PROCEDURE PERFORMED: Left subtotal petrosectomy with resection of cholesteatoma on posterior fossa dura, operating microscope, facial nerve monitoring.

SURGEON: John Doe, MD

DRAINS: Penrose.

ANESTHESIA: General endotracheal, local 10 mL, 1% lidocaine with 100,000 epinephrine.

SPECIMEN: Left mastoid contents, frozen section, consistent with cholesteatoma.

ESTIMATED BLOOD LOSS: 50 mL.

COMPLICATIONS: None.

INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old Hispanic female who was noted to have an incidental left mastoid lesion. Preoperative CT and MRI scanning were most likely consistent with a congenital cholesteatoma.

Due to significant concerns of erosion of posterior fossa dural plate and surrounding bone and compression of the sigmoid sinus, left subtotal petrosectomy with resection of cholesteatoma on posterior fossa dura was recommended.

Options of observation versus surgery were discussed with the patient. Extensive preoperative counseling and laboratory testing was performed.

The patient decided to proceed with left subtotal petrosectomy with resection of cholesteatoma on posterior fossa dura despite potential risks of need for further surgery/therapy, no guarantee of success, recurrence of ear disease, brain fluid leak, meningitis, stroke, heart attack, death, allergic reactions, anesthetic complications, deafness, dizziness, tinnitus, taste changes, facial nerve paralysis as well as other unforeseen problems and complications.

Despite potential risks and complications, the patient decided to proceed with the left subtotal petrosectomy with resection of cholesteatoma on posterior fossa dura.

INTRAOPERATIVE FINDINGS:
1. Cholesteatoma measuring approximately 2.5 cm in greatest dimension extending from approximately the sinodural angle to the retrofacial air cells.
2. Cholesteatoma with significant erosion of surrounding posterior fossa dural plate and thinning of posterior fossa dura.
3. Attenuated sigmoid sinus displaced superiorly due to cholesteatoma.
4. See below for more details.

DESCRIPTION OF PROCEDURE: The patient was taken from the preoperative holding area to the operating room where she was placed supine on the operating table for left subtotal petrosectomy with resection of cholesteatoma on posterior fossa dura. The patient was then intubated.

Once the endotracheal tube was secured, the table was rotated 180 degrees. Pneumatic compression devices were placed on the patient’s legs. A Foley catheter was placed.

Hair was shaved posterior and superior to the left auricle. The proposed incision site was marked with a marking pen. It was one fingerbreadth behind the left postauricular sulcus. Facial nerve monitor needle electrodes were applied.

The proposed incision site was infiltrated with local anesthetic. The patient was given a dose of prophylactic IV antibiotics and steroids. The left lower quadrant of the abdomen was kept out in the surgical field in case abdominal fat graft would be needed.

The patient was prepped and draped in the standard surgical fashion. She was adequately padded, belted, and test rolled to make sure she was in good position on the table. Intraoperative facial nerve monitoring was done by me.

The incision was made through the skin down to the subcutaneous tissue with the 15 blade scalpel. Temporalis fascia was identified. Bovie electrocautery was used.

Weitlaners were used to retract soft tissue. The microscope was brought in to view the surgical field. A Palva flap was created with Bovie electrocautery. Intraoperative photos were taken.

Erosion of the mastoid cortex was noted by the cholesteatoma. Pieces of specimen were then removed and sent off for frozen and permanent section.

Surrounding the area of mastoid cortex erosion, a complete mastoidectomy was performed. Tegmen was identified. Digastric was identified. Lateral semicircular canal was identified.

The facial nerve of the mastoid segment was identified. The cholesteatoma was debulked. The matrix was left on the posterior fossa dura. It was elevated off the posterior fossa dura. There was no evidence of CSF leak after complete removal of the specimen. The specimen was removed in pieces.

After separating this specimen from the dura, Valsalva maneuver was performed to make sure there was no inadvertent CSF leak that was created. None was noted.

The wound was well irrigated. Care was taken to irrigate the middle ear space to avoid any osteoneogenesis and postoperative conductive hearing loss. Areas of bleeding were taken care of with Gelfoam with thrombin as well as with FloSeal.

After complete eradication of tumor, interrupted Vicryl sutures were used to close the Palva flap and subcutaneous tissue. A Prolene stitch was used to close the skin. A Penrose drain was placed due to a mild amount of oozing in the subcutaneous space. A Glasscock pressure dressing was applied.

