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Biopsy of tongue; posterior one-third

CPT4 code

Name of the Procedure:

Biopsy of Tongue; Posterior One-Third

Summary

A biopsy of the tongue involves removing a small piece of tissue from the back third of the tongue for examination. This helps diagnose abnormalities or diseases such as infections, inflammations, or cancers.

Purpose

Addresses: Unexplained masses, lesions, or persistent pain in the posterior one-third of the tongue. Goals: To obtain a tissue sample for microscopic examination to identify if the tissue is benign or malignant, and to diagnose any underlying medical condition.

Indications

  • Persistent ulcers or lesions on the back of the tongue
  • Unexplained pain or bleeding
  • Suspicion of oral cancer
  • Abnormal imaging or screening tests
  • Unexplained swelling or growth

Preparation

  • Fasting: May be required for a few hours before the procedure if general anesthesia is used.
  • Medication Adjustments: Blood thinners or certain medications may need to be paused.
  • Diagnostics: Pre-procedure imaging or blood tests might be required.

Procedure Description

  1. Anesthesia: Local anesthesia to numb the area; general anesthesia if needed.
  2. Positioning: Patient lies down with the mouth open.
  3. Incision: A small incision is made in the posterior part of the tongue.
  4. Tissue Sampling: A biopsy instrument is used to remove a small tissue sample.
  5. Closure: The incision may be closed with stitches if necessary.

Tools: Scalpel, biopsy forceps, sutures, local or general anesthetic agents.

Duration

Typically, 15 to 30 minutes.

Setting

Usually performed in a hospital, outpatient clinic, or surgical center.

Personnel

  • Surgeon or specialized ENT (Ear, Nose, and Throat) doctor
  • Nurse or surgical assistant
  • Anesthesiologist (if general anesthesia is used)

Risks and Complications

  • Common Risks: Bleeding, pain, swelling, infection.
  • Rare Risks: Nerve damage, adverse reactions to anesthesia, difficulty swallowing.
  • Management: Pain relievers, antibiotics if an infection develops, follow-up care for any adverse outcomes.

Benefits

  • Disease Diagnosis: Accurate identification of abnormal tissues.
  • Early Detection: Potentially catching diseases like cancer early, which improves treatment outcomes.
  • Symptom Relief: Can aid in formulating a treatment plan that alleviates symptoms.

Recovery

  • Post-Procedure Care: Avoid certain foods and strenuous activities; maintain oral hygiene.
  • Pain Management: Prescribed pain medications if necessary.
  • Restrictions: Avoid smoking and alcohol.
  • Follow-Up: Subsequent visits to discuss biopsy results and next steps.
  • Recovery Time: Usually a few days to a week for full recovery.

Alternatives

  • Watchful Waiting: Monitoring the condition without immediate biopsy.
  • Imaging Studies: MRI, CT scans, which are less invasive.
  • Pros and Cons: Alternatives may not provide as definitive a diagnosis as a biopsy. Imaging may miss smaller details biopted tissue can reveal.

Patient Experience

  • During Procedure: Might feel pressure or minor discomfort; sedation reduces awareness.
  • After Procedure: Expected numbness, swelling, mild pain managed with medication.
  • Comfort Measures: Use of ice packs, avoiding irritants (spicy or hot foods) to the area, and pain relievers aid recovery.

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