Diffuse cholesteatosis, bilateral
ICD-10 H71.33 is a billable code used to indicate a diagnosis of diffuse cholesteatosis, bilateral.
Diffuse cholesteatosis, bilateral, is a condition characterized by the abnormal accumulation of cholesteatoma tissue in both ears, leading to potential complications such as hearing loss, otitis media, and vestibular dysfunction. Cholesteatomas are cyst-like lesions that can erode surrounding structures, including the mastoid process, and may result from chronic ear infections or eustachian tube dysfunction. Clinically, patients may present with symptoms such as ear fullness, drainage, tinnitus, and progressive hearing loss. Diagnosis typically involves otoscopic examination, audiometry, and imaging studies like CT scans to assess the extent of the disease and any associated complications. Management often requires surgical intervention to remove the cholesteatoma and restore ear function, with follow-up care to monitor for recurrence. The bilateral nature of the condition necessitates careful evaluation and treatment planning to address both ears simultaneously, which can complicate the clinical management and coding process.
Detailed surgical notes, imaging results, and audiometric evaluations.
Patients presenting with chronic ear infections, hearing loss, or post-operative follow-ups.
Ensure clear documentation of the extent of cholesteatosis and any surgical interventions performed.
Comprehensive audiometric evaluations and reports on hearing loss progression.
Patients with hearing loss secondary to cholesteatosis or post-surgical assessments.
Document the relationship between cholesteatosis and hearing impairment for accurate coding.
Performed to remove cholesteatoma and repair the tympanic membrane.
Surgical reports detailing the extent of cholesteatoma and any reconstruction performed.
Otolaryngologists must ensure comprehensive documentation of the surgical approach and findings.
Diffuse cholesteatosis is primarily caused by chronic ear infections and eustachian tube dysfunction, leading to the accumulation of skin cells and debris in the middle ear.
Diagnosis is made through clinical evaluation, audiometric testing, and imaging studies such as CT scans to assess the extent of cholesteatoma.
Treatment typically involves surgical intervention to remove the cholesteatoma and restore ear function, along with follow-up care to monitor for recurrence.
