Unspecified cholesteatoma, right ear
ICD-10 H71.91 is a billable code used to indicate a diagnosis of unspecified cholesteatoma, right ear.
Cholesteatoma is an abnormal skin growth that can develop in the middle ear and mastoid process, often as a result of chronic ear infections. It typically arises when skin cells and other debris accumulate in the ear, leading to the formation of a cyst-like sac. This condition can cause significant complications, including hearing loss, recurrent infections, and damage to surrounding structures. In the case of unspecified cholesteatoma of the right ear, the diagnosis does not specify the type or extent of the cholesteatoma, which can complicate treatment decisions. Patients may present with symptoms such as ear discharge, hearing impairment, and a sensation of fullness in the ear. Diagnosis is primarily made through clinical examination and imaging studies, such as CT scans, which help assess the extent of the cholesteatoma and any associated complications. Management often involves surgical intervention to remove the cholesteatoma and repair any damage to the ear structures. Postoperative care is crucial to monitor for recurrence and manage any complications.
Detailed clinical notes including history, physical examination findings, imaging results, and treatment plans.
Patients presenting with chronic ear infections, hearing loss, or recurrent otorrhea.
Ensure documentation reflects the extent of the cholesteatoma and any surgical interventions performed.
Audiometric evaluations and reports detailing the degree of hearing loss.
Patients undergoing hearing assessments post-cholesteatoma surgery.
Document the relationship between cholesteatoma and hearing impairment for accurate coding.
Performed to remove cholesteatoma and repair the tympanic membrane.
Operative reports detailing the procedure and findings.
Otolaryngologists must document the extent of the cholesteatoma and any complications.
Unspecified cholesteatoma (H71.91) does not detail the type or cause, while acquired cholesteatoma (H71.93) indicates that it developed due to chronic ear conditions.
