I'm fairly new to OTO surgery coding and totally overwhelmed with this case. Can any one offer any help? I was looking at 69603 & 69440 but not confident in my choice.
POSTOPERATIVE DIAGNOSES:1. History of right temporal gunshot trauma.2. Right profound sensorineural hearing loss.3. Right tympanomastoid cholesteatoma.4. Right tympanic foreign body (the bullet).
PROCEDURES:5. Revision right radical mastoidectomy (subtotal petrosectomy).6. Revision blind sac closure of right external auditory canal.7. Right tympanomastoid exploration with removal of foreign body.8. Right mastoid obliteration with inferior musculopericranial.9.
Intraoperative monitoring of right cranial nerve VII.10. Microsurgical technique.
The right ear was prepped with Betadine anddraped sterilely. 0.5% lidocaine with 1:200,000 parts epinephrine wasinfiltrated throughout the postauricular crease and external auditorycanal. Microsurgical technique was utilized intermittently. The old postauricular incision is fashioned. Soft tissue is lifted out ofthe underlying mastoid defect. In doing so, there was noted to beextensive liquidative type fat necrosis that was turbid in appearance. Thebone overlying the sigmoid sinus was intact, yet there was an extensivetegmen defect with prominent herniated yet intact dura. There was nocholesteatoma in the mastoid or remnant middle ear space, yet explorationdid reveal evidence of what appeared to be an iatrogenic external auditorycanal cholesteatoma secondary to previous blind sac closure. Fat was debrided and removed out of the mastoid cavity. The canalcholesteatoma was resected and the blind sac was retransected lateral tothis. The edges of the blind sac were then circumferentially everted andoversewn with multiple interrupted 3-0 Vicryl sutures. Further soft tissue elevation was undertaken overlying thetemporomandibular joint capsule, zygomatic root, and anterior tympanicbone. In doing, so there was noted to be bullet imbedded in the lateraltympanic bone at its junction with the zygomatic root near thetympanosquamosal suture line. The bullet was removed completely. Therewas a high degree of associated reactive granulation tissue which likewisewas debrided. Culture specimens including tissue and swab were obtainedfrom within the tympanomastoid cavity. At this stage, revision of the subtotal petrosectomy was undertaken byremoving residual retrosigmoid tip, retrofacial and sinal air cells. Indoing so, the mastoid tip was amputated off of the digastric ridge. Thedescending facial nerve was identified and noted to be completely intact inboth the tympanic and mastoid segments. It was not traumatized in any way.An inferiorly based musculoperiosteal flap was raised with postauricularand occipital artery blood supply. This was rotated into the residualmastoid defect for obliteration. The eustachian tube remained pluggedaccording to the prior procedure. The surgical defect was then copiouslyirrigated with saline and perfused with ciprofloxacin drops. Layeredclosure of the postauricular wound was then undertaken with multipleinterrupted 2-0 and 3-0 Vicryl sutures. The skin was closed with staples.
POSTOPERATIVE DIAGNOSES:1. History of right temporal gunshot trauma.2. Right profound sensorineural hearing loss.3. Right tympanomastoid cholesteatoma.4. Right tympanic foreign body (the bullet).
PROCEDURES:5. Revision right radical mastoidectomy (subtotal petrosectomy).6. Revision blind sac closure of right external auditory canal.7. Right tympanomastoid exploration with removal of foreign body.8. Right mastoid obliteration with inferior musculopericranial.9.
Intraoperative monitoring of right cranial nerve VII.10. Microsurgical technique.
The right ear was prepped with Betadine anddraped sterilely. 0.5% lidocaine with 1:200,000 parts epinephrine wasinfiltrated throughout the postauricular crease and external auditorycanal. Microsurgical technique was utilized intermittently. The old postauricular incision is fashioned. Soft tissue is lifted out ofthe underlying mastoid defect. In doing so, there was noted to beextensive liquidative type fat necrosis that was turbid in appearance. Thebone overlying the sigmoid sinus was intact, yet there was an extensivetegmen defect with prominent herniated yet intact dura. There was nocholesteatoma in the mastoid or remnant middle ear space, yet explorationdid reveal evidence of what appeared to be an iatrogenic external auditorycanal cholesteatoma secondary to previous blind sac closure. Fat was debrided and removed out of the mastoid cavity. The canalcholesteatoma was resected and the blind sac was retransected lateral tothis. The edges of the blind sac were then circumferentially everted andoversewn with multiple interrupted 3-0 Vicryl sutures. Further soft tissue elevation was undertaken overlying thetemporomandibular joint capsule, zygomatic root, and anterior tympanicbone. In doing, so there was noted to be bullet imbedded in the lateraltympanic bone at its junction with the zygomatic root near thetympanosquamosal suture line. The bullet was removed completely. Therewas a high degree of associated reactive granulation tissue which likewisewas debrided. Culture specimens including tissue and swab were obtainedfrom within the tympanomastoid cavity. At this stage, revision of the subtotal petrosectomy was undertaken byremoving residual retrosigmoid tip, retrofacial and sinal air cells. Indoing so, the mastoid tip was amputated off of the digastric ridge. Thedescending facial nerve was identified and noted to be completely intact inboth the tympanic and mastoid segments. It was not traumatized in any way.An inferiorly based musculoperiosteal flap was raised with postauricularand occipital artery blood supply. This was rotated into the residualmastoid defect for obliteration. The eustachian tube remained pluggedaccording to the prior procedure. The surgical defect was then copiouslyirrigated with saline and perfused with ciprofloxacin drops. Layeredclosure of the postauricular wound was then undertaken with multipleinterrupted 2-0 and 3-0 Vicryl sutures. The skin was closed with staples.