All sponge, needle, and instrument counts were correct at the end of the case. The patient tolerated the procedure well, was extubated and transported to the recovery room. She was noted to have facial nerve function, grade I/VI, with Weber lateralizing to the left ear.

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PREOPERATIVE DIAGNOSIS: Bilateral cervical lymphadenopathy.

POSTOPERATIVE DIAGNOSIS: Bilateral cervical lymphadenopathy.

PROCEDURE PERFORMED: Incisional biopsy, left supraclavicular mass.

SURGEON:  John Doe, MD

INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old female with a history of bilateral cervical lymphadenopathy with evidence of diffuse systemic lymphadenopathy on PET scan who presents for incisional biopsy for the left supraclavicular lymphadenopathy.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating room, and an appropriate plane of anesthesia was obtained using general endotracheal intubation. The head of the bed was turned and 2.5 mL of lidocaine, 1% with 1:100,000 epinephrine, was injected along a skin fold overlying the mass. The area was prepped and draped in the usual sterile fashion.

A 3 cm incision was made through the platysma layer. Small cervical flaps were elevated.

Blunt and sharp dissection was carried down the palpable free border of the matted lymphadenopathy until the capsule of the lymph nodes was identified.

Further blunt and sharp dissection was carried through to provide better exposure of this area.

Two samples were then excised from the large lymph node, one sent for frozen section and one for permanent specimen.

Meticulous hemostasis was obtained.

The wound was closed in layered fashion with 3-0 deep Vicryls for the subcutaneous and platysma layers and a running 5-0 Monocryl for the skin. Dermabond was applied. No immediate complications.

The patient tolerated the procedure well and was transported to the PACU in stable condition.

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POSTOPERATIVE DIAGNOSIS: Recurrent epistaxis.

PROCEDURE PERFORMED: Control of epistaxis, complex, bilateral, with KTP/YAG laser.

SURGEON: John Doe, MD

ANESTHESIA: General endotracheal anesthesia.

ESTIMATED BLOOD LOSS: 10 mL.

SPECIMENS: None.

FINDINGS: Multiple telangiectasias bilaterally on the septum and the floor of the nasal cavity. These were controlled with KTP/YAG laser.

DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and was placed in the supine position on the operating room table. General facemask anesthesia was given until a deep plane of anesthesia was obtained.

At that point, an endotracheal tube was placed by the anesthesiology service without difficulty. Afrin-soaked nasal pledgets were then placed in the nares bilaterally. After allowing time for anesthesia and decongestion, the surgery began with 0-degree nasal endoscope in the right nasal cavity. There were several superficial vessels in the anterior-posterior nasal cavity along the floor. There were also telangiectasias along the septal wall.

The KTP/YAG laser under endoscopic guidance was used at 2 watts for cauterization of these multiple telangiectasias and small superficial vessels. The right nasal cavity was then thoroughly irrigated with normal saline and suctioned clear. There was no evidence of epistaxis.

Attention was then turned towards the left nasal cavity. Again, this was viewed with 0-degree nasal endoscope. This provided visualization of several small telangiectasias along the septum. There was a small septal perforation. Anterior septal perforation appeared to be a small venous lake, approximately 0.5 mm. There were several small superficial vessels along the floor of the left nasal cavity, bilateral walls.

KTP/YAG laser again was used under endoscopic guidance for cauterization of the multiple superficial vessels and telangiectasias. This was also used to control to cauterize the small venous lake anterior to septal perforation. Small area of granulation tissue along the floor of the nasal cavity was visualized with a 45-degree nasal endoscope and cauterized with KTP/YAG laser.

The left nasal cavity was then thoroughly irrigated with warm normal saline. There was small evidence of bleeding from the middle turbinate. It was abraded with the endoscope. This was cauterized with suction Bovie cautery. Again, both nasal cavities were thoroughly irrigated with warm normal saline and suctioned. There was no evidence of bleeding.

At that point, the procedure was terminated. The patient was then awoken from general anesthesia, extubated and sent to postanesthesia care unit.

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ENT Consult Medical Transcription Sample Report

DATE OF ENT CONSULTATION:  MM/DD/YYYY

REASON FOR ENT CONSULTATION:  Right ear pain.

