DOCSLIB.ORG

4 Design of Capsule

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
4 Design of Capsule Bidirectional Propulsion of Devices Along the Gastrointestinal Tract Using Electrostimulation Maurice Paul Burke University College London Department of Medical Physics and Bioengineering Thesis submitted for the degree of Doctor of Philosophy (Ph.D) 1 I Maurice Paul Burke confirm that the work presented in this thesis is my own. Where information has been derived from other sources, I confirm that this has been indicated in the thesis. 2 Abstract This thesis describes a method for propelling devices such as video capsule endoscopes in either direction along the small intestines using electrostimulation-induced muscular contractions. When swallowed, passive diagnostic ‘one-shot’ devices rely on sporadic peristaltic movement, possibly missing vital ‘areas of interest’. This bidirectional propulsion method provides active control for that all-important ‘second look’. Design considerations, within the dimensional constraints, required a device shape that would achieve maximum propulsion from safely induced useful contractions produced by the electrodes and encapsulated miniature electrostimulator. Construction materials would have to produce minimal friction against the mucosal surface while having the physical properties to facilitate construction and electrode attachment. Design investigations included coefficient of friction measurements of different construction materials and the evaluation of different capsule and electrode dimensions over a range of stimulation parameters, to obtain optimal propulsion. A swallowable 11 mm diameter device was propelled at 121 mm/min with stimulation parameters of 12.5 Hz, 20 ms, at 20 V in an anaesthetised pig. A modified passive video capsule endoscope was propelled at 120 mm/min with stimulation parameters of 12.5 Hz, 20 ms, at 10 V in an unanaesthetised human volunteer. A radio-controlled capsule incorporating an electrostimulator, voltage converter and 3 V power supply was propelled at 60 mm/min with stimulation parameters of 12.5 Hz, 20 ms, and 30 V in an anaesthetised pig. 3 Other possible uses of electrostimulation were investigated including propulsion of anally administered large intestine devices and introduction of the intestinal mucosal surface into a biopsy chamber. Results are presented. The ultimate aim of the project was to provide bidirectional propulsion for wireless remote controlled devices along the gastrointestinal tract utilising contractile force produced by electrostimulation of the intestinal wall. The controllability of this system could provide clinicians with a real time view of the entire small intestines without surgical enteroscopy. 4 Acknowledgements I would like to thank my supervisors: Dr. Timothy Mills for his support and guidance throughout the project; Dr. Alexander Mosse for his guidance and insight; Professor Jeremy Hebden for his support, guidance and encouragement especially during the latter stages of the project. I would also like to thank Professor Paul Swain and Dr. Annette Fritcher-Raverns for their guidance and insight, providing a clinician’s point of view to the project, and also for their clinical expertise, without which testing of the equipment would not have been possible. I would like to give special thanks to Professor Gary Royle, Dr. Nick Everdell and Dr. Julian Henty for their continued guidance, support, discussions and invaluable transfer of knowledge. I would like to thank the staff of the Medical Physics Technical Workshop, especially Mr. Billy Raven, Mr. Denzil Booth and Mr. Stuart Morrison for their tuition, guidance and expertise. I would also like to thank my friends and colleagues in the Department of Medical Physics and Bioengineering who provided a convivial atmosphere within which to work. Funding for the project was provided by Given Imaging who I would like to thank along with the Department of Medical Physics and Bioengineering for giving me the opportunity to carry out this research. I would like to thank my family and friends for all their support and encouragement throughout the project. I would especially like to thank my 5 parents, Brigid and Paul Burke for their continued love, support, encouragement and understanding, without which this would not have been possible. 6 Table of Contents Abstract .................................................................................................................. 3 1. Introduction ............................................................................................... 13 1.1 Guide to the Thesis ................................................................................ 15 2. Medical Science Background .................................................................... 18 2.1 Introduction ........................................................................................... 18 2.2 Anatomy of the Gastrointestinal Tract .................................................. 18 2.2.1 Physiology of the Gastrointestinal Tract ........................................ 22 2.3 Pathologies of the Gastrointestinal Tract .............................................. 23 2.4 Methods of Observing the Gastrointestinal Tract ................................. 34 2.4.1 Contrast Enema .............................................................................. 34 2.4.2 Endoscopy ...................................................................................... 35 2.5 Current Methods and Techniques of Observing the Gastrointestinal Tract ............................................................................................................... 