MALT: Board reporting terms for Otolaryngology Head Neck ... · SNOMED Board Reporting Terms for SET and IMG Otolaryngology Head & Neck Surgery ... Endoscopic vocal cord medialisation

Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Otolaryngology Head & Neck Surgery

Prepared by the Royal Australasian College of Surgeons, November 2016

HEAD & NECK/LARYNGOLOGY Endoscopic HE-A Board Reporting Term Terms that roll up to the Board

Reporting Term Indicator Procedure

Reporting Field Procedure Reporting Field Values

Bronchoscopy with removal of foreign body

• Rigid therapeutic bronchoscopy

Bronchoscopy inc. F/B Removal

Bronchoscopy with tracheal dilation Bronchoscopy inc. F/B Removal

Cordotomy of vocal cord • Superior cordotomy Endoscopic dilation of oesophagus using rigid oesophagoscope

Endoscopic vocal cord medialisation Laryngeal Laser Surgery Epiglottopexy Excision of lesion of hypopharynx Method • Laser

• Robotic Excision of lesion of oropharynx Method • Laser

• Robotic Hemilaryngectomy Laryngeal Laser Surgery Method • Laser

• Robotic Insertion of laryngeal keel Laryngoplasty Microlaryngoscopy Microlaryngoscopy Purpose • Excision Vocal Cord

Tumour • Laser Excision Vocal

Cord Tumour • Laser Laryngeal

Papilloma • Shaving Laryngeal



HEAD & NECK/LARYNGOLOGY Endoscopic HE-A Board Reporting Term Terms that roll up to the Board



Papilloma’s • Treatment of

Subglottic Stenosis Microlaryngoscopy and artenoidectomy Laryngeal Laser Surgery Pharyngeal Pouch Diverticulotomy by laser

Pharyngeal Pouch Diverticulotomy by stapling

Removal of calculus from parotid duct

Rigid oesophagoscopy and removal of foreign body

Oesophagoscopy inc. F/B Removal

Supraglottoplasty Supraglottoplasty by laser



HEAD & NECK/LARYNGOLOGY Endoscopic HE-B Board Reporting Term Terms that roll up to the Board



Bronchoscopy • Endoscopy with excision of lesion from bronchus

• Fibreoptic bronchoscopy

• Rigid bronchoscopy


Bronchoscopy with biopsy • Laryngotracheobronchoscopy


Diagnostic microlaryngoscopy and biopsy Microlaryngoscopy Diagnostic rigid oesophagoscopy Dilation of parotid duct Direct laryngoscopy Direct laryngoscopy with biopsy Rigid oesophagoscopy and biopsy

HEAD & NECK/LARYNGOLOGY Non-endoscopic HN-A Board Reporting Term Terms that roll up to the Board



Arytenoid adduction/rotation Arytenoidectomy by external approach Approach • Laryngofissure

• Transcervical






Arytenoidopexy by external approach Biopsy of cranial nerve Complete parotidectomy Parotidectomy

(Superficial/Total)

Control of haemorrhage after tonsillectomy and adenoidectomy

Control Tonsil or Adenoid Haemorrhage

Craniofacial resection Approach • Endoscopic • Open

Cricopharyngeal myotomy Distant cutaneous pedicle flap, myocutaneous

Distant subcutaneous pedicle flap, myocutaneous, to head or neck

Excision of branchial cyst Excision of branchial fistula Excision of branchial sinus Excision of cranial nerve tumour Excision of glomus tumour in the neck • Excision of carotid

body tumour • Excision of glomus

vagale • Excision of

extraadrenal paraganglioma






Excision of intramuscular lipoma Excision of lesion from floor of mouth Lesion size • <1cm (HN-B)

• >1cm (HN-A) Excision of lesion of buccal mucosa Lesion size • <1cm (HN-B)

• >1cm (HN-A) Excision of lesion of dentoalveolar structure

Excision of lesion of gingiva Lesion size • <1cm (HN-B) • >1cm (HN-A)

Excision of lesion of lip Lesion size • <1cm (HN-B) • >1cm (HN-A)

Excision of lesion of palate Lesion size • <1cm (HN-B) • >1cm (HN-A)

Excision of lesion of oral cavity with lingual release

Excision of lesion of oral cavity with mandibular swing

Excision of lesion of oral cavity with visor flap

Excision of lesion of oropharynx with lingual release

Excision of lesion of oropharynx with mandibular swing

Excision of malignant skin tumour • Excision of basal cell Tumour size • <1cm (HN-B)






carcinoma • Excision of malignant

lesion of scalp and neck

• Excision of melanoma • Excision of squamous

cell carcinoma • Excision of skin

carcinoma

• >1cm (HN-A)

Excision of parapharyngeal mass Approach • Transcervical • Transoral • Transoral robotic