REFERRING PHYSICIAN:  John Doe, MD

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female who has been complaining of right ear pain. The patient relates that she had a similar episode approximately 4 weeks ago and saw a nurse practitioner, who diagnosed the patient with acute otitis media and treated her with antibiotics. The patient completed the course and had some improvement after 3-4 days.

The patient denies any hearing loss, any problems with upper respiratory infection prior to the onset of the ear pain, and significantly, she does have allergy problems which have been exacerbated in the fall season. She has been taking Zyrtec prior to admission. She relates that she continues with nasal congestion and drippiness from her nose with associated postnasal drip, despite the fact that she is in the hospital currently. She has had difficulty with sinusitis. Importantly, she has also had problems with infected teeth and had root canals. However, denies any current or recent dental problems. She has had history of TMJ syndrome in the past. She relates that the pain is somewhat similar to this.

The patient relates that she has had difficulty with cervical myalgia in the past as well as migraine headaches. She has undergone chiropractic treatment for her migraine headaches with improvement in her headache symptoms. Significantly, she has been involved in multiple accidents sustaining whiplash injuries on 4 separate occasions, according to the patient.

She recently notes that she was given a diagnosis of a nasal septal deviation as well. She denies any throat pain. She has had tonsillectomy performed in the past. She describes the pain as throbbing, achy pain. She denies any hearing loss, vertigo or otorrhea. She relates that she has had longstanding tinnitus, which she describes as a high-pitched ringing sound, worse on the right than the left, and not associated with fullness of the ear or any facial weakness.

She had been previously evaluated by an otorhinolaryngologist, who performed an audiometric evaluation and found her hearing to be fine. The patient denies any significant noise exposure history. The patient denies eustachian tube dysfunction symptoms including pressure, pain, throbbing or popping sensation of the ears. She denies any acute dental problems. She denies frank symptoms of prodromal aura or migraine headaches. She denies any type of temple headache to suggest temporal arteritis. She has not had any recent trauma to the ear area.

The patient denies upper respiratory infection symptoms or symptoms related to sore throat. She has no numbness or tingling sensation of the face or the head. She has discomfort related to her abdominal procedure. The patient was referred for an ENT consultation.

CURRENT MEDICATIONS:  Pepcid, Ancef, Lidoderm patch as well as a PCA, Lovenox.

PAST MEDICAL HISTORY:  Morbid obesity, GERD, hypercholesterolemia, environmental allergies, peripheral edema, insomnia, chronic arthritis with associated chronic pain, history of hepatitis and TMJ syndrome. Suspect a recent history of acute otitis media.

PAST SURGICAL HISTORY:  Significant for tonsillectomy, ocular procedures, appendectomy, cholecystectomy, gastric banding, bilateral podiatric procedures, tubal ligation, carpal tunnel, rotator cuff surgeries and left total knee arthroplasty.

FAMILY HISTORY:  Significant for diabetes, hypertension, and coronary artery disease.

SOCIAL HISTORY:  Nonsmoker. She uses alcohol on a social basis.

REVIEW OF SYSTEMS:  As noted in HPI.

PHYSICAL EXAMINATION:

