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Ears, nose and throat

Please see below for the policies relating to head, neck, ears, nose and throat. To view the policy, patient leaflet and additional information, please click on the relevant heading.


  • Cosmetic surgery - pinnaplasty
  • Earlobe surgery

     What is ear lobe repair surgery?

    Earlobes are often split by heavy earrings gradually enlarging a piercing over many years. On other occasions, when an earring is forcefully pulled the earlobe can split.

    Repair is usually performed under local anaesthetic; is simple and re-piercing is normally possible within a few weeks.

    Restricted procedure:

    Ear lobe repair surgery for adults, i.e. those over the age of 16 years will not be routinely commissioned.

    Ear lobe repair surgery may be considered for funding if the patient meets the following criteria:

    • A birth deformity
    • Instances where there has been a traumatic injury to the earlobe.

    The clinician in charge of the care of the patient’s specific condition, usually a hospital doctor, can assist the application, if there is exceptional clinical need for the treatment to be funded. The patient’s clinician must evidence clinical exceptionality and must be supported by the patient’s local NHS commissioning organisation. See separate leaflet for more information on Individual Funding Requests (IFRs).

    Advice and further guidance:

    • For more information search for ‘cosmetic procedures’ at www.nhs.uk
    • Choosing Wisely UK is part of a global initiative aimed at improving conversations between patients and their doctors and nurses.
  • Ear pinning surgery

     What is ear pinning surgery?

    Ear pinning surgery (pinnaplasty) is an operation to reshape the ears and make them less prominent. This can be done from the age of approximately six years depending on the thickness of the cartilage.

    This operation can be performed under local anaesthetic for adult patients, but is better under general anaesthetic for children. The surgery is performed as a day case. Ear pinning surgery is not normally funded by the patient’s local NHS commissioning organisation.

    Not normally funded treatment or procedure:

    Ear pinning surgery to improve appearance will not usually be carried out on the NHS for cosmetic reasons. However, there may be rare exceptional circumstances.

    The clinician in charge of the care of the patient’s specific condition, usually a hospital doctor, can assist the application, if there is exceptional clinical need for the treatment to be funded. The patient’s clinician must evidence clinical exceptionality and must be supported by the patient’s local NHS commissioning organisation. See separate leaflet for more information on Individual Funding Requests (IFRs).

    Advice and further guidance:

    Ear pinning surgery generally involves:

    • Making one small cut (incision) behind the ear to expose the ear cartilage
    • Removing small pieces of cartilage if necessary
    • Scoring and stitching the remaining structure into the desired shape and position.
    • For more information search for ‘ear correction surgery’ at www.nhs.uk
    • Choosing Wisely UK is part of a global initiative aimed at improving conversations between patients and their doctors and nurses.
  • Earwax

     What is earwax?

    Earwax is a waxy material produced by glands inside the ear. It helps to keep the ears healthy and clean; it stops the skin that lines our ear canal from drying and cracking and protects the ear by trapping dirt and repelling water so it helps to prevent infections.

    Most of the time our ear canals clean themselves; as we talk, chew and move our jaws the earwax and skin cells slowly move from the eardrum to the ear opening where it usually dries, and falls out. Earwax doesn't usually cause problems, but if too much earwax is produced it can cause a blockage which can be painful or could cause hearing loss. The most common symptoms caused by blocked earwax are:

    • Conductive hearing loss: which is when there is a problem conducting sound waves anywhere along the route through the outer ear, tympanic membrane (eardrum), or middle ear (ossicles)
    • Earache
    • Tinnitus: the patient may hear sounds e.g. ringing or buzzing in one or both ears, or in the head. They may come and go, or the patient might hear the noise all the time
    • Vertigo: vertigo feels like the patient or everything around the patient is spinning –enough to affect balance. It's more than just feeling dizzy.

    Treatment:

    Earwax should be removed if it is totally blocking the ear canal AND one of the following:

    • The person is symptomatic (with conductive hearing loss, earache, tinnitus or vertigo)
    • The tympanic membrane is obscured by wax but needs to be viewed to establish a diagnosis
    • The person wears a hearing aid and an impression needs to be taken for a mould, or wax is causing the hearing-aid to whistle.

