Myringotomy Medical Transcription Operative Sample Report
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Left vocal cord lesion.
2. History of tobacco use.
3. Right middle ear effusion with conductive hearing loss.
POSTOPERATIVE DIAGNOSES:
1. Left vocal cord lesion.
2. History of tobacco use.
3. Right middle ear effusion with conductive hearing loss.
OPERATION PERFORMED:
1. Microlaryngoscopy with excision and biopsy of left vocal cord lesion.
2. Right myringotomy and tube placement.
SURGEON: John Doe, MD
SEDATION: General endotracheal anesthesia.
PROCEDURE FINDINGS: Polypoid lesion of the left vocal cord, excised. Right serous middle ear effusion.
INDICATIONS FOR OPERATION: The patient is an (XX)-year-old female with a history of chronic hoarseness and right-sided hearing loss. She has a history of ongoing tobacco use. Office evaluation with flexible fiberoptic laryngoscopy revealed a polypoid lesion of the left vocal cord and a right serous middle ear effusion. There was no nasopharyngeal lesion. The risks, benefits and alternatives of right myringotomy and tube with microlaryngoscopy and left vocal cord biopsy were discussed with the patient, with emphasis on the risks of otorrhea, persistent perforation, retained myringotomy tube, persistent or worsened hoarseness and dental injury. The patient verbalized understanding of these risks and consented to the procedure.
DESCRIPTION OF OPERATION: After obtaining informed consent, the patient was brought to the operating room and placed supine on the operating table. General anesthesia with endotracheal intubation was induced without difficulty. The eyes were protected with ointment and tape. The table was turned 90 degrees.
The operating microscope was brought in. A #3 otologic speculum was used to examine the right external auditory canal. Cerumen was cleared with a Billeau loop. The ear canal was irrigated with alcohol, which was suctioned and allowed to dry.
A radial incision was made in the anterior-inferior quadrant of the tympanic membrane and serous middle ear effusion was suctioned.
A collar-button myringotomy tube was inserted into the incision and Ciprodex Otic drops instilled into the external auditory canal. A shoulder roll was placed. A head drape was placed. A slimline laryngoscope was used to examine the oral cavity, oropharynx and hypopharynx, which were all normal. The supraglottis was normal. The endolarynx was visualized and the patient was placed into suspension.
A 0 degree telescope was passed through the glottis and used to examine the subglottis, which was normal. The left vocal cord lesion was visualized. It was grasped with microcup forceps.
A mucosal incision was made using microscissors, with care not to disturb normal vocal cord mucosa. The entire polyp was removed and sent for routine pathology.
Hemostasis was obtained by applying cotton pledgets soaked in oxymetazoline. The patient tolerated the procedure well and without complication.
