Acute mastoiditis without complications, bilateral
ICD-10 H70.003 is a billable code used to indicate a diagnosis of acute mastoiditis without complications, bilateral.
Acute mastoiditis is an infection of the mastoid process, typically resulting from an untreated or inadequately treated acute otitis media. This condition is characterized by inflammation and infection of the mastoid air cells, leading to symptoms such as ear pain, fever, and swelling behind the ear. In bilateral cases, both mastoids are affected, which can complicate the clinical picture. Patients may present with otorrhea (ear discharge), hearing loss, and systemic symptoms like malaise. Diagnosis is primarily clinical, supported by imaging studies such as CT scans to assess the extent of the infection and rule out complications like abscess formation. Management typically involves antibiotic therapy, and in some cases, surgical intervention such as mastoidectomy may be necessary to drain infected material. Prompt treatment is crucial to prevent complications, including hearing loss and intracranial infections.
Detailed clinical notes including history, physical examination findings, imaging results, and treatment plans.
Patients presenting with ear pain, fever, and swelling behind the ear, often following an upper respiratory infection.
Ensure clear documentation of bilateral involvement and any surgical interventions performed.
Thorough history of recurrent otitis media, physical exam findings, and any prior treatments.
Children with recurrent ear infections presenting with acute mastoiditis symptoms.
Consider age-related factors in treatment and documentation, especially in young children.
Performed in cases of severe mastoiditis requiring surgical intervention.
Document indications for surgery, findings during the procedure, and post-operative care.
Otolaryngologists must ensure thorough documentation of the surgical necessity and outcomes.
Common symptoms include ear pain, fever, swelling behind the ear, discharge from the ear, and hearing loss. In bilateral cases, symptoms may be more pronounced.
Diagnosis is primarily clinical, supported by imaging studies such as CT scans to assess the extent of the infection and rule out complications.
Treatment usually involves antibiotics, and in severe cases, surgical intervention such as mastoidectomy may be necessary.
Complications can include hearing loss, intracranial infections, and the development of abscesses.
