Cholesteatoma of mastoid, unspecified ear
ICD-10 H71.20 is a billable code used to indicate a diagnosis of cholesteatoma of mastoid, unspecified ear.
Cholesteatoma of the mastoid is a destructive and expanding growth of skin cells in the middle ear and/or mastoid process. It often arises as a complication of chronic otitis media, where the eustachian tube dysfunction leads to negative pressure in the middle ear, resulting in the retraction of the tympanic membrane. This retraction can create a pocket that traps skin cells and other debris, leading to the formation of a cholesteatoma. Patients may present with symptoms such as ear discharge, hearing loss, and sometimes pain or fullness in the ear. If left untreated, cholesteatomas can erode surrounding structures, leading to complications such as hearing loss, facial nerve paralysis, or intracranial infections. Diagnosis is typically made through clinical examination and imaging studies, such as CT scans, which can reveal the extent of the disease. Management often involves surgical intervention to remove the cholesteatoma and reconstruct the tympanic membrane, with the goal of preserving or restoring hearing and preventing complications.
Detailed clinical notes including history, physical examination findings, imaging results, and treatment plans.
Patients presenting with chronic ear infections, hearing loss, or post-operative follow-ups after cholesteatoma surgery.
Ensure clear documentation of the extent of cholesteatoma and any complications to support coding.
Audiometric evaluations and reports detailing the impact of cholesteatoma on hearing.
Assessment of hearing loss in patients with diagnosed cholesteatoma.
Document the relationship between cholesteatoma and hearing impairment for accurate coding.
Performed to remove cholesteatoma and reconstruct the tympanic membrane.
Operative report detailing the procedure, findings, and any complications.
Otolaryngologists must document the extent of the cholesteatoma and any associated procedures.
Cholesteatoma is primarily caused by chronic eustachian tube dysfunction leading to negative pressure in the middle ear, which can result in the retraction of the tympanic membrane and subsequent formation of a cholesteatoma.