    Ear irrigation using an electronic device to remove earwax in adults, CANNOT be used if the person has had or got:

    • An eardrum perforation
    • An ear infection
    • Previous ear surgery.

    Micro suction (earwax removal is undertaken using a microscope and a medical suction device) or other methods of earwax removal (such as, manual removal using a probe) for adults in primary or community care only, might be used if:

    • The practitioner (such as a community nurse or audiologist) has training and expertise in using these methods to remove earwax, AND
    • The correct equipment is available.

    Patient eligibility criteria

    Ear irrigation as a management option for ear wax should be avoided whenever possible. However, it may be carried out in primary care by a specially qualified clinician (in patients over the age of six months), who have the level of understanding required to enable the procedure to be carried out safely if:

    Patient must have used ear drops for at least 3-5 days before irrigation is undertaken AND the patient must have at least ONE of the following symptoms which has persisted despite ear drops AND IF earwax is totally blocking the ear canal:

    • Hearing loss
    • Earache
    • Tinnitus
    • Vertigo
    • If the tympanic membrane is obscured by wax but needs to be viewed to establish a diagnosis
    • The person wears a hearing aid and an impression needs to be taken for a mould, or wax is causing the hearing aid to whistle.

    This means (for patients who DO NOT meet the above criteria) the CCG will ONLY fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG.

    Advice and guidance

    • For more information, search for ‘earwax build up’ at www.nhs.uk 
    • Choosing Wisely UK is part of a global initiative aimed at improving conversations between patients and their doctors and nurses.
  • Face lift or brow lift

    What is a face or brow lift?

    A face or brow lift (rhytidectomy), is a type of cosmetic surgery procedure used to give a more youthful facial appearance. There are multiple surgical techniques. It usually involves the removal of excess facial skin, with or without the tightening of underlying issues, and the redraping of the skin on the patient’s face and neck.

    Face or brow lifts are effectively combined with eyelid surgery (blepharoplasty) and other facial procedures. Face or brow lifts are not routinely funded by the patient's local NHS commissioning organisation for cosmetic reasons and have restricted criteria for non-cosmetic/other reasons.

    Patient eligibility criteria:

    The patient's local NHS commissioning organisation will only fund this treatment if the patient meets one of the following criteria:

    • Recognised diagnosis of facial abnormalities, present from birth (congenital)
    • A weakness of the facial muscles, mainly resulting from temporary or permanent damage to the facial nerve (facial palsy)
    • As part of the treatment of specific conditions affecting the facial skin such as rare connective tissue disorder (cutis laxa), a genetic connective tissue disorder (pseudoxanthoma elasticum, PXE and Grönblad-Strandberg syndrome) and a genetic disorder that causes tumours to form on nerve tissue (neurofibromatosis)
    • To correct the consequences of trauma
    • For significant deformity following corrective surgery. However, funding will not be approved to improve previous cosmetic surgery.

    The clinician in charge of the care of the patient’s specific condition, usually a hospital doctor, can assist the application, if there is exceptional clinical need for the treatment to be funded. The patient’s clinician must evidence clinical exceptionality and must be supported by the patient’s local NHS commissioning organisation. See separate leaflet for more information on Individual Funding Requests (IFRs).

    Advice and further guidance:

    • For more information search for ‘cosmetic surgery’ at www.nhs.uk
    • Choosing Wisely UK is part of a global initiative aimed at improving conversations between patients and their doctors and nurses.
  • Grommets

    What are grommets?

    Grommets are tiny plastic tubes, inserted into the eardrum to relieve glue ear. Glue ear is a common childhood condition where the middle ear becomes filled with fluid. Most cases of glue ear do not require treatment as the condition will improve by itself, usually within three months.

    Treatment is usually only recommended when symptoms last longer than three months and the hearing loss is thought to be significant enough to interfere with a child's speech and language development. For children with recurrent severe middle ear infections, tiny grommet tubes may be inserted into the eardrum to help drain fluid. These tubes are called grommets.

