The following is a long Operative Report for unlisted procedure 69949. Is there an alternative code?
The patient was identified in the preoperative holding area and taken back to the operating room. A
surgical pause was performed to identify the patient and the procedure to be performed. Once atl
were in agreement, surgery commenced. General anesthesia and endotracheal intubation was performed.
The table was turned 180 degrees. Facial nerve monitors were placed. The patient was shaved,
prepared and draped in a sterile fashion.
The binocular microscope was used to visualize the right ear canal. The ear canal was injected with
1o/o lidocaine with 1:100k epinephrine. Standard tympanomeatal flap incisions were made with a
sickle and round knife at 6 o'clock and 12 o'clock.
A small postauricular incision was made and the soft tissue was pulled through and a fascia graft
was harvested with scissors. The incision was closed with 5-0 fast absorbing gut.
The speculum and holder were positioned to visualize the right ear. The tympanomeatal flap was
elevated. The middle ear was entered with a Rosen needle and the annulus was elevated, and the
tympanic membrane was reflected anteriorly to reveal the middle ear space.The posterosuperior edge
of the EAC bone was curetted until the oval window was adequately visualized. Findings were as
noted above. The round window and the space around the oval window were packed with the previously
harvested fascia. The tympanomeatal flap was re- draped and a single disc of gelfoam was placed
over the canal incision. The patient was turned back to anesthesia for uneventfulawakening and
extubation.
The patient was identified in the preoperative holding area and taken back to the operating room. A
surgical pause was performed to identify the patient and the procedure to be performed. Once atl
were in agreement, surgery commenced. General anesthesia and endotracheal intubation was performed.
The table was turned 180 degrees. Facial nerve monitors were placed. The patient was shaved,
prepared and draped in a sterile fashion.
The binocular microscope was used to visualize the right ear canal. The ear canal was injected with
1o/o lidocaine with 1:100k epinephrine. Standard tympanomeatal flap incisions were made with a
sickle and round knife at 6 o'clock and 12 o'clock.
A small postauricular incision was made and the soft tissue was pulled through and a fascia graft
was harvested with scissors. The incision was closed with 5-0 fast absorbing gut.
The speculum and holder were positioned to visualize the right ear. The tympanomeatal flap was
elevated. The middle ear was entered with a Rosen needle and the annulus was elevated, and the
tympanic membrane was reflected anteriorly to reveal the middle ear space.The posterosuperior edge
of the EAC bone was curetted until the oval window was adequately visualized. Findings were as
noted above. The round window and the space around the oval window were packed with the previously
harvested fascia. The tympanomeatal flap was re- draped and a single disc of gelfoam was placed
over the canal incision. The patient was turned back to anesthesia for uneventfulawakening and
extubation.