36 2.5.1 Radiological Examination of the Colon Procedures ...................... 37 2.5.2 Virtual Colonoscopy ...................................................................... 43 2.5.3 Endoscopy (Push Enteroscopy) ..................................................... 48 2.5.4 Video Capsule Endoscopy ............................................................. 50 2.5.5 Evaluation of Current Methods of Observing the Gastrointestinal Tract ........................................................................................................ 56 3. Electrostimulation Considerations ............................................................ 75 3.1 Introduction ........................................................................................... 75 3.2 Electrophysiology of the Gastrointestinal Tract .................................... 75 3.2.1 Cell Membranes ............................................................................. 75 3.2.2 Muscle Contraction ........................................................................ 78 3.2.3 Smooth Muscle Contraction ........................................................... 81 3.3 Functional Electrical Stimulation .......................................................... 82 3.3.1 Electrostimulation of Smooth Muscle ............................................ 86 3.4 Electrical Safety .................................................................................... 91 3.4.1 Introduction .................................................................................... 91 3.4.2 Safety Regulations and Precedents ................................................ 92 3.4.3 Effects and Potential Hazards of Electrical Stimulation ................ 92 3.4.4 The Effects that Charge has on Electrodes During Stimulation .... 94 3.4.5 The Effects of Electrical Stimulation ............................................. 96 3.4.6 In Vivo Electrical Stimulator .......................................................... 97 3.5 A Model for Electrode Impedance ...................................................... 101 7 3.6 Aims of the Project .............................................................................. 111 4. Design, Construction and Testing of a Wire Driven Electrostimulation Induced Propulsion Device ................................................................................ 114 4.1 Objectives and Strategies .................................................................... 114 4.2 Introduction ......................................................................................... 117 4.3 Design Considerations ......................................................................... 118 4.3.1 Selection of Materials for Device Body ....................................... 118 4.3.2 Equipment Used to Determine Coefficients of Friction .............. 119 4.3.3 Measurement of the Coefficients of Friction ............................... 120 4.3.4 Capsule Design ............................................................................ 122 4.4 Initial Designs and Construction ......................................................... 127 4.4.1 Initial Animal Tests ...................................................................... 129 4.4.2 Design and Construction of a Bidirectional Device ..................... 131 4.4.3 Initial Bidirectional Capsule In Vivo Experiment ........................ 134 4.4.4 Design and Construction of Devices of Different Diameter ........ 135 4.4.5 The One Minute Tests .................................................................. 140 4.4.6 Capsule Construction from Animal to Man ................................. 151 4.5 Human Subject Experiments ............................................................... 154 4.5.1 Modifications to the Capsule ....................................................... 155 4.5.2 The First Human Subject Experiment .......................................... 156 4.5.3 The Second Human
Load more

Recommended publications
  • Provocative Testing and Localization in Video Capsule Endoscopy
    1 2 The Role of Provocative 3 4 Testing and Localization of 5 6 the Video Capsule Endoscope in 7 the Management of Small 8 9 Intestinal Bleeding Q4 10 11 a, b 12 Daniel L. Raines, MD *, Douglas G. Adler, MD Q5 Q6 Q7 13 Q1 Q2 14 15 KEYWORDS 16 Small intestinal bleeding Provocative angiography Provocative endoscopy 17 Video capsule endoscopy Device-assisted enteroscopy 18 19 20 KEY POINTS 21 Cases of small intestinal bleeding (SIB) are commonly encountered in clinical practice 22 despite advancements in medical technology that allow consistent visualization of the 23 entire gastrointestinal tract. 24 The use of antithrombotic agents to provoke bleeding has been found to be revealing in 25 cases of SIB when used in combination with angiography as well as endoscopy. 26 The performance of endoscopic procedures, including video capsule endoscopy (VCE) 27 and device-assisted enteroscopy (DAE) on active antiplatelet and/or anticoagulant ther- 28 apy is considered low risk and may improve diagnostic yield. 29 The use of VCE for gastrointestinal bleeding in the inpatient setting has been found to 30 improve diagnostic yield and decrease hospital stay. 31 Because DAE is required for therapeutic intervention in patients with small bowel 32 bleeding, access to this technology is essential for effective management in many cases. 33 34 35 Video content accompanies this article at http://www.giendo.theclinics.com/. 36 37 Q8 38 OBSCURE GASTROINTESTINAL BLEEDING Definitions 39 40 Small intestinal bleeding (SIB) has been described as bleeding that is undefined in 41 cause despite evaluation by standard upper endoscopy, colonoscopy, and small Q9 42 bowel follow-through (SBFT).