    Grommets are inserted under general anaesthetic, which means the child will be asleep and won't feel any pain. The procedure usually only takes about 15 minutes and the child should be able to go home the same day. A grommet will help keep the eardrum open for several months.

    As the eardrum starts to heal, the grommet will slowly be pushed out of the eardrum and will eventually fall out. This process happens naturally and should not be painful. Most grommets will fall out within six to 12 months of being inserted. Some children will need another procedure to replace the grommets if the child is still experiencing problems.

    Patient eligibility criteria:

    The patient's local NHS commissioning organisation will only fund surgical treatment for children from age three to 12 years if the patient meets the following criteria:

    • Children with on-going glue ear over a period of three months, with a hearing level in the better ear of 25–30 dBHL or worse averaged at 0.5, 1, 2 and 4 kHz; or
    • Children with on-going glue ear over a period of three months with a hearing loss less than 25–30 dBHL, where the hearing loss is impacting on a child's development.

    Once a decision has been taken to offer surgical intervention for glue ear in children, the insertion of grommets is recommended. Children who have undergone insertion of grommets for glue ear should be followed up and their hearing should be re-assessed.

    The clinician in charge of the care of the patient’s specific condition, usually a hospital doctor, can assist the application, if there is exceptional clinical need for the treatment to be funded. The patient’s clinician must evidence clinical exceptionality and must be supported by the patient’s local NHS commissioning organisation. See separate leaflet for more information on Individual Funding Requests (IFRs).

    Advice and further guidance:

    For more information read the 'glue ear decision aid' or search for ‘glue ear’ at www.nhs.uk

    • Choosing Wisely UK is part of a global initiative aimed at improving conversations between patients and their doctors and nurses.
  • Snoring

    What is snoring?

    Snoring is caused by the tongue, mouth, throat, or airways in the nose vibrating as the patient breathes. It happens because these parts of the body relax and narrow when the patient is asleep. 

    A patient is more likely to snore if:

    • The patient is overweight
    • The patient smokes
    • The patient drinks too much alcohol
    • The patient sleeps on his/her back
    • Simple lifestyle changes can help stop or reduce snoring.

    Do:

    • Try to lose weight if you’re overweight
    • Sleep on your side – try taping a tennis ball to the back of your sleepwear, or buy a special pillow or bed wedge to help keep you on your side
    • Consider asking your partner to use ear plugs if your snoring affects their sleep.

    Don’t:

    • Smoke
    • Drink too much alcohol
    • Take sleeping pills – these can sometimes cause snoring.

    Not normally funded treatment or procedure:

    There are five procedures which can be done to treat the symptoms of snoring. However, all of the procedures are not routinely commissioned due to poor success rates and the lack of long-term data about their effectiveness and safety.

    1. Surgery performed under general anaesthetic to remove tissues such as the tonsils and glands in the roof of the mouth (adenoids) to widen the airway. This procedureis known as an uvulopalatopharyngoplasty
    2. Laser surgery performed under general anaesthetic to remove parts of the soft tissue in the throat and the roof of the mouth, which can be repeated to widen the airway. This procedure is known as a laser-assisted uvulopalatoplasty
    3. Using an electric current through a metal probe which conducts heat to remove through soft tissue in the throat under general anaesthetic. This procedure is known as a platal stiffening operation
    4. A hollow needle with an implant to pierce the soft tissue at the back of the throat into the muscle layer. This procedure is repeated 2-3 times, as the implant will stiffen the tissue at the back of the throat. This procedure is known as palate implants
    5. Radio-frequency ablation (somnoplasty): an electrode device is put into the mouth,with the patient under general anaesthetic, and a needle tip makes very shallow holes in the underlying muscle at the back of the throat. The radio-frequency energy is delivered at each hole to stiffen the tissue. This procedure is known as radio-frequency ablation (somnoplasty).

