Preauricular sinus and cyst
ICD-10 Q18.1 is a billable code used to indicate a diagnosis of preauricular sinus and cyst.
Preauricular sinus and cyst are congenital malformations characterized by the presence of a small pit or cyst located near the ear, typically at the anterior margin of the auricle. These anomalies arise from incomplete fusion of the embryonic hillocks that form the external ear. While often asymptomatic, they can become infected or inflamed, leading to complications that may require surgical intervention. Preauricular sinuses are more common in certain populations and can be associated with other congenital anomalies, particularly those affecting the ear and face. Clinicians should assess for associated conditions, such as hearing loss or other ear malformations, as part of a comprehensive evaluation. Diagnosis is primarily clinical, but imaging may be utilized in complicated cases to assess the extent of the sinus or cyst. Management typically involves monitoring for infection, and surgical excision may be indicated for recurrent infections or cosmetic concerns.
Detailed history of the child's ear development, any associated symptoms, and family history of congenital conditions.
A pediatric patient presents with recurrent ear infections and a visible preauricular sinus; evaluation for surgical intervention is considered.
Pediatric coders must ensure that all associated conditions are documented to avoid undercoding or misrepresentation of the patient's clinical picture.
Genetic counseling notes, family history of congenital anomalies, and any genetic testing results.
A child with a preauricular sinus is evaluated for potential syndromic associations, prompting genetic testing.
Genetic coders should be aware of the implications of associated chromosomal abnormalities and ensure accurate coding of any syndromic conditions.
Used when a preauricular cyst is excised due to recurrent infections.
Document the size, location, and reason for excision.
Ensure that the procedure is linked to the diagnosis of preauricular sinus.
Common complications include recurrent infections, abscess formation, and potential hearing loss if associated with other ear anomalies. Surgical intervention may be necessary for recurrent cases.
