Hi - is this 69310-50? Pt fell on their face breaking their mandible and temporal bones. ENT takes pt to OR:
DIAGNOSIS: Bilateral temporal bone fracture. Bilateral ear canal stenosis due to injury.
Pt taken to OR intubated.
Microscope was brought into the operative field. Both ears were cleaned under microscope exam of any blood. There was some fresh blood in the left ear canal that was removed under suction. Right ear was esssential addressed first and cleaned. The anterior collapse of the canal was pushed forward with curette in it to stay in place. Eardrops placed. This was followed with a cottonball. On the left side there was complete osbstruction of the left ear canal with blood and bone from anterior canal. This area was cleansed of any clot and then some dilute betadine solution infiltrated in the ear cana. The bone and anterior canal skin reduced with alligator forceps and cerumen curette. Suction used to hold the anterior wall anteriorly and then quarter inch ribbon gauze packed that was coated in Neosporin ointment to hold the fragment forward and keep the ear canal stented. Cottonball was placed externally. Case was terminated pt extubated.
Thank you!
DIAGNOSIS: Bilateral temporal bone fracture. Bilateral ear canal stenosis due to injury.
Pt taken to OR intubated.
Microscope was brought into the operative field. Both ears were cleaned under microscope exam of any blood. There was some fresh blood in the left ear canal that was removed under suction. Right ear was esssential addressed first and cleaned. The anterior collapse of the canal was pushed forward with curette in it to stay in place. Eardrops placed. This was followed with a cottonball. On the left side there was complete osbstruction of the left ear canal with blood and bone from anterior canal. This area was cleansed of any clot and then some dilute betadine solution infiltrated in the ear cana. The bone and anterior canal skin reduced with alligator forceps and cerumen curette. Suction used to hold the anterior wall anteriorly and then quarter inch ribbon gauze packed that was coated in Neosporin ointment to hold the fragment forward and keep the ear canal stented. Cottonball was placed externally. Case was terminated pt extubated.
Thank you!