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#57 Beaver blade

1% lidocaine with 1:100,000 epinephrine

15 Bard-Parker blade

15 blade

30-degree telescope

4-mm, 0-degree endoscope

45-degree Blakesley forceps

90-degree giraffe forceps

Afrin-soaked pledget

alligator forceps

anterior and posterior ethmoid air cells

Armstrong beveled PE tubes

Armstrong grommet ear tube

ArthroCare Coblator

aryepiglottic fold

Asch forceps

backbiter

back-biting forceps

Baron #5 ear suction

Bellucci ear forceps

Bellucci scissors

Blakesley forceps

bony cartilaginous junction

Bowman probe

Buck curette

bulla ethmoidalis

Caldwell-Luc incision

Caldwell-Luc procedure

cephalic trim

cholesteatoma

chorda tympani

coblated

Coblation

Coblator II wand

cocaine and 1% Xylocaine with 1:100,000 epinephrine

cocaine-soaked nasal pledgets

concha bullosa

Cottle elevator

cottonoids

cotton pledgets

cricopharyngeus muscle

Crowe-Davis mouth gag

cryptic tonsils

curved Allis clamp

curved microdebrider

curved single-guarded Neivert osteotome

Davis-McIvor mouthgag

Dedo laryngoscope

Denver splint

Donaldson tube

dorsal hump reduction

dorsal spreader grafts

dorsal strut

Doyle splint

epitympanic space

ethmoid bowl

ethmoid bulla

ethmoid labyrinth

ethmoid sinus roof

Fisher dissector

floor of the nose

Floxin drops

Frazier suction tube

Frazier tip suction

Freer elevator

Freer knife

frontal recess

Gelfoam

Gorney scissors

greater palatine foramen

Guthrie hook

halothane induction

Harmonic scalpel

hemitransfixion incision

Hopkins rod telescope

incudostapedial joint

inferior turbinates

Jansen-Middleton forceps

Keith needle

Kerrison sphenoid punch

Killian incision

lamina papyracea

LandmarX navigation system

L-strut

manubrium of the malleus

maxillary acrylic splint

maxillary crest

Mayo stand

McGee crimper

McGee stapes prosthesis

Merocel Kennedy sinus pack

middle turbinate

middle turbinate was medialized

morselizer

mouth gag

mucoperichondrial flaps

mucoperichondrium

mucoperiosteal flaps

mucosal flaps

mulberry-tip

mustache dressing

myringotomy knife

nasal passageway

nasal vault

Nasopore nasal dressing

Neiman splint

Neo-Synephrine impregnated cottonoid

open septorhinoplasty

oropharyngeal pack

osteotomy done in low-to-low fashion

otoabrader

Parsons window

planum sphenoidale

Pope tympanostomy tube

pull-type rasp

pull-type rasp

quilting stitch

Ray-Tec sponge

reosteotomized

Reuter bivalve splint

Reuter bobbin tube

Richards modified T-tube

Rosen needle

Schobinger incision (radical neck dissection procedure)

septal cartilage sandwich graft

septorhinoplasty

sharp iris scissors

sickle knife

sinusotomy

Skeeter drill

soft palate retractor

sphenoid base

St. Clair-Thompson forceps

stair-step incision

Stammberger side-biting forceps

stapedial footplate

straight-biting Blakesley forceps

StraightShot microdebrider

subperichondrial plane

subperiosteal plane

superior pole of tonsil

superior tonsillar fossa

supratip break of the nose

Tabb knife

Takahashi forceps

Takahashi rongeur

tonsil calculus

tonsillar fossa

tonsil pack

tonsillar pillar

tonsil tenaculum

tonsillolith

tragal pump

transcartilaginous incision

transcolumellar V incision

transnasal red rubber catheter

transoral sphenopalatine block

Tru-Cut forceps

tympanomeatal flap

uncinate

uncinectomy

undersurface of sella

uvulopalatopharyngoplasty

uvulopalatopharyngoplasty

vallecula

vomerine groove

Zeiss operating microscope

zygomatic arch

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ENT Medical Transcription Operative Sample Report #1

OPERATIONS PERFORMED:
A. Lysis of intranasal synechia.

B. Revision of right maxillary antrostomy with tissue removal.

C. Image-guided endoscopic transnasal transsphenoidal hypophysectomy.

DETAILS OF PROCEDURE: The patient was brought into the operating room and was placed on the operating room table in a supine position. After demonstration of adequate endotracheal anesthesia, the table was turned 90 degrees. The registration verification process was performed for the stealth image-guided system using MRI. The nose was prepped with Afrin-soaked neurosurgical pledgets. Greater palatine foramina were infiltrated with 1 mL of 1% lidocaine with 1:100,000 epinephrine bilaterally. The patient was then prepped and draped sterilely.

The left nasal cavity was inspected. There was evidence of previous partial middle turbinectomy and ethmoidectomy. There was a patent maxillary antrostomy. No evidence of polyp or purulence. On the right, similar postoperative changes were identified. The lateral wall was infiltrated with a local anesthetic. Prior to accessing the middle meatus, there was an adhesion between the anterior middle turbinate remnant and the lateral nasal wall. After local anesthetic, this was taken down with a Freer. This allowed access into the middle meatus. The antrostomy was enlarged anteriorly using backbiting forceps. It was approximately doubled in size with this technique as it showed evidence of scarring to some degree. Within the sinus, there was a soft polyp versus a mucus-retention cyst. This was grasped with Blakesley forceps and removed. Care was taken to limit the antrostomy, stopping short of the area of the tear duct.