    All of the procedures are not routinely commissioned due to poor success rates and the lack of long-term data about their effectiveness. This means that the CCG will ONLY fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and this is supported by the CCG. See separate leaflet for more information on Individual Funding Requests (IFRs).

    Advice and further guidance

    • For more information, search for ‘snoring’ at www.nhs.uk
    • Choosing Wisely UK is part of a global initiative aimed at improving conversations between patients and their doctors and nurses.
  • Swelling of the nose (rhinophyma)

    What is swelling of the nose?

    Rhinophyma is a swelling of the nose. If the condition progresses, the nose becomes increasingly redder, swollen at the end and gains a bumpy surface which changes the noses shape.

    The swelling is because there is formation of scar-like tissue, and the glands that produce oil on the skin (sebaceous glands) get bigger. Much more rarely, swellings can arise on other parts of the face such as the ears and chin.

    The condition is mainly seen in those who have a rash that can affect the cheeks, forehead and nose (rosacea). Nose swelling and redness usually only develops in rosacea which has been active for many years.

    There is no cure for rhinophyma, although some non-surgical treatments are available for rosacea to help control it. These may include laser and intense pulsed light (IPL) treatment, oral medications and topical gels.

    Not normally funded treatment or procedure:

    Surgical treatment of swelling of the nose (rhinophyma) is not normally funded by the NHS. This is because this treatment is considered to be a cosmetic procedure.

    The clinician in charge of the care of the patient’s specific condition, usually a hospital doctor, can assist the application, if there is exceptional clinical need for the treatment to be funded. The patient’s clinician must evidence clinical exceptionality and must be supported by the patient’s local NHS commissioning organisation.

    See separate leaflet for more information on Individual Funding Requests (IFRs). 

    Advice and further guidance:

    • For more information search for ‘rosacea’ at www.nhs.uk
    • Choosing Wisely UK is part of a global initiative aimed at improving conversations between patients and their doctors and nurses.
  • Nose correction or reconstruction

    Treatment policy for patients covered by NHS Birmingham and Solihull CCG

    What is nose correction surgery?

    Nose correction or reconstruction surgery ‘nose job’, is a plastic surgery procedure for correcting and reconstructing the form, restoring the functions, and enhancing the appearance of the nose.

    This could be due to nasal trauma, a birth defect, breathing issues or a failed primary nose job.

    Patient eligibility criteria:

    Nose correction surgery or a nose job is not routinely funded by the NHS for purposes of appearance only. This would be considered only a cosmetic procedure. The patient’s local NHS commissioning organisation will only fund the treatment if the patient has medical problems caused by obstruction of the nasal airway which is defined as a medical problem that continually impairs sleep and/or breathing, or corrective nasal surgery is required because of a complex condition from birth, for example, cleft lip and palate.

    The clinician in charge of the care of the patient’s specific condition, usually a hospital doctor, can assist the application, if there is exceptional clinical need for the treatment to be funded. The patient’s clinician must evidence clinical exceptionality and must be supported by the patient’s local NHS commissioning organisation. See separate leaflet for more information on Individual Funding Requests (IFRs).

    Advice and further guidance:

    Nose reshaping is usually carried out under general anaesthetic. The surgeon may do any of the following:

    • Make the nose smaller (nose reduction), by removing some of the cartilage and bone
    • Make the nose larger (nose augmentation), by taking cartilage from the ears and bone from the hips, elbow or skull, and using this to build up the nose (known as a graft)
    • Change the nose’s shape (including the nostrils), by breaking the nose bone and rear ranging the cartilage
    • Change the angle between the nose and top lip.
    • For more information search ‘nose reshaping’ at www.nhs.uk
    • Choosing Wisely UK is part of a global initiative aimed at improving conversations between patients and their doctors and nurses.
  • Tonsillectomy

    What is a tonsillectomy?

    Surgery to remove the tonsils is known as a tonsillectomy. For children with mild sore throats, watchful waiting is recommended rather than removing the tonsils by surgery. A tonsillectomy is only considered for a recurrent sore throat if certain criteria are met.