    [Show full text]
  • Practice Parameters for the Treatment of Patients with Dominantly Inherited Colorectal Cancer
    Practice Parameters For The Treatment Of Patients With Dominantly Inherited Colorectal Cancer Diseases of the Colon & Rectum 2003;46(8):1001-1012 Prepared by: The Standards Task Force The American Society of Colon and Rectal Surgeons James Church, MD; Clifford Simmang, MD; On Behalf of the Collaborative Group of the Americas on Inherited Colorectal Cancer and the Standards Committee of the American Society of Colon and Rectal Surgeons. The American Society of Colon and Rectal Surgeons is dedicated to assuring high quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The standards committee is composed of Society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This Committee was created in order to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus. This is accompanied by developing Clinical Practice Guidelines based on the best available evidence. These guidelines are inclusive, and not prescriptive. Their purpose is to provide information on which decisions can be made, rather than dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. Practice Parameters for the Treatment of Patients With Dominantly Inherited Colorectal Cancer Inherited colorectal cancer includes two main syndromes in which predisposition to the disease is based on a germline mutation that may be transmitted from parent to child.
    [Show full text]
  • Endoscopy Rotation Coordination and Goals and Objects Department of Surgery Stanford School of Medicine (8/15/17, Jnl)
    Endoscopy Rotation Coordination And Goals and Objects Department of Surgery Stanford School of Medicine (8/15/17, jnl) Rotation Director: James Lau, MD ATTENDINGS and CONTACT INFORMATION Cell Phone E-mail Address James Lau, MD (702) 306-8780 [email protected] Homero Rivas, MD MBA (972) 207-2381 [email protected] Dan Azagury, MD (650) 248-3173 [email protected] Shai Friedland, MD [email protected] Andrew Shelton, MD [email protected] Natalie Kirilcuk, MD [email protected] Cindy Kin, MD [email protected] Laren Becker, MD [email protected] Jennifer Pan, MD [email protected] Suzanne Matsui, MD [email protected] Ramsey Cheung, MD [email protected] KEYPOINT The key for this rotation is that you need to show initiative. TEXT Practical Gastrointestinal Endoscopy: The Fundamentals. Sixth Edition. By Peter B. Cotton, Christopher B. Williams, Robert H. Hawes and Brian P. Saunders. You are responsible for the material to enhance your understanding and supplement your past experiences. Lots of pictures and tips and tricks. Quick read. Copy of text available for purchase on Amazon.com or for check out from the Lane Library. Procedure Schedule Monday Tuesday Wednesday Thursday Friday Laren Becker Jennifer Pan Shelton/Kirilcuk/Kin Ramsey Suzanne (VA (VA Colonoscopy 8:00 am Cheung (VA Matsui (VA Livermore) Livermore) (Stanford Endoscopy) Livermore) Livermore) Every other Tuesday Rivas/Lau alternating Upper/Occasional Lower 1 Endoscopy 9a-1p (Stanford Endoscopy) Suzanne Matsui (VA Livermore) The Staff Drs. Becker, Cheung, Pan, and Matsui are gastroenterologists that perform 75% colonoscopies and 25% upper endoscopies at the Livermore location for the Palo Alto VA.
    [Show full text]
  • Colon and Rectal Surgery Case Log Instructions Review Committee for Colon and Rectal Surgery
    Colon and Rectal Surgery Case Log Instructions Review Committee for Colon and Rectal Surgery Background The ACGME Case Log System is a data depository which provides a mechanism that supports programs in complying with requirements, and also provides a uniform mechanism to verify the clinical education of residents among programs. The Case Log System is designed to capture and categorize a resident’s experience with patient care. It was initially instituted in 2001, and the Review Committee for Colon and Rectal Surgery has required its use by accredited programs since 2005. It is the intention of the Review Committee for Colon and Rectal Surgery that each resident has a reasonably equivalent educational experience to prepare for the practice of the specialty. As part of the process, the case numbers for each resident completing a program are collected and analyzed. To accomplish this complex task, a structured database has been created using standard codes for diagnoses and procedures. The Case Log System helps assess the breadth and depth of clinical experience provided to each colon and rectal surgery resident by his or her program with the ultimate goal of improving the programs themselves. It is the responsibility of the individual residents to accurately and in a timely manner enter their case data. The data entered will be monitored by the program directors and analyzed by the Review Committee. Separate analysis reports are created annually for the Committee, for program directors, and for residents. Additionally, the ACGME provides information regarding individual residents’ experience to the American Board of Colon and Rectal Surgery (ABCRS) as one criterion for their admission to the ABCRS’s exam process.
