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

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Consultation Only Privileges

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Surgical Assist ONLY

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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

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a) Adult Sedation

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b) Pediatric Sedation (17 years and under)

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Local Block Anesthesia

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Regional Block anesthesia

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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

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Delineation Of Privileges

Otolaryngology Privileges
Provider Name:
Privilege

Requested Deferred Approved

Lip shave

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Wedge resection

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Neck - I & D abscess

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Excision skin lesions

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Laryngoscopy

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Esophagoscopy:

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a) Diagnostic

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b) With foreign body removal

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c) With structure dilation

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Bronchoscopy - diagnostic

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Adenoidectomy

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Tonsillectomy

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Tracheotomy

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Submaxillary gland excision

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Lateral rhinotomy

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Abbe-Estlander Flap

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Cervical node biopsy

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Scalene node biopsy

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Exploration laryngeal fractures

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Delineation Of Privileges

Otolaryngology Privileges
Provider Name:
Privilege

Requested Deferred Approved

Exploration recurrent laryngeal nerves

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Arytenoidectomy

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Thyroidectomy

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Parathyroidectomy

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Tongue Base Suspension

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Genioglossus Advancement

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Hyoid Myotomy and Suspension

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Uvulopalatopharyngoplasty

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Major vessel ligation

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Branchiogenic cysts

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Thyroglossal cysts

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Dermoids

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Laryngoplasty

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Tracheoplasty

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Bronchoscopy - with foreign body removal

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Bronchoscopy - with stricture dilation

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Superficial parotidectomy with facial nerve dissection

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Total parotidectomy with facial nerve dissection

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Radical parotidectomy with or without nerve graft

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Delineation Of Privileges

Otolaryngology Privileges
Provider Name:
Privilege

Requested Deferred Approved

Partial maxillectomy

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Total maxillectomy

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Radical maxillectomy with orbital extenteration

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Excision nasopharyngeal tumor

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Partial glossectomy

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Partial mandibulectomy

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Composite resection - primary and tumor with RND

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Radical neck dissection

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Extended radical neck dissection (transternal mediastinal dissection)

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Subtotal laryngectomy

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Thyrotomy (laryngofissure)

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Supraglottic laryngectomy

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Hemilaryngectomy

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Total laryngectomy with neck dissection

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Cervical esophagectomy with neck dissection

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Tracheal resection with repair

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Infratemporal fossa surgery

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Hypoglossal facial anastomosis

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Laser Privileges:

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Delineation Of Privileges

Otolaryngology Privileges
Provider Name:
Privilege

Requested Deferred Approved

a) C02 Laser

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b) KTP Laser

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c) Argon Laser

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d) YAG Laser

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Tracheo-Esophageal Puncture (TEP)

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Microlaryngoscopy with Vocal Cord Injection

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Thyroplasty Type 1

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Temporal Artery Biopsy

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Orbital Decompression

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Endoscopic Repair of Zenkers Diverticulum

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Open Repair of Zenkers Diverticulum

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Myringotomy

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Myringoplasty

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Tympanoplasty with/without ossicular reconstruction

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Tympanoplasty with mastoidectomy with/without reconstruction

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Tympanostomy with PE Tube Placement

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Mastoidectomy

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Stapedectomy

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OTOLOGY

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Delineation Of Privileges

Otolaryngology Privileges
Provider Name:
Privilege

Requested Deferred Approved

Stapes mobilization

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Tympanic neurectomy

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Labyrinthectomy

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Excision tumor of ear and mastoid

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Partial temporal bone resection

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Radical temporal bone resection

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Endolymphatic sac operations

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Bone anchored hearing appliance

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Ossicular Reconstruction

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Split thickness skin graft

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Full thickness skin graft

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Composite graft

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Dermal graft

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Scar revision

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Reconstruction of external ear

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Otoplasty

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Rhinoplasty

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Septorhinoplasty

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PLASTIC AND RECONSTRUCTION

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Delineation Of Privileges

Otolaryngology Privileges
Provider Name:
Privilege

Requested Deferred Approved

Rhytidectomy

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Blepharoplasty

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Reduction facial fractures:

