Acquired stenosis of left external ear canal secondary to trauma
ICD-10 H61.312 is a billable code used to indicate a diagnosis of acquired stenosis of left external ear canal secondary to trauma.
Acquired stenosis of the left external ear canal is a condition characterized by the narrowing of the ear canal due to trauma. This can occur from various forms of injury, including blunt force trauma, lacerations, or thermal injuries. The stenosis can lead to complications such as chronic otitis externa, hearing loss, and increased susceptibility to infections. Clinically, patients may present with symptoms such as ear pain, discharge, and a sensation of fullness in the ear. Diagnosis typically involves a thorough history and physical examination, often supplemented by otoscopic examination to assess the degree of stenosis and any associated pathology. Management may include conservative measures such as ear cleaning and topical antibiotics, or surgical interventions like canaloplasty or tympanoplasty in more severe cases. Accurate coding is essential for appropriate reimbursement and to reflect the complexity of the condition.
Detailed history of trauma, physical examination findings, and treatment plan.
Patients presenting with ear pain and history of trauma, chronic ear infections following trauma.
Ensure documentation reflects the severity of stenosis and any surgical interventions performed.
Immediate assessment of trauma, imaging if necessary, and initial treatment plan.
Patients with acute ear trauma presenting to the emergency department.
Document the mechanism of injury and any immediate interventions performed.
Often performed in conjunction with diagnosis of stenosis to clear the canal.
Document the need for cerumen removal due to stenosis.
Otolaryngologists may perform this procedure frequently in patients with stenosis.
Surgical intervention for severe stenosis.
Detailed surgical notes and post-operative care documentation.
Requires thorough documentation of pre-operative assessments.
The primary cause of H61.312 is trauma to the ear canal, which can result from various incidents such as accidents, falls, or blunt force injuries.
Acquired stenosis is linked to a specific history of trauma, while congenital stenosis is present from birth and not associated with any traumatic event.
