AN2114
Guru
How would you code an exploratory tympanotomy with mastoidectomy? Would it be the tympanoplasty code 69641? or would you code just a mastoidectomy? Below is the op note:
The patient was brought back to the operating room and placed in the supine position on the OR table. The patient was intubated by the anesthesia team. A critical timeout was performed and when everyone was in agreement the procedure commenced. The patient was turned 120 degrees to the right . The postauricular skin, external auditory canal, tragus was injected with 2.5 cc of 1% lidocaine with epinephrine 1:100,000. Facial nerve monitoring was set up and found to be working appropriately. The patient was then prepped and draped in sterile fashion. A speculum was unable to be placed in the external auditory canal due to the significantly stenotic ear canal and therefore decision was made to proceed with postauricular incision.
A postauricular incision was made with a #15 blade through the skin, subcutaneous tissue down to the temporalis fascia. Hemostasis was achieved with Bovie cautery. The temporal line was palpated and then a #7 incision was made at the level of the temporal line down to the mastoid bone. There was granulation tissue with thick mucoid effusion emanating from the mastoid cavity. The postauricular skin was then elevated with a Freer. A horizontal incision was then made about 7 mm posterior to the annulus with a Beaver blade to create the tympanomeatal flap. A penrose drain along with a lempert was used to stent open the postauricular skin in order to fully visualize the tympanic membrane. There was evidence of a small hole in the anterior inferior quadrant with mucoid effusion emanating from this. The tympanomeatal flap was then elevated with a weapon and 20 suction down to the annulus. The middle ear space was then entered inferiorly and significant granulation tissue was seen throughout the inferior portion of the middle ear space. The tympanic membrane was then elevated anteriorly as well until the chorda tympani was identified. Chorda tympani was then followed anteriorly until the malleus was seen. The tympanic membrane was elevated off the malleus. There was significant granulation tissue surrounding the malleus both anteriorly and medially. Significant granulation tissue was around the incus as well and this was removed with Rosen and cup forceps. The malleus was palpated and found to be intact with the incus. The stapes was also able to be visualized with the lenticular process intact with significant granulation tissue around the stapes footplate. Once most of the granulation tissue was removed from the inferior portion middle ear space and just the antral portion was left attention was turned to the mastoid cavity.
Using a 5 cutter a revision mastoidectomy was performed removing bone down to the mastoid tip up into the antrum. Tegmen was identified and preserved. Drilling was continued anteriorly into the root until the incus and the head of the malleus was identified. There was significant granulation tissue within the epitympanum which was removed with a Rosen and cup forceps. The lateral process of the incus was identified and granulation tissue removed laterally to this. Saline irrigation was then performed and there was adequate flow going from the mastoid into the middle ear space. There was residual granulation tissue medial to the malleus and around the stapes footplate. It was decided to leave this in place without removing the incus as there was adequate water flow between the mastoid and middle ear space with no evidence of cholesteatoma. The facial canal was then stimulated with good biphasic responses with stimulation probe. The middle ear space was then packed with ciprodex soaked Gelfoam. The tympanic membrane was laid back down with no evidence of additional perforations other then the initial perforation seen at the beginning of the case. The external auditory canal was then packed with Ciprodex soaked Gelfoam.
A 15 blade was used to make a 6 and 12:00 incision into the external auditory canal in order to make a large meatoplasty and allow for better visualization in the office for monitoring. The remaining EAC was packed with ciprodex soaked gelfoam and a ambrose pack was placed. The palva flap was then closed with 3-0 Vicryl suture. The subcutaneous tissue was then closed with 4-0 Vicryl suture. The skin was closed with skin glue. A glasscock dressing was placed.
The patient was brought back to the operating room and placed in the supine position on the OR table. The patient was intubated by the anesthesia team. A critical timeout was performed and when everyone was in agreement the procedure commenced. The patient was turned 120 degrees to the right . The postauricular skin, external auditory canal, tragus was injected with 2.5 cc of 1% lidocaine with epinephrine 1:100,000. Facial nerve monitoring was set up and found to be working appropriately. The patient was then prepped and draped in sterile fashion. A speculum was unable to be placed in the external auditory canal due to the significantly stenotic ear canal and therefore decision was made to proceed with postauricular incision.
A postauricular incision was made with a #15 blade through the skin, subcutaneous tissue down to the temporalis fascia. Hemostasis was achieved with Bovie cautery. The temporal line was palpated and then a #7 incision was made at the level of the temporal line down to the mastoid bone. There was granulation tissue with thick mucoid effusion emanating from the mastoid cavity. The postauricular skin was then elevated with a Freer. A horizontal incision was then made about 7 mm posterior to the annulus with a Beaver blade to create the tympanomeatal flap. A penrose drain along with a lempert was used to stent open the postauricular skin in order to fully visualize the tympanic membrane. There was evidence of a small hole in the anterior inferior quadrant with mucoid effusion emanating from this. The tympanomeatal flap was then elevated with a weapon and 20 suction down to the annulus. The middle ear space was then entered inferiorly and significant granulation tissue was seen throughout the inferior portion of the middle ear space. The tympanic membrane was then elevated anteriorly as well until the chorda tympani was identified. Chorda tympani was then followed anteriorly until the malleus was seen. The tympanic membrane was elevated off the malleus. There was significant granulation tissue surrounding the malleus both anteriorly and medially. Significant granulation tissue was around the incus as well and this was removed with Rosen and cup forceps. The malleus was palpated and found to be intact with the incus. The stapes was also able to be visualized with the lenticular process intact with significant granulation tissue around the stapes footplate. Once most of the granulation tissue was removed from the inferior portion middle ear space and just the antral portion was left attention was turned to the mastoid cavity.
Using a 5 cutter a revision mastoidectomy was performed removing bone down to the mastoid tip up into the antrum. Tegmen was identified and preserved. Drilling was continued anteriorly into the root until the incus and the head of the malleus was identified. There was significant granulation tissue within the epitympanum which was removed with a Rosen and cup forceps. The lateral process of the incus was identified and granulation tissue removed laterally to this. Saline irrigation was then performed and there was adequate flow going from the mastoid into the middle ear space. There was residual granulation tissue medial to the malleus and around the stapes footplate. It was decided to leave this in place without removing the incus as there was adequate water flow between the mastoid and middle ear space with no evidence of cholesteatoma. The facial canal was then stimulated with good biphasic responses with stimulation probe. The middle ear space was then packed with ciprodex soaked Gelfoam. The tympanic membrane was laid back down with no evidence of additional perforations other then the initial perforation seen at the beginning of the case. The external auditory canal was then packed with Ciprodex soaked Gelfoam.
A 15 blade was used to make a 6 and 12:00 incision into the external auditory canal in order to make a large meatoplasty and allow for better visualization in the office for monitoring. The remaining EAC was packed with ciprodex soaked gelfoam and a ambrose pack was placed. The palva flap was then closed with 3-0 Vicryl suture. The subcutaneous tissue was then closed with 4-0 Vicryl suture. The skin was closed with skin glue. A glasscock dressing was placed.