I'm in need of some help with coding for my ENT. here is his op report
FINDINGS: Significant bullet fragments and main body of bullet contained within the left posterior canal wall and floor of the ear canal and into the anterior mastoid air cells.
BLOOD LOSS: 5 mL
SPECIMEN REMOVED: None, other than the foreign body.
PROCEDURE DESCRIPTION: The patient was brought to the operating room and given a general anesthetic via laryngeal mask airway. Area was prepped and draped in sterile manner with Betadine scrub. Xylocaine 2% with 1:100,000 adrenaline was used for infiltration along the postauricular proposed incision line and in the ear canal 4-quadrant canal injection. The operative microscope was brought into position and the ear canal was examined and there was an obvious metallic object filling the ear canal laterally. It appeared to be coming from the posterior canal wall. Tympanic membrane could not be seen due to the foreign body obstructing the view of the canal and tympanic membrane distally. A postauricular incision was created with a 15 blade knife, a periosteal membrane was incised with a 15-blade knife and with needle tip cautery. Periosteal elevation was performed, elevating the periosteum and soft tissues of the ear canal along the posterior margin and elevating this anteriorly keeping the canal skin anterior to the dissection. Self-retaining retraction was then utilized and then the otic drill was used to take down the bone and overhanging bony ridge that was covering the exposure of the bullet. The bullet was firmly adherent to the bone and was not able to be freed by manipulation with instrumentation. Went ahead and started to take down the anterior portion of the mastoid air cells and down to the bullet fragment itself. It became apparent that the foreign body would have to be removed with a drill and was meticulously and carefully removed piecemeal with the drill, removing the lead and metallic over casing from the operative bed. Great care was taken to avoid any trauma to the soft tissues, specifically any risk to the facial nerve that would have been found likely just deep to the foreign body along the posterior ear canal inferiorly. Extensive drilling was accomplished, removing the bulk of the foreign body and smoothing this down into the mastoid itself. There was also apparently a thickened mucus and what appeared to be like epithelial debris, possibly consistent with cholesteatoma that likely retained epithelial debris that was not able to be cleaned due to the obstruction by the foreign body. Once this was opened up, I was able to suction this out of the operative bed and there was a traumatized appearing canal wall that was located superiorly along the posterior canal wall that on suctioning the area was noted that soft tissue granulation tissue was able to be removed and this opened up the view of the tympanic membrane. The opening was widened further with the otic drill and a good view with the tympanic membrane was then obtained. It appeared to be intact and did not have traumatized epithelium along the lateral surface of the tympanic membrane. After this was accomplished, there was still some bullet fragments remaining. These were smoothed down with the otic drill and the location of the foreign body. After removal created a fairly significant opening that was along the floor of the canal and into the anterior mastoid air cells. This was cleaned and suctioned clear. The cavity and the operative bed was copiously irrigated, removing small fragments of metallic remnants from the drilling until the vast majority of this was completely cleaned and suctioned clear. At this time, the ear canal was then packed up against the tympanic membrane using Gelfoam pledgets moistened in Cipro HC otic drops and placing multiple pledgets filling the ear canal and the operative bed from the ear canal side, placing the ear speculum in the canal and after this was noted that a good view of the canal and the tympanic membrane was obtained further packing was accomplished and completed the ear canal out to the entrance to the ear canal. A sterile cotton ball was applied to the ear canal after this and the closure was with layered approximation with 3-0 Vicryl interrupted for the muscle layer and subcutaneous closure and the skin was closed with 5-0 Prolene continuous over-and-over suture technique. A standard mastoid dressing was then applied. Patient was allowed to recover, sent to the recovery room in satisfactory condition. Upon awakening, patient's facial nerve was functioning normally.
FINAL DIAGNOSIS: Foreign body, left ear secondary to a gunshot wound. this took about 2 1/2 hours
FINDINGS: Significant bullet fragments and main body of bullet contained within the left posterior canal wall and floor of the ear canal and into the anterior mastoid air cells.
BLOOD LOSS: 5 mL
SPECIMEN REMOVED: None, other than the foreign body.
PROCEDURE DESCRIPTION: The patient was brought to the operating room and given a general anesthetic via laryngeal mask airway. Area was prepped and draped in sterile manner with Betadine scrub. Xylocaine 2% with 1:100,000 adrenaline was used for infiltration along the postauricular proposed incision line and in the ear canal 4-quadrant canal injection. The operative microscope was brought into position and the ear canal was examined and there was an obvious metallic object filling the ear canal laterally. It appeared to be coming from the posterior canal wall. Tympanic membrane could not be seen due to the foreign body obstructing the view of the canal and tympanic membrane distally. A postauricular incision was created with a 15 blade knife, a periosteal membrane was incised with a 15-blade knife and with needle tip cautery. Periosteal elevation was performed, elevating the periosteum and soft tissues of the ear canal along the posterior margin and elevating this anteriorly keeping the canal skin anterior to the dissection. Self-retaining retraction was then utilized and then the otic drill was used to take down the bone and overhanging bony ridge that was covering the exposure of the bullet. The bullet was firmly adherent to the bone and was not able to be freed by manipulation with instrumentation. Went ahead and started to take down the anterior portion of the mastoid air cells and down to the bullet fragment itself. It became apparent that the foreign body would have to be removed with a drill and was meticulously and carefully removed piecemeal with the drill, removing the lead and metallic over casing from the operative bed. Great care was taken to avoid any trauma to the soft tissues, specifically any risk to the facial nerve that would have been found likely just deep to the foreign body along the posterior ear canal inferiorly. Extensive drilling was accomplished, removing the bulk of the foreign body and smoothing this down into the mastoid itself. There was also apparently a thickened mucus and what appeared to be like epithelial debris, possibly consistent with cholesteatoma that likely retained epithelial debris that was not able to be cleaned due to the obstruction by the foreign body. Once this was opened up, I was able to suction this out of the operative bed and there was a traumatized appearing canal wall that was located superiorly along the posterior canal wall that on suctioning the area was noted that soft tissue granulation tissue was able to be removed and this opened up the view of the tympanic membrane. The opening was widened further with the otic drill and a good view with the tympanic membrane was then obtained. It appeared to be intact and did not have traumatized epithelium along the lateral surface of the tympanic membrane. After this was accomplished, there was still some bullet fragments remaining. These were smoothed down with the otic drill and the location of the foreign body. After removal created a fairly significant opening that was along the floor of the canal and into the anterior mastoid air cells. This was cleaned and suctioned clear. The cavity and the operative bed was copiously irrigated, removing small fragments of metallic remnants from the drilling until the vast majority of this was completely cleaned and suctioned clear. At this time, the ear canal was then packed up against the tympanic membrane using Gelfoam pledgets moistened in Cipro HC otic drops and placing multiple pledgets filling the ear canal and the operative bed from the ear canal side, placing the ear speculum in the canal and after this was noted that a good view of the canal and the tympanic membrane was obtained further packing was accomplished and completed the ear canal out to the entrance to the ear canal. A sterile cotton ball was applied to the ear canal after this and the closure was with layered approximation with 3-0 Vicryl interrupted for the muscle layer and subcutaneous closure and the skin was closed with 5-0 Prolene continuous over-and-over suture technique. A standard mastoid dressing was then applied. Patient was allowed to recover, sent to the recovery room in satisfactory condition. Upon awakening, patient's facial nerve was functioning normally.
FINAL DIAGNOSIS: Foreign body, left ear secondary to a gunshot wound. this took about 2 1/2 hours
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