Perforation of tympanic membrane
Chapter 8:Diseases of the ear and mastoid process
ICD-10 H72 is a billable code used to indicate a diagnosis of perforation of tympanic membrane.
Perforation of the tympanic membrane, commonly known as a ruptured eardrum, occurs when there is a hole or tear in the thin tissue that separates the ear canal from the middle ear. This condition can result from various causes, including infections (such as otitis media), trauma, sudden pressure changes, or foreign objects. Clinically, patients may present with symptoms such as ear pain, hearing loss, tinnitus, and sometimes discharge from the ear. Diagnosis is typically made through otoscopic examination, which reveals the perforation and may also show signs of infection or fluid in the middle ear. Management of tympanic membrane perforation often involves conservative measures, such as keeping the ear dry and monitoring for signs of infection. In some cases, surgical intervention, such as tympanoplasty, may be necessary to repair the perforation, especially if it does not heal on its own or if there is significant hearing loss. The prognosis is generally good, with many perforations healing spontaneously, but complications can arise if infections are not adequately treated.
Detailed history of ear symptoms, otoscopic findings, and treatment plan.
Patients presenting with ear pain, hearing loss, or discharge.
Ensure documentation reflects the cause of perforation and any surgical interventions performed.
History of present illness, physical examination findings, and referral notes.
Patients with acute ear infections or trauma to the ear.
Document any referrals to specialists for further management.
Used when surgical repair of the tympanic membrane is necessary.
Document the indication for surgery and pre-operative assessments.
Otolaryngologists must ensure all surgical notes are complete and accurate.
Common causes include acute otitis media, trauma, barotrauma, and foreign body insertion.
Diagnosis is typically made through otoscopic examination, which reveals the presence of a perforation and may show signs of infection.
Management may include observation, antibiotics for infection, and surgical repair if the perforation does not heal spontaneously.
