# 69620



## pajohnson (Apr 2, 2014)

I need to know if I need to use 69620 bilaterally? What do you all think?

PREOPERATIVE DIAGNOSIS: 
1.  Chronic otitis media, right ear with perforation.  
2.  Left retained ear tube.

POSTOPERATIVE DIAGNOSIS: 
1.  Chronic otitis media, right ear with perforation. 
2.  Left retained ear tube.

PROCEDURE PERFORMED: 
1.  Fat graft myringoplasty, right tympanic membrane.  
2.  Removal of left ear tube and paper patch myringoplasty.

ANESTHESIA:  	General.
CONDITION:	Improved. 

OPERATIVE SUMMARY:  The patient was placed on the operating table in the supine position.  He was scrubbed and draped in the usual manner for the above surgical procedure.  Under binocular microscopy, the left ear tube was gently rotated out of the tympanic membrane and removed from the ear canal.  The edges of the perforation were freshened with a Rosen needle and the undersurface gently abraded with a tab knife.  A sterile paper patch was then placed upon the tympanic membrane covering the perforation in toto. 

The right ear was then examined under binocular microscopy.  No ear tube was noted.  The margins of the perforation were freshened with a Rosen needle and the undersurface, as well as the superior lateral surface, gently debrided with a Rosen needle.  Following this, Gelfoam pledgets were placed in the middle ear space to prevent the fat graft from falling medially.  

Next, an incision was made in the inferior portion of the earlobe and a fat graft was harvested.  The wound was then closed with a running suture of 6-0 mild chromic.  The fat graft was then used to plug the hole in the tympanic membrane in a dumbbell shape fashion.  Then Gelfoam pledgets were used around the perforation to hold the fat graft securely in place.


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## maebelle@gmail.com (Apr 16, 2014)

You would use code 69620-RT for the fat graft myringoplasty and 69610-LT for the paper patch myringoplasty.


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