DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Vocal fold lesions.
POSTOPERATIVE DIAGNOSIS: Bilateral posterior glottic granulation tissue.
PROCEDURES PERFORMED: Esophagoscopy and microsuspension laryngoscopy with biopsy and injection of steroid.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal anesthesia.
ESTIMATED BLOOD LOSS: None.
SPECIMENS: Bilateral posterior vocal fold granulation tissue.
COMPLICATIONS: None.
INDICATION FOR OPERATION: This patient was referred for esophagoscopy and microsuspension laryngoscopy with biopsy and injection of steroid by Dr. John Doe. The patient is here to undergo the same.
DESCRIPTION OF OPERATION: Once the patient signed informed consent, the patient was brought to the operating room and was placed in the supine position on the operating room table. General face mask anesthesia was given until a deep plane of anesthesia was obtained. At that point, an endotracheal tube was placed by anesthesiology service without difficulty. The table was then turned.
A direct laryngoscopy was performed. There were no lesions or masses noted in the base of tongue, vallecula, epiglottis, bilateral aryepiglottic folds, pyriform sinuses or false vocal folds. There were posterior glottic granulation tissue lesions bilaterally. Microsuspension was then used to visualize the lesions. Cup forceps was used to biopsy the lesions of the posterior true vocal folds bilaterally. Lidocaine 1% with 1:100,000 epinephrine on pledgets were then placed on the granulation tissue for hemostasis.
At that point, 0.3 mL of Kenalog 40 was injected into the right posterior vocal fold granulation tissue. Another 0.3 mL of Kenalog 40 steroid was injected into the left posterior vocal fold granulation tissue. The patient was then taken out of microsuspension and the Dedo laryngoscope was removed.
Esophagoscopy was then performed. There were no lesions or masses noted in the esophagus and the full extent of the esophagoscopy. However, there was erythema and cobblestoning of the mucosa of the esophagus consistent with some irritation. The esophagoscope was then removed. The patient was then awoken from general anesthesia, extubated and sent to the postanesthesia care unit in stable condition.
ENT Operative Sample Reports #1
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Fracture of nose, closed.
POSTOPERATIVE DIAGNOSIS: Fracture of nose, closed.
PROCEDURE PERFORMED: Closed reduction of nasal fracture.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal anesthesia.
ESTIMATED BLOOD LOSS: Less than 10 mL.
SPECIMENS: None.
DESCRIPTION OF PROCEDURE: The patient came to the operating room and was placed in the supine position on the operating room table. Facemask anesthesia was given until a deep plane of anesthesia was obtained. At that point, endotracheal tube was placed by the anesthesiology service without difficulty. At that point, Afrin-soaked nasal pledgets were placed into the nares bilaterally for decongestion. After allowing time for decongestion, a butter knife was used and measured from the skull base to the exterior nose. The butter knife was then used in the right nasal cavity to disimpact the patient’s nasal fracture. The nasal fracture was disimpacted nicely. Profile showed a nice straight nose. The septum looked straight. At that point, a nasal splint was placed and secured with Steri-Strips. The procedure was then terminated. Afrin-soaked nasal pledgets were removed. The patient was then awoken from general anesthesia, extubated and sent to the postanesthesia care unit in stable condition.
ENT Operative Sample Reports #2
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Airway emergency secondary to nasal cavity epistaxis.
POSTOPERATIVE DIAGNOSIS: Airway emergency secondary to nasal cavity epistaxis.
PROCEDURE PERFORMED: Emergency transtracheal tracheostomy.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal anesthesia.
ESTIMATED BLOOD LOSS: Less than 20 mL.
SPECIMENS: None.
FINDINGS: Noncontributory.
DESCRIPTION OF OPERATION: The patient came to the operating room and was placed in the supine position on the operating room table. Anesthesia was given through an endotracheal tube. Approximately 10 mL of 1% lidocaine with 1:100,000 epinephrine was injected in the emergency room for planned emergent tracheostomy. A horizontal incision was made with Bovie cautery. This was carried down through the superficial tissues through the platysma muscle. A vertical incision was then carried down to the trachea. A cricoid hook was used to retract the cricoid cartilage. A vertical incision was made in the trachea around the second and third tracheal rings. A #8 Shiley tube was placed without difficulty into the trachea. The trachea was then suctioned to remove blood clots. The patient was then placed on the ventilator, with good CO2 return and good ventilations. The trach tube was then sewn to the anterior neck wall with three 2-0 Prolene stitches. The patient’s nasal cavity was then packed to prevent further bleeding. He was then sent to the angio suite for angiography with possible embolization of the right internal maxillary artery. The patient tolerated the procedure well. There were no complications during the procedure.
