letwalls
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Please help me with this op report.
Came up with 69641.
Operative report:
A decision was made to proceed first with the mastoidectomy. Post auricular incision was made and carried down through the perichondrium and through to the soft tissues, elevated anteriorly and posteriorly, exposing the mastoid cortex. A standard triangular incision was made and simple mastoidectomy accomplished, exposing the antrum. In the roof of the antrum, small clump of granlulations were seen that were carefully teased off of exposed dura. The area of dehiscence measured probably 5x8mm. It was decided to repair this with temporalis fascia and muscle plug. The incision behind the ear was extended up slightly over the temporalis muscle and a cirlce of fascia with a thin layer of muscle attached was removed. This was laid muscle-down against the dural dehiscence, after being certain the CSF leak was coming from that area. Biopsies of the granulations had shown no evidence of neoplastic process. This dural patch on the roof of the antrum was then reinforced with Gelfoam packing to hold the graft in place and postauricular incision closed.
Came up with 69641.
Operative report:
A decision was made to proceed first with the mastoidectomy. Post auricular incision was made and carried down through the perichondrium and through to the soft tissues, elevated anteriorly and posteriorly, exposing the mastoid cortex. A standard triangular incision was made and simple mastoidectomy accomplished, exposing the antrum. In the roof of the antrum, small clump of granlulations were seen that were carefully teased off of exposed dura. The area of dehiscence measured probably 5x8mm. It was decided to repair this with temporalis fascia and muscle plug. The incision behind the ear was extended up slightly over the temporalis muscle and a cirlce of fascia with a thin layer of muscle attached was removed. This was laid muscle-down against the dural dehiscence, after being certain the CSF leak was coming from that area. Biopsies of the granulations had shown no evidence of neoplastic process. This dural patch on the roof of the antrum was then reinforced with Gelfoam packing to hold the graft in place and postauricular incision closed.
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