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Clinical Indicators: Acoustic Neuroma Vestibular Schwannoma Surgery

Clinical Indicators: Acoustic Neuroma Vestibular Schwannoma Surgery
Approach ProcedureCPTRBRVS Global Days
Infratemporal post-auricular approach to middle cranial fossa6159190
Transtemporal approach to posterior cranial fossa6159590
Transcochlear approach to posterior cranial fossa6159690
Transpetrosal approach to posterior cranial fossa6159890
Craniectomy for cerebellopontine angle tumor
6152090
Craniectomy, transtemporal for excision of cerebellopontine angle tumor6152690
Combined with middle/posterior fossa craniotomy/Craniectomy6153090
Definitive ProcedureCPTRBRVS Global Days
Resection of neoplasm, petrous apex, intradural, including dural repair6160690
Resection of neoplasm, posterior cranial fossa, intradural, including repair6161690
Microdissection, intracranial6171290
Stereotactic radiosurgery6179390
Decompression internal auditory canal6996090
Removal of tumor, temporal bone middle fossa approach6997090
Repair ProcedureCPTRBRVS Global Days
Secondary repair of dura for CSF leak, posterior fossa, by free tissue graft6161890
Secondary repair of dura for CSF leak, by local or regional flap or myocutaneous flap6161990
Decompression facial nerve, intratemporal; lateral to geniculate ganglion6972090
Total facial nerve decompression and/or repair (may include graft)6995590
Abdominal fat graft2092690
Fascia lata graft; by stripper2092090
Fascia lata graft; by incision and area exposure, complex or sheet
2092290
Intraoperative Nerve Monitoring Procedure ProcedureCPTRBRVS Global Days
Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive92585
Continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (List separately in addition to code for primary procedure)
95940*
Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby) or for monitoring
of more than one case while in the operating room, per hour (List separately in addition to code for primary procedure)
95941*
Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes (list in addition to
primary procedure)
G0453*
Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs95925
*CPT 92540 and 92541 are “add-on” codes, formerly reported with CPT 95920, which has been deleted and replaced with these 2 new codes. In the 2013 final Medicare Physician Fee Schedule, however, The Centers for Medicare and Medicaid Services (CMS) elected not to accept the CPT Editorial Panel’s addition of CPT +95941, and instead, created a G code to report monitoring which occurs outside the operating room. Providers should therefore, report G0453. The American Medical Association’s Current Procedural Terminology (CPT®) does not limit CPT codes to any particular specialty. However, the CPT® introductory language and AMA coding guidance is clear that in order to bill these codes (+95940, +95941, or G0453) the service must be performed by a monitoring professional who is SOLELY DEDICATED to performing the intraoperative neurophysiologic monitoring and is available to intervene at all times during the service as necessary. The monitoring professional may not provide any other clinical activities during the same period of time. For more, access our CPT for ENT coding guidance article on the Academy’s website.
  1. History
    1. Unilateral Auditory complaints
      • hearing loss
      • fullness
      • distorted sound perception
    2. Unilateral Tinnitus
    3. Disequilibrium
      • unsteadiness
      • dizziness
      • imbalance
      • vertigo (rare)
    4. Headache (rare)
    5. Unilateral Fifth and seventh cranial nerve symptoms (unusual)
    6. Unilateral seventh cranial nerve symptoms (rare)
      • facial pain
      • facial tingling, numbness
      • tics
      • weakness
    7. Family history of neurofibromatosis type II
    8. Diplopia (rare)
    9. Dysarthria, dysphasia, aspiration, hoarseness (rare)
  2. Physical Examination
    1. Complete otolaryngology head and neck examination
    2. Cranial nerve examination, in particular:
      • tuning fork lateralization
      • nystagmus
      • facial hypesthesia
      • ear canal hypesthesia
      • corneal reflex
      • facial nerve function
      • extraocular movements
      • papilledema
    3. Cerebellar examination
      • Romberg
      • gait
      • tandem gait
  3. Preoperative Tests
    1. Imaging (one is required demonstrating tumor before surgery is planned)
      • MRI with and/or without gadolinium contrast enhancement
        • Use of gadolinium allows the smallest of tumors to be identified. Unless a patient is unable to tolerate gadolinium, the MRI should be done with gadolinium.
      • Any patient undergoing surgery for removal of an Acoustic Neuroma should have the tumor documented by MRI as long as it is possible.
      • Most patients with significant asymmetry in hearing (asymmetric sensorineural hearing loss) require an MRI scan to exclude an Acoustic Neuroma. •
      • CT scan, contrast-enhanced
        • Some patients are unable to get an MRI (such as a patient with a pacemaker not compatible with MRI) and in those patients a CT scan with contrast will show the tumor if the tumor is larger.
        • Very small tumors are unable to be imaged even with CT and contrast.
        • In some cases, a CT scan is done for anatomic information prior to surgery, to evaluate the size and shape of the mastoid, the aeration of the mastoid, etc. In such cases, a CT scan without contrast may be done in addition to the MRI scan.
    2. Audiologic
      • Audiogram (pure-tone, speech discrimination)
      • Acoustic Reflex Testing (ART)
      • Auditory Brainstem Response (ABR)
    3. Vestibular
      • ENG (electronystagmography) or VNG (video-electronystagmography)
      • VEMP (vestibular evoked myogenic potentials) (based on the physician’s discretion)
    4. Facial Nerve
      • EEMG (evoked electromyography – only indicated in the case of complete facial paralysis)