    Patient eligibility criteria:

    A clinically significant episode of tonsillitis, should be documented on your medical records and usually includes at least one of the following:

    • Temperature of at least 38.3˚C
    • Tender tonsils, thyroid gland and drainage system for the internal structures of the throat (anterior cervical lymph nodes)
    • A grey or white coating (exudate) on the tonsils
    • Severe infection (positive culture of group A beta haemolytic streptococci)
    • Tonsillar enlargement giving rise to symptoms of upper airways obstruction.

    The patient's local commissioning organisation will fund a tonsillectomy if the patient meets the following criteria:

    • Seven or more documented clinically significant, adequately treated episodes in the preceding year
    • Five or more documented episodes in each of the preceding two years
    • Three or more documented episodes in each of the preceding three years; and
    • If symptoms are disabling and prevent normal functioning.

    Note: Walk- in centre or Out of Hours documented episodes that are communicated in writing to GP practices are included in the episode count. Children or adults with sleep disordered breathing (apnoea) confirmed with sleep studies can undergo a tonsillectomy procedure in line with recognised management of these conditions.

    When in doubt, implementing a six-month period of clinical watchful waiting is recommended. Watchful waiting involves carefully monitoring the patient’s symptoms to see whether they improve or get worse.

    The clinician in charge of the care of the patient’s specific condition, usually a hospital doctor, can assist the application, if there is exceptional clinical need for the treatment to be funded. The patient’s clinician must evidence clinical exceptionality and must be supported by the patient’s local NHS commissioning organisation. See separate leaflet for more information on Individual Funding Requests (IFRs).

    Advice and further guidance:

    About tonsillectomies: The operation can be carried out in a number of ways, as described below:

    • Cold steel surgery – this is the most common method, where a surgical blade is used to cut the tonsils out
    • A probe used to destroy the tissue around the tonsils and to remove the tonsils (diathermy) – it the same time, the heat seals the blood vessels to stop any bleeding
    • A low temperature probe 60˚C used to destroy the tissue around the tonsils and to remove the tonsils (coblation or cold ablation) – this method works in a similar way to diathermy, but uses a lower temperature (60˚C). It's considered less painful than diathermy
    • Lasers – high-energy laser beams are used to cut away the tonsils and seal the underlying blood vessels shut
    • Ultrasound – high-energy ultrasound waves are used in a similar way to lasers.

    Each of these techniques is relatively similar in terms of safety, results and recovery, so the type of surgery used will depend on the expertise and training of the surgeon. The patient will usually be able to leave hospital on the same day as the patient has the surgery, or the day after.

    • For more information search for ‘tonsillitis’ at www.nhs.uk
    • Choosing Wisely UK is part of a global initiative aimed at improving conversations between patients and their doctors and nurses.
  • Surgical intervention for chronic rhinosinusitis

    This guidance is produced by The Academy of Medical Royal Colleges (the Academy) as part of the Evidence-based interventions programme. It is based on recommendations from the Expert Advisory Committee and the National Institute for Health and Care Excellence (NICE).

    All guidance has been reviewed by the Birmingham and Solihull & Sandwell and West Birmingham CCGs’ Treatment Policy Clinical Development Groups (TPCDG). This was reviewed to establish if existing CCG policies were already in place which covered the proposed intervention / treatment in question.

    Where there was no current CCG policy for the area in question, the NHSEI policy has been implemented in full into the CCG’s Clinical Treatment Policy portfolio.

    Where there was a current CCG policy for the area in question, then the existing CCG policy has been reviewed by the TPCDG considering the NHSEI EBI policy rationale and evidence base.  A decision has then been taken by TPCDG based on the review as to the most appropriate policy for implementation by taking into account the healthcare needs of our local population.

    The aims of the Evidence Based Interventions programme is to ensure the quality and safety of patient care by, freeing up valuable resources such as time so that more effective interventions can be carried out, reducing harm or the risk of harm to patients, helping clinicians maintain professional practice, creating headroom for innovation, and maximising value and avoiding waste.

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