DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Right-sided mixed hearing loss, likely from right chronic otitis media.
POSTOPERATIVE DIAGNOSES:
1. Right-sided mixed hearing loss, likely from right chronic otitis media.
2. Dense adhesions involving the right middle ear preventing ossicular mobility, particularly of the incudostapedial joint and the stapes bone.
1. Right middle ear exploration.
2. Lysis of adhesions with restoration of ossicular mobility.
3. Microdissection.
4. Facial nerve monitoring.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General.
ANESTHESIOLOGIST: Jean Doe, MD
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Minimal.
DESCRIPTION OF OPERATION: The patient was taken to the operating room, placed supine on the operating table. After general anesthesia had been obtained via endotracheal intubation, the patient was appropriately positioned and padded.
Attention was then turned to the patient’s right ear. Monitoring electrodes were placed into the orbicularis oculi and orbicularis auris muscles. The facial nerve monitoring system was noted to be appropriately functioning and was then used throughout the procedure. The patient’s right ear was then prepped and draped in the standard surgical fashion. The operative microscope was used throughout the entire length of the procedure.
Next, the ear canal was suctioned and cleaned. Lidocaine 1% with 1:100,000 epinephrine was then injected into the 4 quadrants of the ear canal. The postauricular crease was similarly injected. A 2-cm incision was made in the postauricular crease and carried down to the level of the mastoid periosteum. A small segment of fascia tissue was harvested. This was passed off the table to dry. Hemostasis was obtained in the postauricular incision and this was closed with absorbable sutures.
Attention was then turned to the ear canal and 6 o’clock and 12 o’clock vertical incisions were made followed by horizontal connecting incision 8 mm lateral from the annulus. The tympanomeatal flap was elevated. The middle ear space was entered. The posterosuperior canal wall was then alternately drilled and curetted away. This fully exposed the ossicular chain. There was noted to be multiple dense adhesions present throughout the posterior quadrant of the middle ear, in particular involving the posterosuperior quadrant. There was noted to be poor mobility of the ossicular chain upon palpation of the malleus. Entire stapes bone was obscured with granulation tissue.
With the use of a CO2 lasered 5-watt single, these adhesions were gently lysed. Chorda tympani nerve was noted to be significantly adherent to these adhesions. To prevent a traction injury on the nerve, the chorda tympani nerve was sharply suctioned. This allowed improved exposure and allowed lysis of the remaining adhesions, particularly involving the superior portion of the stapes at the region of the tympanic segment of the facial nerve. The incudostapedial joint was separated to prevent noise trauma.
The remainder of the adhesions were then carefully dissected circumferentially around the stapes bone. Facial nerves of the bony canal were noted to be completely intact without dehiscences. This was stimulated easily at 0.5 mA to the region of the oval window. After all adhesions had been carefully lysed, the entire ossicular chain was noted to regain its normal mobility. The incudostapedial joint was replaced in its normal anatomical position. A microdrop of Dermabond was placed on the joint to allow for reapproximation.
Next, the tympanomeatal flap was then replaced into its normal anatomical position. Gelfoam with saline was then packed lateral to the drum. Medial one-half of the ear canal was packed in this fashion. Lateral one-half of the ear canal Imak was packed with bacitracin ointment.
Next, the facial nerve monitoring electrodes were removed. The patient was then awakened by the anesthesia service, extubated, and taken in the recovery room in stable condition. In the recovery room, the patient had normal cranial nerve VII function bilaterally.
