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Sample39.pdf

OPERATIVE NOTE
YOUR HOSPITAL
RT/DOCUMENTATION
MED IMAGESSM, INC.
(Sample 39)
DATE: Confidential
PATIENT: Confidential
DIAGNOSIS: Left anterior perforation with TM retraction up into the attic anterior to the
malleus.
OPERATION: Tympanoplasty.
SURGEON: Confidential, M.D.
ANESTHESIA: General endotracheal.
OPERATIVE REPORT
DESCRIPTION OF PROCEDURE: After satisfactory general endotracheal anesthesia, the left
ear was prepped and draped in the usual manner. Endaural and postauricular injection was
performed with 1% Xylocaine and epinephrine 1:100,000. A vascular strip incision was made. A
postauricular incision was made. Hemostasis was obtained with cautery. The temporalis fascia
graft was taken in the usual manner and set aside to dry. The periosteal incision was made and
the mastoid and temporal line elevated forward with the Lembert elevator. Self-retaining
retractors were placed giving good visualization of the external canal, as shown in Photo 1. There
was a prominent spine of Henle which was drilled away with suction irrigation, Bien electric drill
and operating microscope enlarging the canal posteriorly giving good visualization of the anterior
annulus. There was an old ventilation tube with granulation tissue which was removed. There was
a large tympanosclerotic plaque posteriorly which was removed and the edges of the anterior
retraction and perforation were cut with a #1 knife and superior and inferior skin flaps were then
developed. The TM remnant was then removed and some of the middle ear mucosa had been
RT/DOCUMENTATION
MED IMAGESSM, INC.
(Sample 39)
DATE: Confidential
PATIENT: Confidential
removed around the area where the ventilation tube and granulation tissue were. The ossicular
chain was intact and moved freely. The anterior retraction pocket was carefully dissected out of
the attic anterior to the malleus and there was no evidence of cholesteatoma other than the
retraction pocket. Copious irrigation to remove all debris was performed. The middle ear was
packed with Gelfoam. The temporalis fascia graft was cut to the appropriate size and placed
medial to the annulus and up the posterior bony canal wall, as shown in Photo 2. Superior and
inferior skin flaps were placed over the graft, as shown in Photo 2. The external canal was filled
with Gelfoam and Polysporin ophthalmic ointment, as shown in Photo 3. The postauricular
incision was closed with interrupted 3-0 chromic without a drain. Endaural inspection revealed
the vascular strip to be in good position and the rest of the external canal was filled with
Polysporin ophthalmic ointment. A mastoid dressing was placed. The patient was awakened,
extubated and sent to recovery for full recovery from anesthesia. The patient will be discharged
home on Percocet and Phenergan and seen in the office in one week.

Source: http://www.emedimages.com/Samples/Sample39/Sample39.pdf

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