I have a case where the physician has openly repaired a maxillary sinus fracture and release/decompressed the intraorbital nerve. I can not find anything that even remotely resembles that was done for a cpt code. I have attached the op report below in hopes that someone out there can give me some direction.

PREOPERATIVE DIAGNOSIS: Right maxilla fracture.

POSTOPERATIVE DIAGNOSIS: Right maxilla fracture.

PROCEDURES: 1. Open repair of septal nasal fracture.
2. Bilateral turbinate outfracture.
3. Exploration, repair and nerve release, right maxilla.


DESCRIPTION OF PROCEDURE: The indications, alternatives, risks, benefits, and complications of the procedure including bleeding, infection, nasal airway obstruction, the possible need for secondary procedures, snoring, sinusitis, as well as asymmetry, were all discussed preoperatively. Questions were answered and postoperative instructions were reviewed.

The patient was taken to the operating room and given general anesthesia. 10 mL of 1% Xylocaine with 1:100,000 epinephrine were infiltrated in both sides of the septum, the nasal tip, and underneath both nasal bones, the columella, as well as the nasolabial neurovascular bundles. Next, 2 mL of 1:1000 epinephrine on 6 cotton pledgets were placed in the nose with three pledgets on each side. The surgeon scrubbed, gowned and gloved. The patient was prepped and draped in the usual fashion. The cotton pledgets were removed.

Brown-Adsons were used to grasp the columella. A 15 blade was used to make a transfixion incision on the left side. The mucoperichondrium and mucoperiosteum were elevated off the quadrangular cartilage and the perpendicular plate on the left side. The offending portions of the septum were taken down with the Cottle, the Freer, and the double-action scissors posteriorly, leaving support for the anterior septum. A 2-mm inferior strip was taken in order to place the septum back in midline. Next, 4-0 plain on a straight needle was used in a mattress-type fashion to sew the mucoperichondrial flaps together, tying the knot on the left side. The transfixion incision was closed with interrupted 5-0 plain on a P3 needle.

An incision was made just superior to the anterior, inferior turbinate on each side. The Cottle was used to develop a "pocket" underneath the nasal bones on each side. The 4-mm chisel was used to accomplish lateral and medial osteotomies on each side. This allowed me to place the nose back into midline. These incisions were closed with 5-0 plain on a P3 needle. The middle and inferior turbinates were gently outfractured with a Boise to further open up the nasal airway. The nose was cleansed. Mastisol was applied and 2 layers of paper tape. Then, an Aqua splint was formed to support the nose externally. A drip pad was applied.

Prior to the nose being secured with the tape as described above, a new #15 blade was used to make an incision in the canine fossa on the right side. Dissection was taken down to the periosteum. There was a fracture here that was followed superiorly. The infraorbital nerve was released from its impingement. The medial superior aspect of the maxilla was pushed back out using a finger after opening out the inferior, anterior, and lateral canine fossa with Hajek.

Old blood was suctioned out of the maxillary sinus and then this area was irrigated. The maxillary ostium was visualized and opened (septal fracture had been against this on the medial side). Because of an intradermal contracting hematoma on the right side, the nose was secured with tape (without a splint). The canine fossa was closed with 3-0 chromic. The globes were watched during the entire case. There were no complications. Sponge and needle counts were correct. The patient tolerated the procedure well, left the operating room in a stable condition.