Oropharyngeal ulcer debridement


Jacksonville Beach, FL
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:confused:This is a new one for me, the surgeon said he debrided pharyngeal ulceration and a he also did a laryngoscopy with biopsy. Here is some of the op note: Im not sure how to code it...31510...
Thank you for any help.

A standard Dedo laryngoscope was used to analyze the patient. This was inserted transorally. There was large left lateral posterior pharyngeal ulceration. There were no changes to the base of tongue. The posterior and lateral deep aspect of the phalangeal mucosa has normal appearance. Piriformis sinuses were normal. The visualized portion of the glottis and postglottic areas were normal. The laryngoscope was then removed.

The Crowe-Davis oral retractor was then placed using a size 4 and the patient was put into retraction and suspension. Palpation of the soft palate revealed no submucous clefting. The palate was suspended using a 12-French red rubber catheter placed through each naris. There were significant necrotic tissues in the central portion with large ulceration the posterolateral aspect of the left side of the pharynx. Surrounding this was reactive granulation tissue. Palpation revealed a rim of firmed fibrous tissue around the ulceration, but there did not appear to be deep mass extension. I began by separating the ulceration in the quadrants. Using a #15 scalpel blade, I started at the area of the granulation tissue and cut centrally into the deep ulcerative bed. I did this in all 4 quadrants. These were sent separately to pathology for permanent sectioning. I then debrided the remaining necrotic tissue. I then surface cauterized the area with suction Bovie cautery on 15 watts. I then injected the area with 0.25%Marcaine with epinephrine. The pharynx was then irrigated with saline, suction evacuated. The red rubber catheters were released. The patient was then taken out of suspension and retraction and after a 10-second count was re-retracted at which time hemostasis was noted to be excellent.