T13-2B OPERATIVE REPORT, ADENOIDECTOMY, PE TUBES

question 6

Essay

T13-2B OPERATIVE REPORT, ADENOIDECTOMY, PE TUBES
PREOPERATIVE DIAGNOSES:
1. Bilateral recurrent acute otitis media.
2. Chronic otitis media.
3. Conductive hearing loss.
4. Nasal obstruction secondary to adenoid hypertrophy.
POSTOPERATIVE DIAGNOSES:
1. Bilateral recurrent acute otitis media.
2. Chronic otitis media.
3. Conductive hearing loss.
4. Nasal obstruction secondary to adenoid hypertrophy.
PROCEDURE PERFORMED:
1. Bilateral PE (pressure equalization) tube placement.
2. Primary adenoidectomy.
3. Intraoperative ABR (auditory brain-stem response) testing.
OPERATIVE NOTE: The patient is a 12-year-old who was seen in the office and diagnosed with the above condition. The decision was made in consultation with his parents to undergo the above-named procedure.
He was admitted through the same-day surgery program, where he was administered a general anesthetic by intravenous injection. He was then intubated endotracheally. A 4-mm (millimeter) speculum was inserted into the right ear, and wax was removed from the canal. An anterior/inferior incision was created, and a large amount of glue-like material was removed from the middle ear cavity. PE (pressure equalization) tube was placed through the incision, and two drops of Cortisporin were applied. The speculum was removed and inserted in the opposite ear. Again, wax was removed from the canal. An anterior/inferior incision was created, and a glue-like material was removed from the middle ear cavity. PE tube was placed through the incision, and two drops of Cortisporin were applied. The speculum was then removed. The patient was turned 90 degrees. A Jennings gag was placed in the mouth and expanded. This was secured to a Mayo stand. Two red rubber catheters were placed through the nose and brought out through the mouth. These were secured with snaps. This was done to elevate the palate. The laryngeal mirror was placed in the nasopharynx. The adenoid tissue was visualized. There was a significant amount present here. Suction cautery was then used to remove this in a systematic fashion. This produced a marked improvement in the nasal airway. We then turned the patient back 90 degrees, and the inserts were placed in each ear for limited ABR testing. This was performed under my supervision. When this was completed, the patient was allowed to recover from the general anesthetic and taken to the post anesthesia care unit in stable condition. There were no complications during this procedure.
T13-2B:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

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