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a) Frontal

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b) Nasal

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c) Maxilla

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d) Malar

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e) Malar with orbital floor

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f) Orbital blowout

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g) Mandibular - closed

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h) Mandibular - open

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Implants

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Fascial sling procedures

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Condylectomy

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Dacryocystorhinostomy

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Regional myocutaneous flaps

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Bone grafts

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Liposuction

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Prognathism correction

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Delineation Of Privileges

Otolaryngology Privileges
Provider Name:
Privilege

Retrognathism correction

Requested Deferred Approved

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Nasal polypectomy

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Submucous resection

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Nasal septoplasty

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Turbinectomy

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Antrotomy

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Caldwell Luc

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Oroantral fistula repair

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Choanal atresia repair

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Transantral ligation of vessels

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Transorbital Ligation of Vessels

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Vidian neurectomy

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Intranasal ethmoidectomy

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External ethmoidectomy

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Frontoethmoidectomy

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Frontal sinus trephine

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Osteoplastic frontal sinusectomy

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Frontal sinus ablation

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NASAL/SINUS

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Delineation Of Privileges

Otolaryngology Privileges
Provider Name:
Privilege

Requested Deferred Approved

Nasal endoscopy, diagnostic

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Endoscopic Sinus Surgery

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Approach for Hypophysectomy

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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

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Cleft palate repair

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Cochlear implant

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Major vessel grafting

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Resection acoustic neuroma translabyrinthine (transmastoid)

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Middle cranial fossa surgery

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VIII nerve section via middle fossa

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Retrolabyrinthine nerve section

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T.M.J. exploration

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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 a minimum of twenty (20) robotic assisted procedures, with at least ten (10) as the primary surgeon.
Route "1" Proctoring Requirements:
At least the first three (3) cases as the primary surgeon, proctored by a surgeon who has performed a minimum of ten
(10) robotic procedures.
Competency Requirements: Performance of at least five (5) robotic procedures per year as primary surgeon to
maintain robotic privileges. Physicians who fail to meet the competency requirements will be required to undergo
proctoring of at least three (3) cases.
Route "2" Criteria:
Completion of an approved residency or fellowship program in the surgical specialty.
Route "2" Proctoring Requirements:
At least the first five (5) cases as the primary surgeon, proctored by two different surgeons who have performed a
minimum of ten (10) robotic procedures.
Competency Requirements: Performance of at least five (5) robotic procedures per year as primary surgeon to maintain
robotic privileges. Physicians who fail to meet the competency requirements will be required to undergo proctoring of
at least five (5) cases.
CATEGORY 2 - ROBOTIC ASSISTED SURGERIES
Radical Tonsillectomy

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Supraglottic laryngectomy (includes resection of tumors of the pharynx and the

larynx)

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Base of tongue cancer resection

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Sleep Apnea

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Revised: 04/23/10, 10/28/10, 5/26/11; 01/26/12; 05/23/13; 5/22/14; 10/30/2014

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Delineation Of Privileges

Otolaryngology Privileges
Provider Name:
Privilege

Requested Deferred Approved

ACKNOWLEDGEMENT OF THE PRACTITIONER:

I have requested only those privileges for which my education, training, current experience and demonstrated
performance I am qualified to perform, and that I wish to exercise at Huntington Hospital, and I understand that: a) in
exercising my clinical privileges granted, I am constrained by hospital and medical staff policies and rules applicable
generally and any applicable to the particular situation; b) any restriction on the clinical privileges granted to me is
waived in an emergency situation and in such a situation my actions are governed by the applicable section of the
Medical Staff Bylaws or related documents.

Signature of Applicant: ___________________________________ Date:___________________________

DEPARTMENT CHAIR RECOMMENDATIONS

I have reviewed the requested clinical privileges and supportive documentation for the above named applicant and
recommend action on the privileges as noted above.
Applicant may perform privileges and procedures as indicated: ______ YES ______ NO
Exceptions/Limitations (Please Specify): ________________________________________________________________

APPROVALS:
Robotic Medical Director: ___________________________________ Date: __________
Section Chair: _____________________________________________ Date: __________
Department Chair: _________________________________________ Date: __________
Credential Committee Date: __________
Medical Executive Committee Date: __________
Board of Directors Approved on: __________

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