal space biopsy is required to exclude an underlying malignancy; or
- recurrent acute otitis media; or
- atrophic tympanic membranes; or
- access to middle ear for transtympanic instillation of medication; or
- investigation of unilateral glue ear in adults
Evidence base
Otitis media with effusion in under 12s: surgery – In cases of otitis media with effusion in adults, grommets are not routinely funded as unlike in children where the outcome of OME is generally good, this is not clear in adults: Otitis media with effusion in under 12s: surgery
Pinnaplasty / otoplasty
The clinician proposing this intervention is required to secure prior approval via Blueteq from the Armed Forces Health Commissioning team.
Ear reshaping is a type of aesthetic surgery used to treat protruding ears. The operation is also known as pinnaplasty or otoplasty. Surgery to reshape the ears involves remodelling the cartilage into a less protruding shape. Pinnaplasty or otoplasty (pinning back the ears) is where the cartilage is remodelled to create the missing folds and position the ear closer to the head.
Pinnaplasty or otoplasty are regarded as procedures of low clinical value and therefore not routinely funded.
NHS England will fund if one of the following sets of criteria are met:
Set A
- age between 5 – 18 years old at the time of referral and procedure; and
- the child has prominent ears; and
- the child is suffering from significant distress, e.g., from bullying. The impact of this distress should be recorded within the application.
or
Set B
- in children and adults when correction of ear prominence is required to better support a hearing aid.
GMC guidance: It is important that it is the child who desires surgical correction; referral should not be made for children who appear indifferent or opposed to the idea of surgery. Parents requesting surgery for their child in order to prevent psychological distress when their child starts school or at some time in the future should be advised to wait until their child specifically requests treatment.
NHS England does not fund:
External ear repair surgery
The Armed Forces Health Commissioning team will not routinely fund external ear surgery such as ‘cauliflower ear’ or holes in their pinna or lobes from ‘stretching’ with devices. This is because surgery or treatments to alter physical appearance alone are not routinely funded.
Evidence base
Septoplasty, rhinoplasty and septorhinoplasty
The clinician proposing this intervention is required to secure prior approval via Blueteq from the Armed Forces Health Commissioning team.
NHS England will fund:
Septoplasty
Septoplasty will be funded only for the following indications:
deviated nasal septum causing one or more of the following functional conditions:
- recurrent epistaxis (nosebleeds) related to the nasal deformity, or
- documented recurrent sinusitis not relieved by appropriate conservative measures including a 3-month trial of intranasal steroids and nasal saline irrigation, or
- continuous nasal airway obstruction due to severe septal deviation which results in nasal breathing difficulty not responding to 3 or more months of documented appropriate conservative measures and with no other cause for the symptoms for example rhinitis, or
- confirmed continuous obstruction of one or both nostrils causing symptoms experienced at all times of the day which significantly affect daily activities (for example severe difficulty in sleeping or during exercise / exertion), and
- the overuse of nasal sprays has been excluded as a cause of the nasal congestion or has been ceased prior to the referral and the nasal congestion persists
Rhinoplasty
Rhinoplasty will be funded only if the patient meets the following criteria:
- after significant nasal trauma, where there is significant distortion of external anatomy after recent trauma. There needs to be a convincing history of trauma within the previous 2 years of sufficient severity to cause the deformity. A humped or bent nose is not by itself sufficient evidence of injury;
Or
- to correct chronic non-septal nasal airway obstruction from vestibular stenosis (collapsed internal valves) 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 airway obstruction is causing continuous obstruction of one or both nostrils causing symptoms experienced at all times of the day which significantly affect daily activities (for example severe difficulty in sleeping or during exercise/exertion)
- obstructive symptoms persist despite conservative management for 3 months or longer, which includes, where appropriate, for example, nasal steroids
- photographs demonstrate an external nasal deformity
- there is significant obstruction of one or both nares, documented usually by outpatient nasal endoscopy. There is an average 50% or greater obstruction of nares (for example, 50% obstruction of both nares, or 75% obstruction of one nare and 25% obstruction of other nare, or 100 % obstruction of one nare), documented by internal inspection of the nose by an ENT surgeon, endoscopy, CT scan or other appropriate imaging modality
Septorhinoplasty
Septorhinoplasty will be funded only when the following criteria are met:
Deviated nasal septum causing one or more of the following functional conditions:
- the procedure is required as an integral part of a septoplasty, and
- recurrent epistaxis (nosebleeds) related to the nasal deformity, or
- documented recurrent sinusitis not relieved by appropriate conservative measures including a 3-month trial of intranasal steroids and nasal saline irrigation, or
- continuous nasal airway obstruction due to severe septal deviation which results in nasal breathing difficulty not responding to 3 or more months of documented appropriate conservative measures and with no other cause for the symptoms e.g rhinitis, or
- confirmed continuous obstruction of one or both nostrils causing symptoms experienced at all times of the day which significantly affect daily activities (for example severe difficulty in sleeping or during exercise/ exertion), or
- the overuse of nasal sprays has been excluded as a cause of the nasal congestion or has been ceased prior to the referral and the nasal congestion persists
And
- there is 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; and
- the prior approval application must be submitted by an ENT surgeon and include details of the reasons for this request with an assessment detailing the expected outcome of the difference in functional improvement compared to septoplasty alone (this must be related to functional outcome and not appearance alone)
Nasal polyps
Nasal polyps surgical intervention will be funded if the patient meets the following criteria:
- for patients who fail to improve after a trial of maximal medical treatment for a period of at least 6 months, and
- this is fully documented within the patient’s clinical records
The following procedures are outside of the scope of this policy:
Cleft lip and palate services include all specialist care delivered by cleft lip and palate centres including outreach when delivered as part of a provider network. This applies to provision for adults and children. Septoplasty or rhinoplasty for indications relating to cleft lip / palate are commissioned by NHS England Specialised Commissioning teams and are therefore outside the scope of this policy: NHS England » Prescribed specialised services manual
Where treatment is sought for conditions where patients require:
- an aesthetic, cosmetic or reconstructive procedure to restore normal or near normal function or appearance as a direct consequence of trauma, burns, destructive surgery, cancer treatment; or
- a recognised congenital malformation
These are funded as part of the relevant pathway of care are therefore excluded from this policy.
Treatment / procedures undertaken as part of an externally funded trial or as part of locally agreed contracts or pathways of care are excluded from this policy – locally agreed pathways take precedent over this policy.
Nasal surgery
Nasal surgery is not routinely funded for the following conditions:
- to stop snoring
- to change the aesthetic appearance of the nose
- where patients are unhappy with the outcome of previous surgeries including immediate post-trauma corrections (whether provided by the NHS or other providers)
- procedures undertaken for patients who require revision of previous nasal surgery will only be undertaken for functional improvement and not for aesthetic appearance
Extracorporeal (open) septoplasty
Extracorporeal septoplasty is not normally funded except for initial correction of an extremely deviated nasal septum that cannot adequately be corrected with an intranasal approach, for patients who meet criteria for septoplasty listed above.
Extracorporeal septoplasty for revision of deviated septum is considered experimental and investigational because its effectiveness for this indication has not been established and should only be funded by research and development budgets as part of a clinical trial.