Good afternoon fellow ENT professionals! I am with hope I can get some feedback on how this case would be coded.
PREOPERATIVE DIAGNOSIS:
Left Epidermal inclusion cyst
POSTOPERATIVE DIAGNOSIS:
Left Squamous cell carcinoma of temporal bone
PROCEDURE PERFORMED:
Left Lateral temporal bone resection.
Left Facial nerve monitoring for 2 hours.
Left Use of operative microscope.
Left Temporalis muscle flap.
Left Local rotational flap to the ear, meatal closure
Biopsy Positive for squamous cell carcinoma
PREOPERATIVE HISTORY, INDICATION: Patient had no prior history of otologic disease until 2010 when he went swimming in contaminated water in Lake Michigan. This resulted in a severe mastoid infection requiring hospitalization and long-term IV antibiotics. He also stated he had emergent mastoid surgery performed on 2 separate occasions and rather quick sequence to help eradicate infection. Once infection had resolved he has been doing well with really no issue until last few months when he started to have recurrent left-sided otorrhea. He had developed a posterior subdermal cyst in his lateral bony ear canal obstructing normal oral toilet. This was thought to be reason for his recurrent infections. Infections are resolved with aggressive topical treatment but patient was recommended to have surgical removal of his postauricular cyst to help improve oral toilet. Preoperative CT scan showed a well aerated mastoid with no obvious bony erosion and typical findings one would see with history of recurrent otitis externa. During surgical approach to remove planned epidermal inclusion cyst patient had odd appearing tissue which was suspicious for
carcinoma. This was only noted after a postauricular incision was made. Frozen sections were taken that confirmed suspicion of carcinoma. I then left the operating room and went talk to patient's wife and discussed surgical findings. Options were made to stop surgery and closed wound or move forward with formal cancer resection. Decision was made to remove cancer which would entail a very similar postoperative recovery process and would and relatively little additional risk.
LATERAL TEMPORAL BONE RESECTION: Postauricular incision was made, ear was brought forward. The ear canal was transected lateral to the tumor. This area was transected and cutting through the medial portion of the tragal cartilage, and the pinna was retracted anteriorly. Next, the mastoid periosteum was incised posterior to the meatus and the mastoid periosteum was elevated superiorly and posteriorly, leaving the soft tissue along the medial meatus intact.
Patient had evidence of a prior canal wall up mastoidectomy. Once the ear was elevated forward and mastoid contents were evaluated it was noted that patient had posteriorly laterally based lesion that is actively eroding into the lateral ear canal bone. Was also invading mastoid air cell system inferiorly. Bone over the posterior fossa plate was partially eroded covering sigmoid sinus. Posterior bony ear canal was polished away using different sized diamond burs and all visible neoplastic tissue was removed. Areas of suspicion were biopsied and confirmed carcinoma. Multiple biopsies were taken throughout the surgical field to ensure complete tumor removal.
Bony ear canal was taken down to the facial nerve. Soft tissue contents and bony ear canal were removed. Bony ear canal was polished away up to the glenoid fossa air cells and the attic were removed. There was a suspicious lesion in the epitympanic air cells that was biopsied and also found to be positive for carcinoma. All air cells were opened and removed down to cortical bone. Soft tissue over sigmoid sinus was removed neoplastic tissue was scraped off the posterior fossa dura. Dura remained intact. There is no signs of CSF leak. There was a small pinpoint hole made in the sigmoid sinus that was easily controlled with Gelfoam with thrombin. Once all visible tumor was removed air was irrigated with copious amounts of warm saline and then rotational tissue flaps were
performed to close the wound. Once wound was closed patient was awakened from general anesthesia was taken to the recovery room in stable condition.
TEMPORALIS MUSCLE FLAP: The temporalis was then incised and was rotated inferiorly and then the mastoid periosteum that was elevated inferiorly had a pedicled inferiorly. This mastoid periosteum was rotated anteriorly and the temporalis muscle was rotated around inferiorly. This created a "Z-plasty" with mastoid periosteum and this covered the mastoid defect and gave a nice fibrous soft tissue bolster medial to the pinna. This was sutured into place using 3-0 Biosyn. The wound was again irrigated with warm saline and then the pinna was brought back into normal anatomic position and was closed with interrupted 3-0 Biosyn and interrupted 4-0 Vicryl.
USE OF OPERATIVE MICROSCOPE: Operative microscope was used throughout the case to aid in visualization and bony dissection along the temporal bone resection.
TISSUE TRANSFER TO THE EAR, OVER SEWING MEATUS: The skin of the lateral cartilaginous canal was dissected from the underlying cartilage, everted out of
the meatus. Anterior skin flap was rotated posteriorly, and excess skin removed. The anterior skin flap was sewn to the skin edge of the posterior meatus with interrupted chromic suture. Next the medial edge of the tragal cartilage was rotated posteriorly and sewn to the anterior edge of the concha cavum cartilage with interrupted absorbable suture. This gave a nice two layered closure to the meatus.
FACIAL NERVE MONITORING: Electrode montage was placed in orbicularis oris and orbicularis oculi and ground electrode was placed in the contralateral shoulder. The facial nerve monitor was tested for adequate function and was used to aid in preservation of the facial nerve throughout the case. This gave auditory feedback during the case if the facial nerve perineurium was touched inadvertently with the suction. Postoperatively, facial nerve function was completely normal. Facial nerve was intact.
A sterile Glasscock dressing was applied. The patient was awakened from general anesthesia and was taken to recovery room in stable condition.
