Diffuse cholesteatosis, left ear
ICD-10 H71.32 is a billable code used to indicate a diagnosis of diffuse cholesteatosis, left ear.
Diffuse cholesteatosis of the left ear is a condition characterized by the abnormal accumulation of skin cells and other debris in the middle ear and mastoid process. This condition often arises from chronic otitis media, where recurrent infections lead to the formation of a cyst-like structure filled with keratin and other materials. Patients may present with symptoms such as hearing loss, ear fullness, and discharge from the ear. The presence of cholesteatoma can lead to further complications, including erosion of surrounding structures, which may result in facial nerve paralysis or intracranial infections if left untreated. Diagnosis typically involves otoscopic examination, audiometric testing, and imaging studies such as CT scans to assess the extent of the disease. Management often requires surgical intervention to remove the cholesteatoma and restore normal ear function, which may include tympanoplasty or mastoidectomy. Postoperative care and monitoring are crucial to prevent recurrence and manage any complications.
Detailed notes on patient history, physical examination findings, imaging results, and surgical procedures performed.
Patients presenting with chronic ear infections, hearing loss, or complications from cholesteatoma.
Ensure that all surgical interventions and follow-up care are documented to support coding.
Audiometric evaluations and reports detailing the extent of hearing loss.
Assessment of hearing loss in patients with known cholesteatosis.
Document the relationship between cholesteatosis and hearing impairment for accurate coding.
Performed to repair the tympanic membrane and remove cholesteatoma.
Operative report detailing the procedure and findings.
Otolaryngologists must document the extent of cholesteatoma removal.
Common symptoms include hearing loss, ear fullness, discharge from the ear, and in some cases, facial weakness due to nerve involvement.
