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Biopsy of floor of mouth

CPT4 code

Name of the Procedure:

Biopsy of the Floor of Mouth
Common names: Floor of mouth biopsy

Summary

A biopsy of the floor of the mouth involves removing a small sample of tissue from the area underneath your tongue. This sample is then examined under a microscope to check for abnormalities, including infections, cancer, or other medical conditions.

Purpose

The main purpose of the biopsy is to diagnose abnormalities in the mouth’s floor such as sores, lesions, or growths. The goal is to identify the nature of any suspicious tissue and guide appropriate treatment.

Indications

  • Unexplained lumps or masses
  • Persistent mouth sores or ulcers
  • Abnormal patches of tissue
  • Unexplained pain or bleeding
  • Suspicious findings from imaging or clinical exams

Preparation

  • Follow instructions regarding fasting, typically not required for this procedure.
  • Inform the healthcare provider of all medications you are taking.
  • Arrange for transportation if sedation is being used.
  • Pre-procedure imaging or blood tests may be required.

Procedure Description

  1. Local Anesthesia: The area will be numbed with a local anesthetic.
  2. Incision or Punch Biopsy: A small incision or punch tool is used to remove a tissue sample from the floor of your mouth.
  3. Collection: The tissue sample is collected and preserved for laboratory analysis.
  4. Hemostasis: Control of any bleeding in the area.
  5. Closure: If necessary, sutures may be used to close the biopsy site.

Duration

The procedure typically takes about 15 to 30 minutes.

Setting

This procedure is commonly performed in a hospital, outpatient clinic, or surgical center.

Personnel

  • Oral and Maxillofacial Surgeon or ENT Specialist
  • Attending nurse
  • Anesthesiologist if general anesthesia or sedation is used

Risks and Complications

  • Infection at the biopsy site
  • Bleeding or hematoma formation
  • Pain or discomfort
  • Swelling or bruising
  • Nerve damage (rare)
  • Difficulty speaking or swallowing temporarily

Benefits

  • Accurate diagnosis of the underlying issue
  • Proper treatment plan based on biopsy results
  • Minimal invasive procedure with relatively quick recovery

Recovery

  • Keep the biopsy site clean to prevent infection.
  • Avoid eating spicy or hot foods for a few days.
  • Eat soft foods and avoid trauma to the area.
  • Follow-up appointment for review of biopsy results and suture removal if necessary.
  • Most patients can return to normal activities within a day or two.

Alternatives

  • Observation and Monitoring: For small, non-symptomatic lesions.
  • Fine Needle Aspiration (FNA): Less invasive, but may not provide a definitive diagnosis.
  • Non-invasive Imaging: Ultrasound, MRI, or CT scans for initial assessment.

Pros and cons of alternatives:

  • Less invasive options may delay a definitive diagnosis.
  • Non-invasive imaging cannot provide a tissue diagnosis.

Patient Experience

During the procedure, you may feel slight pressure but should not feel pain due to local anesthesia. Post-procedure, mild pain or discomfort is common and can be managed with over-the-counter pain medications. You may experience some swelling or bruising, which should subside within a few days. Follow comfort measures and aftercare instructions provided by your healthcare team.

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