Excision of peripheral nerve tumour Excision of pharyngeal pouch • Diverticulectomy of

hypopharynx with myotomy by cervical approach

Excision of sublingual gland Excision of submandibular gland • Excision of lesion of

submandibular gland

Excision Submandibular Gland

Excision of thyroglossal duct cyst Excision of thyroglossal duct fistula Excision of thyroglossal tract Excisional biopsy of lymph node of neck






Exenteration of orbit Extended radical neck dissection of cervical lymph nodes

Neck Dissection (Extended, Modified Radical, Radical, Selective)

Geniotubercle advancement Hemiglossectomy Hemithyroidectomy Hyoid bone suspension Incision and drainage of deep abscess of soft tissues of neck

• Incision and drainage of branchial abscess

• Drainage of dental abscess by extraoral approach

Drainage of Neck Abscess Large

Inversion of pharyngeal pouch Laryngopharyngectomy Laryngotomy with removal of laryngocele Laryngotracheal reconstruction using cartilage graft

Laryngotracheal resection • Cricotracheal Resection

Laryngotracheoplasty Lateral pharyngotomy Ligation of major artery of neck • Ligation of internal

carotid artery






• Ligation of common carotid artery

• Ligation of external carotid artery

• Ligation of internal jugular vein

Maxillectomy with orbital exenteration Modified radical neck dissection • Modified radical neck

dissection of cervical lymph nodes, with preservation of accessory nerve, sternocleidomastoid muscle and internal jugular vein

• Modified radical neck dissection of cervical lymph nodes, with preservation of accessory nerve and internal jugular vein

• Modified radical neck dissection of cervical lymph nodes, with preservation of







accessory nerve Operation on lesion of peripheral nerve Parathyroidectomy Partial glossectomy Lesion size • <1cm (HN-B)

• >1cm (HN-A) Partial mandibulectomy Partial maxillectomy Partial pharyngolaryngectomy Pharyngolaryngo-oesophagectomy Postoperative haemorrhage control Radical excision of parotid gland with sacrifice of facial nerve

Parotidectomy (Superficial/Total)

Radical neck dissection Neck Dissection (Extended, Modified Radical, Radical, Selective)

Reconstruction with free flap • Distant microvascular transferred flap, fasciocutaneous

• Distant microvascular transferred flap, osseomyocutaneous

• Distant microvascular transferred flap, osseofasciocutaneous

Reconstruction with local flap • Local rotation flap






• Local transposition flap Repair of laryngotracheal cleft Repair of oroantral fistula Repair of trachea • Repair of traumatic

rupture of the trachea

Resection of trachea • Resection and anastomosis of trachea

Revision of stoma of trachea Revision thyroidectomy Rim excision of mandible Selective neck dissection of cervical lymph nodes


Subtotal glossectomy Subtotal thyroidectomy Superficial parotidectomy Parotidectomy

(Superficial/Total)

Supracricoid Laryngectomy Total Laryngectomy Supraglottic Laryngectomy Total Laryngectomy Suspension of pharyngeal pouch Thyroplasty External Thyroplasty Total glossectomy Total laryngectomy Total laryngectomy Total mandibulectomy






Total maxillectomy Total thyroidectomy Thyroidectomy (Hemi or

Total)

Trachea reconstruction • Tracheal reconstruction with patch

• Tracheoplasty by cervical approach

• Tracheoplasty by intrathoracic approach

Tracheo-oesophageal puncture procedure • Tracheo-oesophageal puncture and insertion of prosthesis

• Tracheo-oesophageal puncture and insertion of voice prosthesis

Tracheotomy Tracheotomy Transposition of submandibular duct Uvulopalatopharyngoplasty



HEAD & NECK/LARYNGOLOGY Endoscopic HN-B Board Reporting Term Terms that roll up to the Board



Adenoidectomy • Excision adenoidal tags • Excision of lesion of

adenoids • Suction diathermy

adenoidectomy

Adenotonsillectomy • Dissection tonsillectomy and adenoidectomy

Diagnostic endoscopic examination and biopsy of nasopharynx

Division of frenulum of tongue Examination of oral cavity under general anaesthesia

Biopsy • With biopsy • Without biopsy

Examination of oropharynx under anaesthetic

Biopsy • With biopsy • Without biopsy

Excision of lesion of skin • Excision of sebaceous cyst of head or neck

• Excision of preauricular sinus

• Excision of preauricular cyst

• Incisional biopsy of skin lesion

• Excision of intradermal






naevus • Excision of sebaceous

cyst • Excision of skin cyst • Excision of pigmented

skin lesion • Excision biopsy of

lesion of skin of head or neck

• Excision of neurofibroma of cutaneous nerve

Excision of lipoma of subcutaneous tissue • Excision of lipoma of subcutaneous tissue of head

