Acquired stenosis of external ear canal secondary to trauma
ICD-10 H61.31 is a billable code used to indicate a diagnosis of acquired stenosis of external ear canal secondary to trauma.
Acquired stenosis of the 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 evaluation to assess the degree of canal narrowing. 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 proper reimbursement and tracking of treatment outcomes.
Detailed history of trauma, physical examination findings, and treatment plan.
Patients presenting with ear pain and history of trauma, requiring surgical intervention.
Ensure clear documentation of the mechanism of injury and any associated complications.
Comprehensive history and physical exam, including any referrals to specialists.
Initial evaluation of ear symptoms following trauma.
Document any conservative management strategies attempted before referral.
Used when surgical intervention is required to correct stenosis.
Detailed operative report and pre-operative assessment.
Otolaryngologists should document the extent of stenosis and any associated procedures performed.
Documentation should include a detailed history of the trauma, physical examination findings, and any treatment provided. It is essential to specify the mechanism of injury and any complications that arise.
