Removal of Chrondrosarcoma of Middle Turbinate
We are having a standoff in this office due to this procedure can someone please give us some insight on this issue?
Please review the following op note? What do we use for the excision of the middle turbinate, we really don't want to use 30999 as it limits us to $200 allowable.
Amy M. Cypert-Barton, RMA, CCS
This is a ?-year-old boy who previously had left endoscopic sinus surgery with partial excision of an unidentified mass from the left middle turbinate. Subsequently pathology report was returned after second opinion at M.D. Anderson as being either a grade 1 chondrosarcoma or possibly an atypical chondroma. It was felt to have low metastatic potential, possibly to be locally aggressive.
Based on this, I have recommended a return to the operating room for debridement of the ethmoid cavity as well as complete excision of the left middle turbinate. We have carefully discussed the potential risks, including a higher risk of spinal fluid leak, as well as possible retained tumor and the potential for recurrence. Christianâ€™s mother wishes to proceed and signed the consent form.
Operative Procedure: The patient was taken to the operating room and placed on the operating room table in supine position. After adequate general endotracheal anesthesia was induced, the left nostril was examined. He had already been sprayed with Afrin. The left middle turbinate was injected with 2 cc of 1% lidocaine with 1:100,000 dilution of epinephrine and he was repacked with Afrin-soaked pledgets for approximately 5 minutes. He was draped in a sterile fashion. At this point the packs were removed and a 0-degree endoscope was attached to a video camera and monitor. Exam revealed a surprising degree of regrowth of the tumor from the medial residual wall of the middle turbinate. The other concern is this appeared now to extend much more posteriorly than it had previously.
Slow piece-meal excision of the middle turbinate was performed all the way back to the face of the sphenoid and up along the fovea. Great care was taken not to torque the middle turbinate so as to reduce the risk of cribriform plate fracture or foveal fracture. No evidence of spinal fluid leakage was noted. The turbinate was excised to the point rostral to obvious tumor. Posteriorly, again, it had been taken back to the sphenoid. All visible tumor was gone. The ethmoids were debrided. Fairly heavy scarring was present. These were opened up. The frontal recess was opened as well.
Bleeding was encountered at the face of the sphenoid and was controlled with bipolar cautery and topical Afrin packing.
Amy Cypert-Barton, NRMA, CCS, CPC