Diffuse cholesteatosis, unspecified ear

This code represents a non-neoplastic, diffuse accumulation of cholesterol crystals within the middle ear or mastoid, without specifying the affected ear. It is a form of cholesterol granuloma, often resulting from chronic inflammation or hemorrhage within the temporal bone. This condition can lead to conductive hearing loss and other otologic symptoms.

Use this code when documentation clearly indicates diffuse cholesteatosis of the middle ear or mastoid, and the specific ear (left or right) is not documented. This diagnosis is typically made based on imaging studies (e.g., CT or MRI) and/or surgical findings. It is appropriate when the provider has not specified laterality.

• Do not confuse diffuse cholesteatosis with acquired or congenital cholesteatoma, which are distinct conditions with different ICD-10-CM codes.
• If laterality is documented (e.g., right or left ear), use the more specific codes H71.31 or H71.32.
• Code any associated symptoms or complications, such as conductive hearing loss, separately.