• Excision of lipoma of subcutaneous tissue of neck

Full thickness skin graft Incision of superficial abscess of soft tissue

Incisional biopsy of cervical lymph node Repair of mouth laceration Split thickness skin graft Surgical biopsy of tongue






Surgical debridement of wound • Excisional debridement of wound for infection

• Shave debridement of skin wound

Tonsillectomy

OTOLOGY External Ear OE-A Board Reporting Term Terms that roll up to the Board



Insertion of bone anchors for subcutaneous bone anchored hearing aid

Canaloplasty of external auditory meatus • Auditory canaloplasty External Canal Reconstruction/Canalplasty

Excision of exostosis from external auditory canal

Exostoses Removal

Total reconstruction of external ear using cartilage graft, fascia flap and skin graft



OTOLOGY External Ear OE-B Board Reporting Term Terms that roll up to the Board



Excision of aural polyp • Excision of polyp from external auditory canal

Meatoplasty of external ear • Correction of atresia of external meatus of ear

• Construction of ear meatus, osseous, skin-lined

Meatoplasty

Microsuction clearance of external auditory canal

Removal of foreign body from external auditory canal

OTOLOGY Middle Ear Mastoid OM-A Board Reporting Term Terms that roll up to the Board



Atticotomy of ear • Removal of outer attic wall of middle ear

Closure of fistula of middle ear Intact canal wall mastoidectomy • Excision of

cholesteatoma of mastoid

• Excision of






cholesteatoma of middle ear

• Combined approach tympanoplasty

Cortical mastoidectomy • Mastoidectomy, cortical, conservative

Cortical mastoidectomy

Decompression of temporal section of facial nerve

• Exploration of facial nerve (VII)

Intact canal wall mastoidectomy • Combined approach tympanoplasty

• Excision of cholesteatoma of mastoid

• Excision of cholesteatoma of middle ear

Lateral temporal bone resection

Mastoid obliteration

• Primary obliteration of mastoid cavity

• Secondary obliteration of mastoid cavity

Myringoplasty • Formal myringoplasty

using biological graft Myringoplasty

Operation on endolymphatic sac






Plug myringoplasty

• Myringoplasty using fat

• Myringoplasty using gelatin

Myringoplasty

Radical mastoidectomy

Radical mastoidectomy, modified Mastoidectomy Modified

Radical

Reconstruction of ossicular chain Ossicular Reconstruction Revision of mastoidectomy

Stapes operation

• Malleostapediopexy • Revision of

stapedectomy • Stapedectomy • Stapes mobilisation

Stapedectomy or Revision Stapedectomy

Transection of Jacobson’s nerve Tympanotomy

OTOLOGY Middle Ear Mastoid OM-B Board Reporting Term Terms that roll up to the Board



Myringotomy and drainage of middle ear



OTOLOGY Middle Ear Mastoid OM-B Board Reporting Term Terms that roll up to the Board



Myringotomy and insertion of tympanic ventilation tube

Laterality • Bilateral • Unilateral

Transtympanic injection of middle ear • Chemical labyrinthectomy

• Injection of steroid

OTOLOGY Neurotology ON-A Board Reporting Term Terms that roll up to the Board



Blind sac closure of external auditory canal

Cranial venous sinus ligation Craniectomy and excision of cerebellopontine angle tumour

Excision of aural glomus tumour, transcanal

Excision of aural glomus tumour, transmastoid

Excision of base of skull in middle cranial fossa

Excision of lesion of infratemporal fossa Excision of lesion of jugular foramen • Excision of glomus






jugulare tumour Implantation of cochlear prosthetic device

• Cochlear device implantation with mastoidectomy

• Implantation of cochlear electrode

• Implantation of cochlear prosthetic device, single channel

Labyrinthectomy with mastoidectomy Labyrinthectomy, transcanal Middle fossa craniotomy Obliteration of posterior semicircular canal

Obliteration of superior semicircular canal Posterior fossa craniotomy

Removal of acoustic neuroma

Approach • Middle fossa approach

• Retrosigmoid approach

• Translabyrinthine approach

Removal of cochlear implant or prosthetic device

Repair of cranial cerebrospinal fluid fistula






Repair of facial nerve (VII)

• Faciofacial anastomosis

• Suture of facial nerve, extracranial

• Suture of facial nerve, intratemporal, with grafting

• Total facial nerve repair

Resection of temporal bone by external approach

RHINOLOGY Endoscopic RE-A Board Reporting Term Terms that roll up to the Board



Closure of cerebrospinal fluid leak from nose

Decompression of orbit Drainage of subperiosteal abscess of orbit Approach • Endoscopic

