New to coding need help
PREOPERATFVE DIAGNOSIS: Chronic right tympanic membrane perforation.
POSTOPERATIVE DIAGNOSIS: Chronic right tympanic membrane perforation.
NAME OF PROCEDURE- Right type 1 tympanoplasty postauricular approach, posterior graft harvest.
BLOOD LOSS: Less than 20 ml.
FINDINGS Patient is a pleasant 18-year-old white male with a history of the above noted diagnoses. Operative findings included anterior superior perforation. It extended into the complete pars flaccida. The ossicles were otherwise intact. The chorda tympani nerve was protected.
TECHNIQUE: Patient was brought into the operative suite and comfortably positioned on the table. General endotracheal anesthesia was induced. The bed was turned 180 degrees in a clockwise fashion. His right ear was prepped and draped in the usual sterile fashion. The external canal and postauricular sulcus was injected with TA lidocaine with 1:100,000 epinephrine. A posterior tympanomeatal flap was then elevated with the Beaver blades. The annulus was carefully lifted out of the sulcus. An anterior and superior tympanomeatal flap was elevated as well. This allowed the deliverance of the tympanic membrane off the lateral process of the malleus but keeping it tethered to the umbo The perforation free edges were then freshened with a pick and a cup forceps.
A posterior incision was then made with a sharp knife in the postauricular sulcus. Dissection was earned down to the superficial temporal fascia and the soft tissues over the mastoid. A piece of deep temporal fascia was harvested and placed in the fascia press. An incision was made through the tympanomastoid suture line and down, bisecting the soft tissues over the mastoid. The periosteal elevator was then used to elevate the posterior external canal skin. A Penrose drain was placed through the external canal and used to elevate the area anteriorly. This gave a much better view of the tympanic membrane. This allowed further dissection in the anterior sulcus, exposing the tympanic membrane perforation more clearly.
The graft as then appropriately shaped and placed under the tympanic membrane perforation with an anterior lobe extending into the perforation and the posterior lobe wrapped around the lateral process of the malleus and into the posterior aspect of the tympanic membrane. The middle ear was then packed with Merogel and Gelfoam soaked in Ciprodex. The flap and graft were reflected back into normal position, making sure all edges of the perforation were covered underneath by the graft. The Penrose drain was removed. The ear was placed into normal position and making sure the lateral aspect of the flap was in normal positioning. The tissues over the mastoid were then closed with interrupted 3-0 chromic sutures and the ear closed in a layered fashion with 3-0 chromic sutures. The skin was closed with subcuticular 3-0 chromic sutures and Steri-Strips. The external canal was packed with Gelfoam, Merogel soaked in Ciprodex, a cotton ball soaked in bacitracin ointment and a pressure dressing applied. The drapes and instruments were removed. The patient was returned to the care of Anesthesia, allowed to awaken, extubated and transported in stable condition to the recovery room having tolerated the procedure quite well.
I'm also new, but here's what I came up with.
384.20-perforation of tympanic membrane, unspecified
19.4-tympanoplasty with graft