Thank you in advance!
PREOPERATIVE DIAGNOSIS:
Left Epidermal inclusion cyst
POSTOPERATIVE DIAGNOSIS:
Left Squamous cell carcinoma of temporal bone
PROCEDURE PERFORMED:
Left Lateral temporal bone resection.
Left Facial nerve monitoring for 2 hours.
Left Use of operative microscope.
Left Temporalis muscle flap.
Left Local rotational flap to the ear, meatal closure
Biopsy Positive for squamous cell carcinoma
PREOPERATIVE HISTORY, INDICATION: Patient had no prior history of otologic disease until 2010 when he went swimming in contaminated water in Lake Michigan. This resulted in a severe mastoid infection requiring hospitalization and long-term IV antibiotics. He also stated he had emergent mastoid surgery performed on 2 separate occasions and rather quick sequence to help eradicate infection. Once infection had resolved he has been doing well with really no issue until last few months when he started to have recurrent left-sided otorrhea. He had developed a posterior subdermal cyst in his lateral bony ear canal obstructing normal oral toilet. This was thought to be reason for his recurrent infections. Infections are resolved with aggressive topical treatment but patient was recommended to have surgical removal of his postauricular cyst to help improve oral toilet. Preoperative CT scan showed a well aerated mastoid with no obvious bony erosion and typical findings one would see with history of recurrent otitis externa. During surgical approach to remove planned epidermal inclusion cyst patient had odd appearing tissue which was suspicious for
carcinoma. This was only noted after a postauricular incision was made. Frozen sections were taken that confirmed suspicion of carcinoma. I then left the operating room and went talk to patient's wife and discussed surgical findings. Options were made to stop surgery and closed wound or move forward with formal cancer resection. Decision was made to remove cancer which would entail a very similar postoperative recovery process and would and relatively little additional risk.
LATERAL TEMPORAL BONE RESECTION: Postauricular incision was made, ear was brought forward. The ear canal was transected lateral to the tumor. This area was transected and cutting through the medial portion of the tragal cartilage, and the pinna was retracted anteriorly. Next, the mastoid periosteum was incised posterior to the meatus and the mastoid periosteum was elevated superiorly and posteriorly, leaving the soft tissue along the medial meatus intact.
Patient had evidence of a prior canal wall up mastoidectomy. Once the ear was elevated forward and mastoid contents were evaluated it was noted that patient had posteriorly laterally based lesion that is actively eroding into the lateral ear canal bone. Was also invading mastoid air cell system inferiorly. Bone over the posterior fossa plate was partially eroded covering sigmoid sinus. Posterior bony ear canal was polished away using different sized diamond burs and all visible neoplastic tissue was removed. Areas of suspicion were biopsied and confirmed carcinoma. Multiple biopsies were taken throughout the surgical field to ensure complete tumor removal.
Bony ear canal was taken down to the facial nerve. Soft tissue contents and bony ear canal were removed. Bony ear canal was polished away up to the glenoid fossa air cells and the attic were removed. There was a suspicious lesion in the epitympanic air cells that was biopsied and also found to be positive for carcinoma. All air cells were opened and removed down to cortical bone. Soft tissue over sigmoid sinus was removed neoplastic tissue was scraped off the posterior fossa dura. Dura remained intact. There is no signs of CSF leak. There was a small pinpoint hole made in the sigmoid sinus that was easily controlled with Gelfoam with thrombin. Once all visible tumor was removed air was irrigated with copious amounts of warm saline and then rotational tissue flaps were
performed to close the wound. Once wound was closed patient was awakened from general anesthesia was taken to the recovery room in stable condition.
TEMPORALIS MUSCLE FLAP: The temporalis was then incised and was rotated inferiorly and then the mastoid periosteum that was elevated inferiorly had a pedicled inferiorly. This mastoid periosteum was rotated anteriorly and the temporalis muscle was rotated around inferiorly. This created a "Z-plasty" with mastoid periosteum and this covered the mastoid defect and gave a nice fibrous soft tissue bolster medial to the pinna. This was sutured into place using 3-0 Biosyn. The wound was again irrigated with warm saline and then the pinna was brought back into normal anatomic position and was closed with interrupted 3-0 Biosyn and interrupted 4-0 Vicryl.
USE OF OPERATIVE MICROSCOPE: Operative microscope was used throughout the case to aid in visualization and bony dissection along the temporal bone resection.
TISSUE TRANSFER TO THE EAR, OVER SEWING MEATUS: The skin of the lateral cartilaginous canal was dissected from the underlying cartilage, everted out of
the meatus. Anterior skin flap was rotated posteriorly, and excess skin removed. The anterior skin flap was sewn to the skin edge of the posterior meatus with interrupted chromic suture. Next the medial edge of the tragal cartilage was rotated posteriorly and sewn to the anterior edge of the concha cavum cartilage with interrupted absorbable suture. This gave a nice two layered closure to the meatus.
FACIAL NERVE MONITORING: Electrode montage was placed in orbicularis oris and orbicularis oculi and ground electrode was placed in the contralateral shoulder. The facial nerve monitor was tested for adequate function and was used to aid in preservation of the facial nerve throughout the case. This gave auditory feedback during the case if the facial nerve perineurium was touched inadvertently with the suction. Postoperatively, facial nerve function was completely normal. Facial nerve was intact.
A sterile Glasscock dressing was applied. The patient was awakened from general anesthesia and was taken to recovery room in stable condition.
Thank you in advance!