• Open Endoscopic dacryocystorhinostomy • Dacryocystorhinostomy

and insertion of tube






• Dacryocystorhinostomy via internal approach with laser

Endoscopic decompression of optic nerve Endoscopic ligation of sphenopalatine artery

Vascular ligation for epistaxis (external or endoscopic)

Excision of sinonasal tumour involving skull base

Excision of sinonasal tumour not involving skull base

FESS - Functional endoscopic sinus surgery - sphenoethmoidectomy

FESS - Functional sinus surgery - frontal recess dissection

FESS - Functional sinus surgery - frontoethmoidectomy

FESS - Functional sinus surgery - frontoethmosphenoidectomy

FESS - Sphenoidotomy • Endoscopic sphenoidectomy with turbinectomy

MMA and Ethmoidectomy +/- Frontal Sinusotomy, Sphenoidotomy

Frontal sinusotomy Functional endoscopic sinus surgery - anterior ethmoidectomy and frontal

MMA and Ethmoidectomy +/- Frontal Sinusotomy,






recess dissection Sphenoidotomy

Medial maxillectomy Approach • Endoscopic

• Open Osteoplasty of frontal sinus • Excision of frontal sinus

and nasal turbinate

Repair of choanal atresia, intranasal Repair of choanal atresia, transpalatine Repair of encephalocele • Cranioplasty with

synchronous repair of encephalocele

• Repair of meningoencephalocele

Transsphenoidal hypophysectomy Approach • Endoscopic

• Open Vidian Neurectomy

RHINOLOGY Endoscopic RE-B Board Reporting Term Terms that roll up to the Board



FESS - Functional endoscopic sinus surgery - posterior ethmoidectomy



RHINOLOGY Endoscopic RE-B Board Reporting Term Terms that roll up to the Board



FESS - Functional sinus surgery - intranasal anterior and posterior ethmoidectomy

MMA

FESS - Functional sinus surgery - intranasal anterior ethmoidectomy

FESS - Middle meatal antrostomy MMA Nasal polypectomy Polypectomy Nasal sinus endoscopy Nasal Endoscopy Turbinectomy Turbinectomy Approach • Endoscopic

• Open Uncinectomy

RHINOLOGY Non-endoscopic RN-A Board Reporting Term Terms that roll up to the Board



External ethmoidectomy External ethmoidectomy External frontoethmoidectomy External frontoethmosphenoidectomy Lateral rhinotomy Ligation of ethmoid artery Vascular ligation for epistaxis

(external or endoscopic)



RHINOLOGY Non-endoscopic RN-A Board Reporting Term Terms that roll up to the Board



Maxillary sinusotomy by Caldwell-Luc approach

• Excision of lesion of maxillary sinus by Caldwell-Luc approach

• Caldwell-Luc operation with removal of membrane lining

• Removal of foreign body from maxillary sinus by Caldwell-Luc approach

Nasal septoplasty Septoplasty Osteoplastic frontal flap operation Repair of nasal septal perforation Transantral ligation of maxillary artery

RHINOLOGY Non-endoscopic RN-B Board Reporting Term Terms that roll up to the Board



Biopsy of nose Cauterisation and packing of nose Cauterisation of Littles area



RHINOLOGY Non-endoscopic RN-B Board Reporting Term Terms that roll up to the Board



Cauterisation of nasal turbinate • Cauterisation of turbinates, intramural

• Cauterisation of turbinates, superficial

• Radiofrequency ablation of nasal turbinate

Division of adhesions Drainage of abscess of nasal septum Drainage of haematoma of nasal septum Examination of nose under anaesthetic Frontal sinusotomy with trephine Inferior meatal antrostomy Maxillary antrotomy by external approach Midfacial degloving Nasal packing for control of haemorrhage Packing of cavity of nose Reduction of fractured nasal bone Removal of foreign body • Endoscopy and

removal of foreign material

• Imaging guided removal of foreign body



FACIAL PLASTICS Facial Plastics FP-A Board Reporting Term Terms that roll up to the Board



Bilateral otoplasty of external ear Otoplasty Blepharoplasty Browlift • Bicoronal Browlift

• Direct browlift • Internal browlift • Rhytidectomy of

glabellar frown lines • Simple browlift

Closed rhinoseptoplasty Rhinoplasty +/- Septoplasty Genioplasty • Augmentation

genioplasty with graft and implant

• Forward sliding genioplasty

• Reduction genioplasty

Harvest of cartilage Source • Ear • Rib

Open rhinoseptoplasty Rhinoplasty +/- Septoplasty Reduction of fracture of facial bone Simple facelift Submental lipectomy

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MALT: Board reporting terms for Otolaryngology Head Neck ... · SNOMED Board Reporting Terms for SET and IMG Otolaryngology Head & Neck Surgery ... Endoscopic vocal cord medialisation