Cholesteatoma of mastoid, right ear
ICD-10 H71.21 is a billable code used to indicate a diagnosis of cholesteatoma of mastoid, right ear.
Cholesteatoma of the mastoid process is a destructive and expanding growth of skin cells and other tissues in the middle ear and mastoid process. This condition often arises as a complication of chronic otitis media, where repeated infections lead to the accumulation of skin cells and debris. The cholesteatoma can erode surrounding structures, including the mastoid bone, leading to potential complications such as hearing loss, dizziness, and facial nerve paralysis. Patients may present with symptoms such as ear discharge, hearing impairment, and a sensation of fullness in the ear. Diagnosis typically involves otoscopic examination, imaging studies like CT scans, and audiometric testing to assess hearing loss. Management often requires surgical intervention to remove the cholesteatoma and repair any damage to the ear structures. Postoperative care is crucial to monitor for recurrence and manage any complications.
Detailed notes on the patient's history, physical examination findings, imaging results, and surgical details.
Patients presenting with chronic ear infections, hearing loss, or complications from cholesteatoma.
Ensure that all surgical interventions and follow-up visits are documented to support coding.
Audiometric evaluations and reports detailing the extent of hearing loss.
Assessment of hearing loss in patients with known cholesteatoma.
Document the relationship between the cholesteatoma and hearing impairment.
Performed to remove cholesteatoma and repair the mastoid process.
Operative report detailing the procedure and findings.
Otolaryngology specialists must ensure all surgical details are documented.
Cholesteatoma is primarily caused by chronic ear infections, which lead to the accumulation of skin cells and debris in the middle ear.
