Wondering if anyone can give me any thoughts on a CPT code for this. I'm leaning more towards an unlisted code. It looks like he just cleaned everything out and removed the TORP. Thanks!!!


Procedure: Left middle ear exploration with removal of total ossicular reconstruction prosthesis (partially extruded)

Preoperative diagnosis: Partially extruded total ossicular reconstruction prosthesis, status post modified radical mastoidectomy with known dehiscence of the facial nerve and tegmen

Findings: Partially extruded ossicular reconstruction prosthesis (plastipore) with extensive squamoceruminous debris and some granulation tissue. The middle ear space was found to be essentially absent, with tympanic membrane directly adherent to the promontory and over the footplate. Decision was made to avoid further reconstructive elements over the footplate and allow the dermis to apply directly to the footplate.

Description of procedure: the patient was brought to the operating room and placed in supine position. Following induction of general anesthetic and oroendotracheal intubation, correct site and surgery were verified, the patient prepped, draped and locally injected with 1% lidocaine with epinephrine 1:100,000.

The mastoid bowl was then meticulously cleaned. Facial canal identified and dehiscent area of facial nerve gently identified by palpitation. The patient received 8 mg of decadron prior to the beginning of procedure as well as ancef. A large amount of squamoceruminous debris around the partially extruded TORP was then carefully disimpacted and removed, noting squamous tissue and granulation tissue suggestive of ?psuedocholesteatoma formation?. This term is utilized as the material appeared to be trapped between the total ossicular reconstruction prosthesis and surrounding granulation tissue but did not really have a middle ear space was essentially obliterated with granulation tissue and cicatricial tissues, which were carefully debrided around the tract extending down onto the footplate. After ensuring all removal of squamous tissue and verifying direct apposition of the tympanic membrane/dermis to the oval window, original incision flaps were gently laid into a proximal position. It did not appear that repair of the tympanic membrane/dermis would be required given a relatively solid sheath of underlying granulation tissue/cicatrix and an absence of middle ear space in the posterior quadrants.

Ear was then copiously irrigated, suctioned, cleaned, and all squamous tissue s verified free from the extraction site. Flaps were laid back into position and ciloxan drops and solu-medrol instilled. Cotton ball with bacitracin was then placed in the concha bowl followed by band-aid dressing. The patient was suctioned, awakened and transported to the recovery room in stable condition.