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Frontal sinus trephination bilateral with endoscopic drainage of ethmoid sinus

Elaine Posted Mon 28th of January, 2013 21:34:38 PM

How would you code the following:

After adequate general anesthesia was established, the pateint was registered with the BrainLab image guided system and draped in a sterile fashion. Small incisions were outlined in the medial aspect of the eyebrows bilaterally. This area was prepped with Betadine. Starting on the left-hand side, a small brow incision was made. The incision was carried down to the anterior table of the frontal sinus. A small was used to enter the frontal sinus. Upon entering the frontal sinus, a severe amount of purulent material was evacuated. The sinus was then irrigated with 60 cc of sterile saline. Good drainage occurred in the nasal cavity. The CT scan did show bony erosion on the right-hand side, and so a small incision was made here. Trephination was performed. No significant purulent material was obtained. It was presumed that the left frontal sinus trephination did drain the right side of the frontal sinus. The endoscopic portion of the procedure was performed next. The nasal cavity was decongested bilaterally with 1:1000 Epinephrine on cotton pledgets. Starting on the patient's left hand side, the middle turbinate was medialized. A significant amount of purulent material was suctioned from the ethmoid sinus. Using a curved suction, a maxillary antrostomy was performed and again a large amount of purulent material was lateralized. Again, a large amount of purulent material was suctioned from the ethmoid sinus. A maxillary antrostomy was performed here and a large amount of purulent material was obtained. The areas were checked for hemostatis. A small amount of Nasopore packing impregnated with Cortisporin otic suspension was placed into the middle meatus bilaterally. The frontal sinus trephinations were closed using interrupted 4-0 Vicryl suture and interrupted 4-0 Prolene suture. Small half Penrose drain was placed into the area of trephination on th e left-hand side because of continuous purulent drainage.

SuperCoder Answered Tue 29th of January, 2013 16:48:46 PM


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