DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Right chronic otitis media with tympanic membrane perforation and conductive hearing loss.
POSTOPERATIVE DIAGNOSIS:
Right chronic otitis media with tympanic membrane perforation and conductive hearing loss.
OPERATION PERFORMED:
Right tympanoplasty, harvesting temporalis fascia graft and use of operating microscope.
SURGEON: John Doe, MD
ANESTHESIA:
General.
COMPLICATIONS:
None.
INDICATION OF PROCEDURE:
This patient had a right chronic draining ear with about a 60% anterior perforation of tympanic membrane. CT of the temporal bone was normal. She has a conductive hearing loss in the left ear.
DESCRIPTION OF PROCEDURE:
With the patient under general anesthesia and the oral endotracheal tube in place, the left ear was prepped and draped sterilely. The post auricular area was injected with 1% Xylocaine with epinephrine 1:100,000 as well as the external canal. The ear was examined under microscope and noted have a 60% perforation in the anterior portion of the tympanic membrane. It was felt that it was best handled through a postauricular incision. Intercanal incision was made and then a postauricular incision was made and the two were connected through the ear canal and the auricle retracted anteriorly.
A temporalis fascia graft was then harvested and satisfactorily used. The perforation was then well visualized and the edges of the perforation were de-epithelialized. Tympanomeatal flap was then elevated from 12 o’clock to 6 o’clock. The ossicles were palpated and noted to have intact motility. The middle ear was then filled with Gelfoam, with Ciloxan drops, and the previously set aside temporalis fascia graft was then placed underneath the tympanomeatal flap. Then, the tympanomeatal flap was returned to its original position. The graft was then meticulously tucked under all edges with perforation under the operating microscope. Once this was in proper location, the external canal was filled with Gelfoam.
The subcutaneous tissue was closed with 3-0 chromic and skin was closed with a running 4-0 nylon. A mastoid dressing was applied. The patient tolerated the procedure well. Estimated blood loss was 10 mL. The patient was brought to the recovery room in good condition. We will see the patient in the office tomorrow for removal of the dressing. The patient was instructed not to do any heavy lifting, any heavy exertion, and not to blow her nose. The patient was given prescription for Levaquin 500 mg daily for a week and also for Vicodin 1 to 2 p.o. q. 4 h. p.r.n. pain.
