Huntington Memorial Hospital Delineation Of Privileges Otolaryngology Privileges Provider Name: Privilege Requested Deferred Approved OTOLARYNGOLOGY PRIVILEGES Criteria - New Applicants: Board Certification or qualified for certification by the American Board of Otolaryngology. Criteria - Current Staff Members Only: Successful completion of an ACGME or AOA approved training program; OR demonstrated acceptable practice in the privileges being requested. Proctoring Requirements: A minimum of four (4) cases, in accordance with the Medical Staff Proctoring Protocol. Current Competence: Evidence of the successful performance, as primary surgeon, of at least four (4) Category 1 procedures every 2 years. GENERAL PRIVILEGES: ___ ___ ___ Admit patients ___ ___ ___ Consultation Only Privileges ___ ___ ___ Surgical Assist ONLY ___ ___ ___ Sedation Analgesia: ___ ___ ___ Criteria: Requires successful completion of the Sedation Assessment Test. Additional criteria effective April 1, 2015:a) Evidence of current ACLS and/or PALS certification from the American Heart Association; AND b) Evidence of completion of an Airway Management Course a) Adult Sedation ___ ___ ___ b) Pediatric Sedation (17 years and under) ___ ___ ___ Local Block Anesthesia ___ ___ ___ Regional Block anesthesia ___ ___ ___ CATEGORY 1 - OTOLARYNGOLOGY PRIVILEGES ___ ___ ___ Includes the management and coordination of care, treatment and services, including: Medical History and Physical examinations; consultations and prescribing medication in accordance with DEA certificate. HEAD AND NECK ___ ___ ___ Lip shave ___ ___ ___ Wedge resection ___ ___ ___ Neck - I & D abscess ___ ___ ___ Excision skin lesions ___ ___ ___ Laryngoscopy ___ ___ ___ Esophagoscopy: ___ ___ ___ a) Diagnostic ___ ___ ___ b) With foreign body removal ___ ___ ___ c) With structure dilation ___ ___ ___ Bronchoscopy - diagnostic ___ ___ ___ Adenoidectomy ___ ___ ___ Tonsillectomy ___ ___ ___ Page 1 Printed on Thursday, December 21, 2017 Huntington Memorial Hospital Delineation Of Privileges Otolaryngology Privileges Provider Name: Privilege Requested Deferred Approved Tracheotomy ___ ___ ___ Submaxillary gland excision ___ ___ ___ Lateral rhinotomy ___ ___ ___ Abbe-Estlander Flap ___ ___ ___ Cervical node biopsy ___ ___ ___ Scalene node biopsy ___ ___ ___ Exploration laryngeal fractures ___ ___ ___ Exploration recurrent laryngeal nerves ___ ___ ___ Arytenoidectomy ___ ___ ___ Thyroidectomy ___ ___ ___ Parathyroidectomy ___ ___ ___ Tongue Base Suspension ___ ___ ___ Genioglossus Advancement ___ ___ ___ Hyoid Myotomy and Suspension ___ ___ ___ Uvulopalatopharyngoplasty ___ ___ ___ Major vessel ligation ___ ___ ___ Branchiogenic cysts ___ ___ ___ Thyroglossal cysts ___ ___ ___ Dermoids ___ ___ ___ Laryngoplasty ___ ___ ___ Tracheoplasty ___ ___ ___ Bronchoscopy - with foreign body removal ___ ___ ___ Bronchoscopy - with stricture dilation ___ ___ ___ Superficial parotidectomy with facial nerve dissection ___ ___ ___ Total parotidectomy with facial nerve dissection ___ ___ ___ Radical parotidectomy with or without nerve graft ___ ___ ___ Partial maxillectomy ___ ___ ___ Total maxillectomy ___ ___ ___ Radical maxillectomy with orbital extenteration ___ ___ ___ Excision nasopharyngeal tumor ___ ___ ___ Partial glossectomy ___ ___ ___ Page 2 Printed on Thursday, December 21, 2017 Huntington Memorial Hospital Delineation Of Privileges Otolaryngology Privileges Provider Name: Privilege Requested Deferred Approved Partial mandibulectomy ___ ___ ___ Composite resection - primary and tumor with RND ___ ___ ___ Radical neck dissection ___ ___ ___ Extended radical neck dissection (transternal mediastinal dissection) ___ ___ ___ Subtotal laryngectomy ___ ___ ___ Thyrotomy (laryngofissure) ___ ___ ___ Supraglottic laryngectomy ___ ___ ___ Hemilaryngectomy ___ ___ ___ Total laryngectomy with neck dissection ___ ___ ___ Cervical esophagectomy with neck dissection ___ ___ ___ Tracheal resection with repair ___ ___ ___ Infratemporal fossa surgery ___ ___ ___ Hypoglossal facial anastomosis ___ ___ ___ Laser Privileges: ___ ___ ___ a) C02 Laser ___ ___ ___ b) KTP Laser ___ ___ ___ c) Argon Laser ___ ___ ___ d) YAG Laser ___ ___ ___ Tracheo-Esophageal Puncture (TEP) ___ ___ ___ Microlaryngoscopy with Vocal Cord Injection ___ ___ ___ Thyroplasty Type 1 ___ ___ ___ Temporal Artery Biopsy ___ ___ ___ Orbital Decompression ___ ___ ___ Endoscopic Repair of Zenker’s Diverticulum ___ ___ ___ Open Repair of Zenker’s Diverticulum ___ ___ ___ OTOLOGY ___ ___ ___ Myringotomy ___ ___ ___ Myringoplasty ___ ___ ___ Tympanoplasty with/without ossicular reconstruction ___ ___ ___ Tympanoplasty with mastoidectomy with/without reconstruction ___ ___ ___ Tympanostomy with PE Tube Placement ___ ___ ___ Page 3 Printed on Thursday, December 