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Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; sublingual

CPT4 code

Name of the Procedure:

Extraoral Incision and Drainage of Abscess, Cyst, or Hematoma of the Floor of the Mouth; Sublingual

Summary

This procedure involves making an incision on the outside of the mouth to drain an abscess, cyst, or hematoma located in the floor of the mouth.

Purpose

The main aim is to relieve pain, reduce swelling, and prevent the spread of infection or other complications caused by the abscess, cyst, or hematoma.

Indications

  • Severe pain and swelling in the floor of the mouth
  • Evidence of infection, such as redness, warmth, or pus formation
  • Difficulty swallowing or breathing
  • Confirmed diagnosis of sublingual abscess, cyst, or hematoma through imaging or physical examination

Preparation

  • Patients may need to fast for several hours before the procedure.
  • Adjustments to medications (especially blood thinners) as advised by the healthcare provider.
  • Pre-procedure imaging tests like an ultrasound or CT scan to locate the abscess, cyst, or hematoma.

Procedure Description

  1. Anesthesia is administered to numb the area or sedate the patient.
  2. The surgeon makes an external incision on the skin under the chin.
  3. Using surgical tools, the underlying tissue is carefully dissected to reach the affected area in the floor of the mouth.
  4. The abscess, cyst, or hematoma is drained or removed.
  5. The area is cleaned, and a drain may be placed to allow further drainage.
  6. The incision is closed with sutures or surgical staples.

Duration

The procedure typically takes about 30 to 60 minutes.

Setting

Usually performed in a hospital or an outpatient surgical center.

Personnel

  • Oral surgeon or maxillofacial surgeon
  • Surgical nurse
  • Anesthesiologist (if general anesthesia or sedation is used)

Risks and Complications

  • Infection at the incision site
  • Bleeding
  • Damage to surrounding structures, such as nerves or salivary glands
  • Scarring
  • Recurrence of the abscess, cyst, or hematoma

Benefits

  • Relief from pain and swelling
  • Prevention of further infection or complications
  • Improved ability to eat, swallow, and breathe

Recovery

  • Patients may need to take antibiotics to prevent infection.
  • Pain management with prescribed or over-the-counter medications.
  • Instructions to keep the incision area clean and dry.
  • Possible dietary modifications to avoid irritation.
  • Follow-up appointments to remove the drain and monitor healing.

Alternatives

  • Antibiotic therapy alone for less severe cases.
  • Needle aspiration if the abscess, cyst, or hematoma is accessible.
  • Observation and conservative management if the condition is stable and not causing significant symptoms.

Patient Experience

During the procedure, patients will be under anesthesia, so they should not feel any pain. Post-procedure, there may be some discomfort, swelling, and bruising at the incision site. Pain management will be provided to ensure comfort. Recovery typically involves a few days to a week of rest and limited activity.

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