    [Show full text]
  • Diagnostic Direct Laryngoscopy, Bronchoscopy & Esophagoscopy
    Post-Operative Instruction Sheet Diagnostic Direct Laryngoscopy, Bronchoscopy & Esophagoscopy Direct Laryngoscopy: Examination of the voice box or larynx (pronounced “lair-inks”) under general anesthesia. An instrument called a laryngoscope is carefully placed into the mouth and used to visualize the larynx and surrounding structures. Bronchoscopy: Examination of the windpipe below the voice box in the neck and chest under general anesthesia. A long narrow telescope is passed through the larynx and used to carefully inspect the structures of the trachea and bronchi. Esophagoscopy: Examination of the swallowing pipe in the neck and chest under general anesthesia. An instrument called an esophagoscope is passed into the esophagus (just behind the larynx and trachea) and used to visualize the mucus membranes and surrounding structures of the esophagus. Frequently a small biopsy is taken to evaluate for signs of esophageal inflammation (esophagitis). What to Expect: Diagnostic airway endoscopy procedures generally take about 45 minutes to complete. Usually the procedure is well-tolerated and the child is back-to-normal the next day. Mild throat or tongue discomfort may persist for a few days after the procedure and is usually well-controlled with over-the-counter acetaminophen (Tylenol) or ibuprofen (Motrin). Warning Signs: Contact the office immediately at (603) 650-4399 if any of the following develop: • Worsening harsh, high-pitched noisy-breathing (stridor) • Labored breathing with chest retractions or flaring of the nostrils • Bluish discoloration of the lips or fingernails (cyanosis) • Persistent fever above 102°F that does not respond to Tylenol or Motrin • Excessive coughing or respiratory distress during feeding • Coughing or throwing up bright red blood • Excessive drowsiness or unresponsiveness Diet: Resume baseline diet (no special postoperative diet restrictions).
    [Show full text]
  • Laryngeal Endoscopy (Rigid, Flexible, and Stroboscopy)
    Laryngeal Endoscopy (Rigid, Flexible, and Stroboscopy) Visualization of the larynx can be performed via several different methods. Special tools are required for laryngeal evaluation. Mirror laryngoscopy (1) o While the patient’s tongue is protruded, a mirror is placed in the posterior oropharynx with gentle pressure on the soft palate while light is reflected caudally into the larynx. o Mirror laryngoscopy can be challenging for both the examiner and the patient, has limited magnification, and may require topical anesthesia. o Mirror laryngoscopy provides the most accurate color representation of laryngeal and pharyngeal tissue because there is no light or digital distortion. Flexible laryngoscopy (2) o A flexible laryngoscope is placed into the nasal cavity, through the naso- and oropharynx and positioned cephalad to the larynx for a full laryngeal assessment. o Nasal anesthesia (lidocaine) and/or nasal decongestants (oxymetazoline/phenylephrine) may be applied to the nose for the purpose of improving patient comfort and tolerance o Supplemental procedures such as dynamic voice assessment (comprehensive laryngeal movement evaluation), functional endoscopic evaluation of swallowing (+/- sensory testing), and other laryngeal procedures (ex. injections, laser surgery, biopsies) can be performed during flexible laryngoscopy. o Flexible laryngoscopy is ideal for evaluating vocal fold weakness, real-time/unencumbered evaluation of task-specific abnormalities (ex. my voice is problematic when I do this), and assessing the intensity of glottal attack. Rigid Laryngoscopy (3) o Rigid laryngoscopy is performed by placing a rigid 70- or 90-degree telescope into the oropharynx during tongue protrusion. o Sometimes, oropharyngeal and/or tongue application of anesthesia (ex. lidocaine, cetacaine) can be helpful for patient tolerance.