21, 2017 Huntington Memorial Hospital Delineation Of Privileges Otolaryngology Privileges Provider Name: Privilege Requested Deferred Approved Mastoidectomy ___ ___ ___ Stapedectomy ___ ___ ___ Stapes mobilization ___ ___ ___ Tympanic neurectomy ___ ___ ___ Labyrinthectomy ___ ___ ___ Excision tumor of ear and mastoid ___ ___ ___ Partial temporal bone resection ___ ___ ___ Radical temporal bone resection ___ ___ ___ Endolymphatic sac operations ___ ___ ___ Bone anchored hearing appliance ___ ___ ___ Ossicular Reconstruction ___ ___ ___ PLASTIC AND RECONSTRUCTION ___ ___ ___ Split thickness skin graft ___ ___ ___ Full thickness skin graft ___ ___ ___ Composite graft ___ ___ ___ Dermal graft ___ ___ ___ Scar revision ___ ___ ___ Reconstruction of external ear ___ ___ ___ Otoplasty ___ ___ ___ Rhinoplasty ___ ___ ___ Septorhinoplasty ___ ___ ___ Rhytidectomy ___ ___ ___ Blepharoplasty ___ ___ ___ Reduction facial fractures: ___ ___ ___ a) Frontal ___ ___ ___ b) Nasal ___ ___ ___ c) Maxilla ___ ___ ___ d) Malar ___ ___ ___ e) Malar with orbital floor ___ ___ ___ f) Orbital blowout ___ ___ ___ g) Mandibular - closed ___ ___ ___ Page 4 Printed on Thursday, December 21, 2017 Huntington Memorial Hospital Delineation Of Privileges Otolaryngology Privileges Provider Name: Privilege Requested Deferred Approved h) Mandibular - open ___ ___ ___ Implants ___ ___ ___ Fascial sling procedures ___ ___ ___ Condylectomy ___ ___ ___ Dacryocystorhinostomy ___ ___ ___ Regional myocutaneous flaps ___ ___ ___ Bone grafts ___ ___ ___ Liposuction ___ ___ ___ Prognathism correction ___ ___ ___ Retrognathism correction ___ ___ ___ NASAL/SINUS ___ ___ ___ Nasal polypectomy ___ ___ ___ Submucous resection ___ ___ ___ Nasal septoplasty ___ ___ ___ Turbinectomy ___ ___ ___ Antrotomy ___ ___ ___ Caldwell Luc ___ ___ ___ Oroantral fistula repair ___ ___ ___ Choanal atresia repair ___ ___ ___ Transantral ligation of vessels ___ ___ ___ Transorbital Ligation of Vessels ___ ___ ___ Vidian neurectomy ___ ___ ___ Intranasal ethmoidectomy ___ ___ ___ External ethmoidectomy ___ ___ ___ Frontoethmoidectomy ___ ___ ___ Frontal sinus trephine ___ ___ ___ Osteoplastic frontal sinusectomy ___ ___ ___ Frontal sinus ablation ___ ___ ___ Nasal endoscopy, diagnostic ___ ___ ___ Endoscopic Sinus Surgery ___ ___ ___ Approach for Hypophysectomy ___ ___ ___ Page 5 Printed on Thursday, December 21, 2017 Huntington Memorial Hospital Delineation Of Privileges Otolaryngology Privileges Provider Name: Privilege Requested Deferred Approved CATEGORY 2 – ADVANCED OTOLARYNGOLOGY PRIVILEGES Criteria: Applicants must meet the criteria outlined for Category 1 Otolaryngology privileges; AND provide documentation of ability to perform the procedures requested, via certification by a Training Director regarding experience and demonstrated competence. Proctoring Requirements: Of the four (4) required proctoring cases, two (2) must be from the Category 2 Advanced privilege section, if Category 2 privileges are requested. Current Competence Requirements: Evidence of the successful performance, as primary surgeon, of at least three (3) Category 2 procedures every 2 years. CATEGORY 2 – Advanced Otolaryngology Privileges: ___ ___ ___ Cleft lip repair ___ ___ ___ Cleft palate repair ___ ___ ___ Cochlear implant ___ ___ ___ Major vessel grafting ___ ___ ___ Resection acoustic neuroma translabyrinthine (transmastoid) ___ ___ ___ Middle cranial fossa surgery ___ ___ ___ VIII nerve section via middle fossa ___ ___ ___ Retrolabyrinthine nerve section ___ ___ ___ T.M.J. exploration ___ ___ ___ FREE FLAP PROCEDURES Criteria: Applicant must demonstrate training, experience, and current competence. Applicant must have performed at least ten (10) procedures in order to meet qualifications for initial appointment. Proctoring Requirements: A minimum of two (2) procedures to be proctored. Current Competence Requirements: Applicant must have performed at least ten (10) procedures in the past two (2) years in order to meet qualifications at the time of reappointment Free Flap Procedures ___ ___ ___ Page 6 Printed on Thursday, December 21, 2017 Huntington Memorial Hospital Delineation Of Privileges Otolaryngology Privileges Provider Name: Privilege Requested Deferred Approved CATEGORY 2 - ROBOTIC ASSISTED SURGERIES: Criteria: Applicants must be Board Certified or eligible for certification by the American Board of Otolaryngology. Must meet the criteria outlined for Category 1. Must provide documentation of course attendance and completion of the Training Workshop for the da Vinci system as it applies to ENT procedures; and meet one of the following: Route "1" Criteria: Requires previous practical experience via an accredited residency or fellowship program with documented clinical experience of