Post Op: Necrotic/eroding tumor of the skull
Description: An elliptical incision was made around the nodule with th scalpel. This was carried down to the sub-q tissue. Then I did inner cystic type lesion with old blood present. Upon dissecting free this capsule incorporating the cyst, I did note that the skull was eroded away in this area approx. 2x2 cm segment. Deep to the skull with the pocket of old bloody fluid measuring approx. 2x3 cm. Fluid was aspirated and sent for cytology. The skin as well as the fibrous capsule, and this lesion were then delivered off the field. I was able to close membranous tissue that was present somewhat cover the defect in the skull, where the 3-0 Vicryl ligatures in an interrupted fasion. The area was irrigated with saline solution. The sub-q tissue was then reapproximated with 3-0 Vicryl in interrupted fasion.
The path came back consistent with Hematoma, but the aspiration of fluid is non-small cell carcinoma, metastatic. My first instinct was 21015, but I am second guessing myself. Any thoughts are appreciated!!
Description: An elliptical incision was made around the nodule with th scalpel. This was carried down to the sub-q tissue. Then I did inner cystic type lesion with old blood present. Upon dissecting free this capsule incorporating the cyst, I did note that the skull was eroded away in this area approx. 2x2 cm segment. Deep to the skull with the pocket of old bloody fluid measuring approx. 2x3 cm. Fluid was aspirated and sent for cytology. The skin as well as the fibrous capsule, and this lesion were then delivered off the field. I was able to close membranous tissue that was present somewhat cover the defect in the skull, where the 3-0 Vicryl ligatures in an interrupted fasion. The area was irrigated with saline solution. The sub-q tissue was then reapproximated with 3-0 Vicryl in interrupted fasion.
The path came back consistent with Hematoma, but the aspiration of fluid is non-small cell carcinoma, metastatic. My first instinct was 21015, but I am second guessing myself. Any thoughts are appreciated!!