CPT® Code 69440

The CPT® Code 69440 refers to a surgical procedure known as middle ear exploration, which can be performed through either a postauricular incision or an ear canal incision. In the postauricular approach, a surgical incision is made in the skin fold located behind the ear, allowing access to the middle ear. Alternatively, if the ear canal approach is utilized, the external ear canal, or meatus, is incised, and a tympanomeatal flap is created and elevated to gain entry into the middle ear. During this exploration, the surgeon inspects the bones of the middle ear, which include the malleus, incus, and stapes, assessing their articulations and overall condition. Additionally, the oval and round windows, which are critical structures in the ear, are examined, along with the Eustachian tube, which connects the middle ear to the nasopharynx. It is important to note that this procedure is primarily diagnostic; no definitive surgical interventions are performed during this exploration. Any abnormal findings observed during the procedure are documented for further evaluation. After the exploration is complete, the postauricular incision is either closed, or in the case of the tympanomeatal flap, it is replaced, and the incision in the ear canal is sutured closed.