Diffuse cholesteatosis, right ear

This code signifies a non-neoplastic, destructive lesion of the right middle ear and/or mastoid, characterized by the accumulation of keratinizing squamous epithelium. This diffuse form implies a widespread involvement rather than a localized sac or pearl. It can lead to bone erosion and potential complications affecting hearing and balance.

Use this code when documentation explicitly states "diffuse cholesteatosis" affecting the right ear. This diagnosis is typically made based on otoscopic examination, imaging studies (CT scan), and surgical findings. Supporting documentation should detail the extent and laterality of the cholesteatoma.

• Differentiate from localized cholesteatoma (H71.2-) which is a distinct entity.
• Ensure laterality is clearly documented (right, left, or bilateral) to select the correct subcategory.
• Code any associated complications, such as ossicular chain disruption or mastoiditis, separately.