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Excision, lesion of palate, uvula; without closure

CPT4 code

Name of the Procedure:

Excision, Lesion of Palate, Uvula; Without Closure
Common Names: Palate Lesion Removal, Uvula Lesion Excision

Summary

This surgical procedure involves the removal of abnormal tissue (lesions) located on the palate (roof of the mouth) or uvula (the small fleshy extension at the back of the soft palate) without the need for closure (stitches or sutures).

Purpose

The procedure is performed to address pathological conditions such as benign or malignant lesions, cysts, or polyps that may cause discomfort, difficulty swallowing, breathing issues, or other health concerns. The primary goal is to remove the abnormal tissue, alleviate symptoms, and prevent any potential progression of disease.

Indications

  • Presence of abnormal growths or lesions on the palate or uvula
  • Persistent sore throat or difficulty swallowing
  • Breathing difficulties or snoring related to the lesion
  • Recurrent infections or ulcerations in the affected area
  • Biopsy indicating potential malignancy or dysplasia

Preparation

  • Patients may be instructed to fast for 6-8 hours before the procedure.
  • Blood tests or imaging studies (like MRI or CT scans) may be required for diagnosis.
  • Patients should inform their healthcare provider about any medications or allergies.
  • Pre-operative consultation to discuss anesthesia and potential risks.

Procedure Description

  1. The patient is positioned, and local or general anesthesia is administered depending on the case complexity.
  2. A surgical instrument is used to excise the lesion from the palate or uvula.
  3. The area is cauterized to prevent bleeding.
  4. No sutures are applied; the wound is left to heal naturally.

Duration

The procedure typically takes 30 minutes to 1 hour, depending on the size and location of the lesion.

Setting

This procedure is generally performed in a hospital operating room or an outpatient surgical center.

Personnel

  • Surgeon (Otolaryngologist or Oral and Maxillofacial Surgeon)
  • Anesthesiologist or nurse anesthetist
  • Surgical nurse(s) and/or technician(s)

Risks and Complications

  • Bleeding or infection at the site of excision
  • Pain or discomfort post-procedure
  • Swelling or mild difficulty swallowing temporarily
  • Rare complications include adverse reactions to anesthesia, changes in speech, or scarring.

Benefits

  • Removal of problematic tissue
  • Relief from symptoms such as pain, infection, and difficulty swallowing
  • Prevention of potential malignancy progression
  • Improved quality of life and function

Recovery

  • Post-procedure, patients are monitored for a short period and can usually go home the same day.
  • Pain relief through prescribed medications if necessary.
  • Soft food diet and avoiding hot or spicy foods for a few days.
  • Follow-up appointments to ensure proper healing.

Alternatives

  • Watchful waiting with regular monitoring if the lesion is not causing significant symptoms.
  • Non-surgical treatments such as cryotherapy or laser ablation.
  • Pros: Less invasive, shorter recovery time.
  • Cons: May not be as definitive as surgical excision, potential need for multiple treatments.

Patient Experience

  • During the procedure: Depending on the type of anesthesia used, patients may feel nothing or be groggy but generally will not feel pain.
  • After the procedure: Mild pain or discomfort, managed with medication. Patients may experience temporary difficulty in swallowing and are advised on a soft food diet along with rest and hydration.
  • Pain management and comfort measures include prescribed analgesics and recommendations for soothing foods and beverages.

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