lilleyea
Networker
I am stuck on how to code this one. It was scheduled as 69641 but it doesn't appear that was done at all. Any feedback would be appreciated!
PREOPERATIVE DIAGNOSIS:
Right chronic otitis media with conductive hearing loss.
*
POSTOPERATIVE DIAGNOSIS:
Right chronic otitis media with conductive hearing loss.
*
PROCEDURE:
Right revision ossiculoplasty.
*
BRIEF HISTORY:
The patient is a 39-year-old male who underwent a staged right ossiculoplasty approximately one year ago with initial gain in hearing and eventual decline in hearing in the ear over time. A preoperative audiogram showed a moderate mixed hearing loss in the right ear and a preoperative high resolution CT scan of the temporal bone showed evidence of a displaced middle ear prosthesis on the right side.
*
DESCRIPTION OF PROCEDURE:
The patient was brought to operating room, placed in supine position where he underwent endotracheal intubation for general anesthesia. The table was turned 180 degrees and 2% Xylocaine with 1:100,000 epinephrine was used to infiltrate the tragus, the meatus, the postauricular skin and subcutaneous tissue. The facial nerve monitor was placed on the right side. The right ear was prepped and draped in a sterile fashion. Canal incisions were made at 6 and 12 o'clock and connected by a separate incision approximately 6 mm lateral to the posterior bony annulus. A posterior tympanomeatal flap was elevated and the middle ear was entered. The epitympanic space and middle ear space appeared to be clear. There was scar tissue extending from the undersurface of the tympanic membrane to the cochlear promontory. There was also scar around a displaced middle ear prosthesis that had tilted posteriorly. The scar bands were lysed with Bellucci scissors and the prosthesis removed. The incus was absent. The stapes crura were absent and the stapes footplate was intact and mobile. Palpation of the stapes footplate elicited a brisk round window reflex. A 3 cm incision was made in the superior aspect of the postauricular region through the old postauricular scar and carried down through the subcutaneous tissue to the level of the superficial layer of the deep temporal fascia. A small amount of areolar tissue was obtained and placed on the back table to air dry. This soft tissue was flattened out against a Teflon block and allowed to air dry. The postauricular incision was closed in layers using interrupted 2-0 chromic for the deep layers and a running subcuticular 4-0 chromic for the skin. Two Steri-Strips were placed over the postauricular incision. Once the areolar tissue was dry, it was cut to proper dimensions and placed as a soft tissue graft over top of the mobile stapes footplate. This was done in order to cushion the footplate upon placement of a total middle ear prosthesis. A Grace Medical hydroxyapatite titanium total prosthesis was chosen and cut to approximately 4 mm in length. This was placed without difficulty between the undersurface of the tympanic membrane and onto soft tissue graft overlying the stapes footplate. The middle ear space was then packed with Ciprodex-soaked Gelfoam pledgets. The tympanomeatal flap was then reapplied to the posterior canal wall and the canal was packed with Ciprodex-soaked Gelfoam pledgets. A cotton ball was placed in the concha. The patient was subsequently extubated and returned to the recovery room having tolerated the procedure well.
PREOPERATIVE DIAGNOSIS:
Right chronic otitis media with conductive hearing loss.
*
POSTOPERATIVE DIAGNOSIS:
Right chronic otitis media with conductive hearing loss.
*
PROCEDURE:
Right revision ossiculoplasty.
*
BRIEF HISTORY:
The patient is a 39-year-old male who underwent a staged right ossiculoplasty approximately one year ago with initial gain in hearing and eventual decline in hearing in the ear over time. A preoperative audiogram showed a moderate mixed hearing loss in the right ear and a preoperative high resolution CT scan of the temporal bone showed evidence of a displaced middle ear prosthesis on the right side.
*
DESCRIPTION OF PROCEDURE:
The patient was brought to operating room, placed in supine position where he underwent endotracheal intubation for general anesthesia. The table was turned 180 degrees and 2% Xylocaine with 1:100,000 epinephrine was used to infiltrate the tragus, the meatus, the postauricular skin and subcutaneous tissue. The facial nerve monitor was placed on the right side. The right ear was prepped and draped in a sterile fashion. Canal incisions were made at 6 and 12 o'clock and connected by a separate incision approximately 6 mm lateral to the posterior bony annulus. A posterior tympanomeatal flap was elevated and the middle ear was entered. The epitympanic space and middle ear space appeared to be clear. There was scar tissue extending from the undersurface of the tympanic membrane to the cochlear promontory. There was also scar around a displaced middle ear prosthesis that had tilted posteriorly. The scar bands were lysed with Bellucci scissors and the prosthesis removed. The incus was absent. The stapes crura were absent and the stapes footplate was intact and mobile. Palpation of the stapes footplate elicited a brisk round window reflex. A 3 cm incision was made in the superior aspect of the postauricular region through the old postauricular scar and carried down through the subcutaneous tissue to the level of the superficial layer of the deep temporal fascia. A small amount of areolar tissue was obtained and placed on the back table to air dry. This soft tissue was flattened out against a Teflon block and allowed to air dry. The postauricular incision was closed in layers using interrupted 2-0 chromic for the deep layers and a running subcuticular 4-0 chromic for the skin. Two Steri-Strips were placed over the postauricular incision. Once the areolar tissue was dry, it was cut to proper dimensions and placed as a soft tissue graft over top of the mobile stapes footplate. This was done in order to cushion the footplate upon placement of a total middle ear prosthesis. A Grace Medical hydroxyapatite titanium total prosthesis was chosen and cut to approximately 4 mm in length. This was placed without difficulty between the undersurface of the tympanic membrane and onto soft tissue graft overlying the stapes footplate. The middle ear space was then packed with Ciprodex-soaked Gelfoam pledgets. The tympanomeatal flap was then reapplied to the posterior canal wall and the canal was packed with Ciprodex-soaked Gelfoam pledgets. A cotton ball was placed in the concha. The patient was subsequently extubated and returned to the recovery room having tolerated the procedure well.