Postoperative Observations and Interventions

  1. Neurological and/or mental status changes suggestive of cerebral edema.
  2. Cerebrospinal fluid leak—pressure dressings, bed rest, elevate head-of-bed, place lumbar drainage catheter (monitor output). These are often managed conservatively, but may require reoperation for closure.
  3. Hematoma (cerebellopontine angle, epidural)—drainage, pressure dressings, neurological checks. Can often be observed if patient is stable on repeat neurological checks and hematoma is not expanding on imaging studies; may require operative
  4. Headache, nuchal rigidity, or fever—suggestive of meningitis.
  5. Tuning fork test to evaluate hearing.
  6. Facial paresis—protect cornea.
  7. Monitor intake and output to detect inappropriate antidiuretic hormone syndrome.
  8. Bleeding at wound sites—reinforce dressings.


Outcome Review

  1. One Week
    1. dizziness and unsteadiness
    2. hearing level—audiogram when able
    3. facial function—House-Brackmann Grade
    4. dwound healing
    5. donor site, if appropriate
    6. be alert for possibility of delayed CSF leak
  2. Beyond One Month
    1. headache
    2. hearing level—audiometric documentation
    3. cfacial function—House-Brackmann Grade
    4. MRI with gadolinium contrast to check for residual tumor
    5. Follow up MRI with gadolinium contrast after performing subtotal resection, as indicated
    6. MRI fat suppression image sequence when a fat graft has been used at the time of surgery
    7. CT with contrast to check for residual tumor or surveillance when MRI is contraindicated

 

Associated ICD-10-CM Diagnostic Codes (Representative, but not all inclusive codes)

  • D33.3 Benign neoplasm of cranial nerves
  • Q85.02 Neurofibromatosis, type 2
  • H55.00 Unspecified nystagmus (may want to consider also):
    • H55.01 Congenital nystagmus
    • H55.02 Latent nystagmus
    • H55.03 Visual deprivation nystagmus
    • H55.04 Dissociated nystagmus
    • H55.09 Other forms nystagmus
  • H81.90 Unspecified disorder of vestibular function, unspecified ear
  • H81.91 Unspecified disorder of vestibular function, right ear
  • H81.92 Unspecified disorder of vestibular function, left ear
  • H81.93 Unspecified disorder of vestibular function, bilateral
  • H81.391 Other peripheral vertigo, right ear
  • H81.392 Other peripheral vertigo, left ear
  • H81.392 Other peripheral vertigo, bilateral ear
  • H81.392 Other peripheral vertigo, unspecified ear
  • H93.11 Tinnitus, right ear
  • H93.12 Tinnitus, left ear
  • H93.13 Tinnitus, bilateral ear
  • H93.19 Tinnitus, unspecified ear
  • H93.221 Diplacusis, right ear
  • H93.222 Diplacusis, left ear
  • H93.223 Diplacusis, bilateral
  • H93.229 Diplacusis, unspecified ear
  • H93.231 Hyperacusis, right ear
  • H93.232 Hyperacusis, left ear
  • H93.233 Hyperacusis, bilateral
  • H93.239 Hyperacusis, unspecified ear
  • H93.291 Other abnormal auditory perception, right ear
  • H93.292 Other abnormal auditory perception, left ear
  • H93.293 Other abnormal auditory perception, bilateral
  • H93.299 Other abnormal auditory perception, unspecified ear
  • H93.211 Auditory recruitment, right ear
  • H93.212 Auditory recruitment, left ear
  • H93.213 Auditory recruitment, bilateral
  • H93.219 Auditory recruitment, unspecified ear
  • H92.01 Otalgia, right ear
  • H92.02 Otalgia, left ear
  • H92.03 Otalgia, bilateral
  • H92.09 Otalgia, unspecified ear
  • H95.5 Unspecified sensorineural hearing loss
  • G50.0 Trigeminal neuralgia
  • G51.0 Bell’s palsy
  • H53.2 Diplopia
  • R42 Dizziness and giddiness
  • R27.9 Unspecified lack of coordination
  • R27.8 Other lack of coordination
  • R51 Headache
  • R49.0 Dysphonia
  • R47.02 Dysphasia
  • R13.10 Dysphagia, unspecified 