    [Show full text]
  • ACG Clinical Guideline: Diagnosis and Management of Small Bowel Bleeding
    nature publishing group PRACTICE GUIDELINES 1265 CME ACG Clinical Guideline: Diagnosis and Management of Small Bowel Bleeding L a u r e n B . G e r s o n , M D , M S c , F A C G1 , J e ff L. Fidler , MD 2 , D a v i d R . C a v e , M D , P h D , F A C G 3 a n d J o n a t h a n A . L e i g h t o n , M D , F A C G 4 Bleeding from the small intestine remains a relatively uncommon event, accounting for ~5–10% of all patients presenting with gastrointestinal (GI) bleeding. Given advances in small bowel imaging with video capsule endoscopy (VCE), deep enteroscopy, and radiographic imaging, the cause of bleeding in the small bowel can now be identifi ed in most patients. The term small bowel bleeding is therefore proposed as a replacement for the previous classifi cation of obscure GI bleeding (OGIB). We recommend that the term OGIB should be reserved for patients in whom a source of bleeding cannot be identifi ed anywhere in the GI tract. A source of small bowel bleeding should be considered in patients with GI bleeding after performance of a normal upper and lower endoscopic examination. Second-look examinations using upper endoscopy, push enteroscopy, and/or colonoscopy can be performed if indicated before small bowel evaluation. VCE should be considered a fi rst-line procedure for small bowel investigation. Any method of deep enteroscopy can be used when endoscopic evaluation and therapy are required.
    [Show full text]
  • Obscure Gastrointestinal Bleeding in Cirrhosis: Work-Up and Management
    Current Hepatology Reports (2019) 18:81–86 https://doi.org/10.1007/s11901-019-00452-6 MANAGEMENT OF CIRRHOTIC PATIENT (A CARDENAS AND P TANDON, SECTION EDITORS) Obscure Gastrointestinal Bleeding in Cirrhosis: Work-up and Management Sergio Zepeda-Gómez1 & Brendan Halloran1 Published online: 12 February 2019 # Springer Science+Business Media, LLC, part of Springer Nature 2019 Abstract Purpose of Review Obscure gastrointestinal bleeding (OGIB) in patients with cirrhosis can be a diagnostic and therapeutic challenge. Recent advances in the approach and management of this group of patients can help to identify the source of bleeding. While the work-up of patients with cirrhosis and OGIB is the same as with patients without cirrhosis, clinicians must be aware that there are conditions exclusive for patients with portal hypertension that can potentially cause OGIB. Recent Findings New endoscopic and imaging techniques are capable to identify sources of OGIB. Balloon-assisted enteroscopy (BAE) allows direct examination of the small-bowel mucosa and deliver specific endoscopic therapy. Conditions such as ectopic varices and portal hypertensive enteropathy are better characterized with the improvement in visualization by these techniques. New algorithms in the approach and management of these patients have been proposed. Summary There are new strategies for the approach and management of patients with cirrhosis and OGIB due to new develop- ments in endoscopic techniques for direct visualization of the small bowel along with the capability of endoscopic treatment for different types of lesions. Patients with cirrhosis may present with OGIB secondary to conditions associated with portal hypertension. Keywords Obscure gastrointestinal bleeding . Cirrhosis . Portal hypertension .
    [Show full text]
  • Flexible Sigmoidoscopy – Outpatients
    Flexible sigmoidoscopy – Outpatients You have been referred by your doctor to have a flexible sigmoidoscopy. his information booklet has been written to explain the procedure. This will help you to make an informed decision before consenting to the procedure. If you are unable to attend your appointment please inform us as soon as possible. Please ensure you read this booklet and the enclosed consent form thoroughly. Please also complete the enclosed health questionnaire. You may be contacted by an endoscopy trained nurse before your procedure to go through the admission process and answer any queries you may have. If you are not contacted please come to your appointment at the time stated in your letter. Please note your appointment time is your arrival time on the unit and not the time of your procedure. If you have any mobility issues or if there is a possibility you could be pregnant, please contact the appointment staff on 01284 713551 Please remember there will be other patients in the unit who may arrive after you but are taken in for their procedure before you, this is for medical reasons or they are seeing a different doctor. Due to limited space available and to maintain other patients’ privacy and dignity, we only allow patients (and carers) through to the ward area. Relatives/ escorts will be contacted once you are ready for collection. The Endoscopy Unit endeavours to offer single sex facilities, and we aim to make you stay as comfortable and stress free as possible. Source: Endoscopy Reference No: 5035-14 Issue date: 8/1/21 Review date: 8/1/24 Page 1 of 11 Medication If you are taking WARFARIN, CLOPIDOGREL, RIVAROXABAN or any other anticoagulant (blood thinning medication), please contact the appointment staff on 01284 713551, your GP or anticoagulation nurse, as special arrangements may be necessary.
