NESmith
Guest
- Messages
- 309
- Location
- Zephyrhills, FL
Please help with the coding of this operative report. I am new to ENT.
Pre-Operative Dx: Eustachian tube dysfunction. Granulation tissue of the right ear.
Post-Operative Dx. Eustachian tube dysfunction. Foreign body in the right middle ear speace.
Description of Procedure: Following signing the consent, the patient was taken to the operating room and placed on the table in supine positon. Monitors for heart rate, blood pressure, and O2 sat were placed. IV access was obtained. Intrvenous sedation as administered and the patient was intubated without difficulty. The patient was positioned, prepped and draped in the usual sterile fashion. The microscope was brought into the field. A ear speculum was placed into the external meatus. Examination showed a mild cerumen, which was removed. The canal was washed with Betadine and saline. On examination, the tympanic membrane was thickened with hypervascularity. Ther was no evidence of tube and the eardrum had healed. I could see the tube had fallen into the middle ear space. A myringotomy knife was used to place the radial incision into the anteroinferior quadrant. A 2# suction was used to grasp a tube and withdrawn through the myringotomy. The suction was not strong enough to pull the tube out. I attempted to use the alligator forceps without success. The tube fell out of visula field most likely into the hypotympanum and could not be retrieved with multiple attempts using the suction.
At this point, I decided to repair the myringotomy by placing a Gelfoam-soaked in floxin oic and mupirocin ointment.
The patient tolerated the procedures well without any complications.
Provider used 69436RT53.
Please advise. Thank You for your help.
Pre-Operative Dx: Eustachian tube dysfunction. Granulation tissue of the right ear.
Post-Operative Dx. Eustachian tube dysfunction. Foreign body in the right middle ear speace.
Description of Procedure: Following signing the consent, the patient was taken to the operating room and placed on the table in supine positon. Monitors for heart rate, blood pressure, and O2 sat were placed. IV access was obtained. Intrvenous sedation as administered and the patient was intubated without difficulty. The patient was positioned, prepped and draped in the usual sterile fashion. The microscope was brought into the field. A ear speculum was placed into the external meatus. Examination showed a mild cerumen, which was removed. The canal was washed with Betadine and saline. On examination, the tympanic membrane was thickened with hypervascularity. Ther was no evidence of tube and the eardrum had healed. I could see the tube had fallen into the middle ear space. A myringotomy knife was used to place the radial incision into the anteroinferior quadrant. A 2# suction was used to grasp a tube and withdrawn through the myringotomy. The suction was not strong enough to pull the tube out. I attempted to use the alligator forceps without success. The tube fell out of visula field most likely into the hypotympanum and could not be retrieved with multiple attempts using the suction.
At this point, I decided to repair the myringotomy by placing a Gelfoam-soaked in floxin oic and mupirocin ointment.
The patient tolerated the procedures well without any complications.
Provider used 69436RT53.
Please advise. Thank You for your help.