Additional Information

  • Co-Surgeon – Neurosurgeon if using team approach
  • Assistant Surgeon – Varies by procedure and hospital (whether residents are available, etc.)

Patient Information

Vestibular schwannoma, also called acoustic neuroma, is a benign tumor involving the hearing and balance nerve at the base of the brain. It occurs in is about 1 per 100,000 people per year. Acoustic neuromas do not spread throughout the body, but can cause significant disability, including hearing loss, dizziness, facial numbness, and, rarely in this era, even death, by local growth into nearby important brain structures.

Early symptoms of an acoustic neuroma include hearing loss, distorted sound perception, tinnitus, dizziness, and disequilibrium. Later symptoms may include headache, unsteadiness, facial pain, tingling, or numbness, facial tics or weakness, double vision, and difficulty in swallowing or talking.

There are a number of tests that can be utilized to diagnose acoustic neuromas, the utility of which should be based upon a complete history and physical by an experienced physician. The definitive diagnostic test is an MRI with gadolinium enhancement. However, this test should only be obtained following appropriate clinical evaluation, and hearing, and balance testing where indicated.

Management options include observation with serial MRIs, partial or total surgical removal, and radiation therapy. For patients with the syndrome neurofibromatosis type 2 who have severe disease burden – vestibular schwannomas affecting both ears and other intracranial or spinal tumors – medical treatments would include molecular therapy as well as other therapies such as Avastin. May be available to reduce the size of the tumors, delay tumor growth, and preserve or restore hearing. The treatment is tailored to the individual, and depends upon the patient’s symptoms, hearing level, health status, age, and the growth rate of the tumor, and the wishes of the patient.

Surgery for acoustic neuromas requiring intervention will involve one of three basic approaches: (1) through the temple, (2) through the ear, and (3) through the back of the head. The approach used depends upon the size and location of the tumor, the status of the preoperative hearing, and the experience and preference of the surgical team. The optimal treatment goal is removal of the tumor while maintaining existing hearing and facial function. In many cases, hearing in the affected ear cannot be preserved. Since acoustic neuromas are usually slow growing, partial tumor removal may be elected by the surgeon to reduce surgical time and preserve facial function. For patients with a growing tumor who are not surgical candidates for whatever reason, targeted radiation is a good alternative.

Possible complications that may require further medical and/or surgical rehabilitation include: hearing loss, dizziness, facial weakness or paralysis, prolonged headaches, fluid leak from around the brain, and tumor recurrence. Many of these complications can occur after either microsurgery or radiation therapy.

Important Disclaimer Notice

Clinical indicators for otolaryngology serve as a checklist for practitioners and a quality care review tool for clinical departments. The American Academy of Otolaryngology—Head and Neck Surgery, Inc. and Foundation (AAO-HNS/F) Clinical Indicators are intended as suggestions, not rules, and should be modified by users when deemed medically necessary. In no sense do they represent a standard of care.

The applicability of an indicator for a procedure must be determined by the responsible physician in light of all the circumstances presented by the individual patient.

Adherence to these clinical indicators will not ensure successful treatment in every situation.

The AAO-HNS/F emphasizes that these clinical indicators should not be deemed inclusive of all proper treatment decisions or methods of care, nor exclusive of other treatment decisions or methods of care reasonably directed to obtaining the same results. The AAO-HNS/F is not responsible for treatment decisions or care provided by individual physicians.

CPT five-digit codes, nomenclature and other data are copyright 2014 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein.

Approved May 2014

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