    [Show full text]
  • SPECIALTY CARE Digestive Health
    SPECIALTY CARE Digestive Health Through our Day Kimball Medical Group A lot of people care about your health. Including us. So if you’re 45 or practices and other associated specialty over and due for a colon screening, you should know that Day Kimball physicians, Day Kimball Healthcare has one of the most comprehensive digestive health programs around. provides you access to expert specialized care for virtually every body system Gastroenterology deals with the function, diseases and disorders of and condition, within an integrated and the digestive system, including the esophagus, stomach, pancreas, gall coordinated approach. bladder, bile ducts, liver, small intestine, colon (or large intestine), and rectum. Most everyone will need specialized care at some point in life. It’s good to know Physician Consultations that when that time comes you’ll have Consults for advanced treatment of digestive and liver disorders are access to physicians and facilities focused available through our associated board-certified gastroenterologists solely on providing you with top-notch from Connecticut GI. A referral from your primary care practitioner specialized care, close to home. (PCP) is required. Day Kimball Healthcare offers integrated, comprehensive care Endoscopy Services With our state-of-the-art Doris E. Madeira Endoscopy Suite at Day close to home. To learn more Kimball Hospital and the services of our associated gastroenterologists about all of our specialty from Connecticut GI, we are able to offer comprehensive screening, medical services
    [Show full text]
  • Antibiotic Prophylaxis for GI Endoscopy
    GUIDELINE Antibiotic prophylaxis for GI endoscopy This is one of a series of statements discussing the use of procedure. Endoscopy-related bacteremia carries a small GI endoscopy in common clinical situations. The Stan- risk of localization of infection in remote tissues (ie, infec- dards of Practice Committee of the American Society for tive endocarditis [IE]). Endoscopy also may result in local Gastrointestinal Endoscopy (ASGE) prepared this docu- infections in which a typically sterile space or tissue is ment, and it updates a previously issued document on breached and contaminated by an endoscopic accessory this topic.1 In preparing this guideline, MEDLINE and or by contrast material injection. This document is an up- PubMed databases were used to search for publications date of the prior ASGE document on antibiotic prophylaxis between January 1975 and December 2013 pertaining for GI endoscopy,1 discusses infectious adverse events to this topic. The search was supplemented by accessing related to endoscopy, and provides recommendations for the “related articles” feature of PubMed, with articles periprocedural antibiotic therapy. identified on MEDLINE and PubMed as the references. Additional references were obtained from the bibliogra- phies of the identified articles and from recommenda- BACTEREMIA ASSOCIATED WITH tions of expert consultants. When few or no data were ENDOSCOPIC PROCEDURES available from well-designed prospective trials, emphasis was given to results from large series and reports from Bacteremia can occur after endoscopic procedures and has been advocated as a surrogate marker for IE risk. How- recognized experts. Weaker recommendations are indi- fi cated by phrases such as “We suggest.” whereas stronger ever, clinically signi cant infections are extremely rare.
    [Show full text]
  • Endoscopy Matrix
    Endoscopy Matrix CPT Description of Endoscopy Diagnostic Therapeutic Code (Surgical) 31231 Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure) X 31233 Nasal/sinus endoscopy, diagnostic with maxillary sinusoscopy (via X inferior meatus or canine fossa puncture) 31235 Nasal/sinus endoscopy, diagnostic with sphenoid sinusoscopy (via X puncture of sphenoidal face or cannulation of ostium) 31237 Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or X debridement (separate procedure) 31238 Nasal/sinus endoscopy, surgical; with control of hemorrhage X 31239 Nasal/sinus endoscopy, surgical; with dacryocystorhinostomy X 31240 Nasal/sinus endoscopy, surgical; with concha bullosa resection X 31241 Nasal/sinus endoscopy, surgical; with ligation of sphenopalatine artery X 31253 Nasal/sinus endoscopy, surgical; with ethmoidectomy, total (anterior X and posterior), including frontal sinus exploration, with removal of tissue from frontal sinus, when performed 31254 Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior) X 31255 Nasal/sinus endoscopy, surgical; with ethmoidectomy, total (anterior X and posterior 31256 Nasal/sinus endoscopy, surgical; with maxillary antrostomy X 31257 Nasal/sinus endoscopy, surgical; with ethmoidectomy, total (anterior X and posterior), including sphenoidotomy 31259 Nasal/sinus endoscopy, surgical; with ethmoidectomy, total (anterior X and posterior), including sphenoidotomy, with removal of tissue from the sphenoid sinus 31267 Nasal/sinus endoscopy, surgical; with removal of
    [Show full text]