Next, the right sphenoid sinus was cannulated with a beta probe. It was then enlarged with 1 and 2 mm Kerrison rongeurs. Access into the region, on both sides, was assisted by lateralizing the middle and superior turbinates. On the left, the sphenoidotomy was again made and enlarged with the Kerrison rongeurs. The posterior nasal septum was then infractured and taken down with backbiting forceps. Some fragments of bone were kept in saline for later use. The intrasphenoid sinus septum was partially removed with Takahashi forceps; this was done delicately. There was thick bone between the sphenoid sinus and the carotid artery.

Dr. John Doe then performed removal of mucosa from over the roof of the sinus and entry into the sella. Tumor resection will be dictated separately. CSF was encountered just left of the midline portion of exposure. Frozen section confirmed pituitary adenoma. When his tumor resection was completed, he then harvested abdominal fat. I used this to place directly into the sella. Two pieces measuring approximately 8 mm were used. They were slightly dehydrated with suction over a patty. Next, a bone fragment accommodating the size of the sellar defect was placed. This was followed by Tisseel. A separate layer of 2 Gelfoam patties followed by further Tisseel was then placed and more Gelfoam was positioned. The turbinates were medialized. Merogel was rolled and placed in the right middle meatus as a spacer. Merocel packs were then placed in both the right and left nasal cavity and tied loosely about the columella. The patient was turned over to the care of the anesthesia team. She was taken out of the pins. She was set for extubation and returned to the recovery room. She tolerated the procedure well without immediate complications.

ENT Medical Transcription Operative Sample Report #2

PROCEDURE PERFORMED: Total thyroidectomy.

DETAILS OF PROCEDURE: The patient was taken to the operating room and placed supine on the operating room table. After general anesthesia was induced, an IV inflating bag was placed horizontally on her shoulder blades and inflated, thereby extending her neck. Her neck and chest were prepped with Betadine solution and sterilely draped in the usual manner for procedure in this area.

An anterior cervical incision along natural skin lines was created and extended through subcutaneous tissues to the subplatysmal layer. Hemostasis was obtained with Bovie cautery. A superior subplatysmal flap was created to the level of the thyroid cartilage and inferior subplatysmal flap to the level of the clavicular heads. Dissection was done in the midline avascular plane between the strap muscles. Attention was first placed to the patient’s right side.

The right strap muscles were retracted laterally. The right thyroid lobe was retracted medially. Blunt dissection of the loose fibroareolar tissue between the thyroid capsule and the undersurface of the strap muscles was done. Blunt dissection in the tracheoesophageal groove area revealed the recurrent laryngeal nerve along its entire extent throughout the thyroid fossa. Both superior and inferior parathyroid glands were identified and preserved intact from their vascular pedicles. Attention was placed to the superior pole vessels.

The right superior pole vessels were divided between 4-0 silk ligatures and small hemoclips. Mobilization of the right superior lobe allowed better mobilization of the right lobe medially. Small vascular pedicles were divided between 4-0 silk ligatures and small hemoclips. The inferior thyroid pole vessels were divided between 4-0 silk ligatures and small hemoclips. The thyroid was removed off of the trachea. The right thyroid fossa was irrigated with warm normal saline. Meticulous hemostasis was obtained. It was packed with a dry Ray-Tec gauze and attention placed to the patient’s left side.

The left strap muscles were retracted laterally. The left thyroid lobe was retracted medially. Blunt dissection of the loose fibroareolar tissue between the thyroid capsule and the undersurface of the strap muscles was done. Blunt dissection in the tracheoesophageal groove area revealed the recurrent laryngeal nerve along its entire extent throughout the thyroid fossa. Both superior and inferior parathyroid glands were identified and preserved intact from their vascular pedicles. Attention was placed to the superior pole vessels.

The left superior pole vessels were divided between 4-0 silk ligatures and small hemoclips. Mobilization of the left superior lobe allowed better mobilization of the entire left lobe medially. Small vascular pedicles were divided between 4-0 silk ligatures and small hemoclips. The inferior thyroid pole vessels were divided between 4-0 silk ligatures and small hemoclips. The thyroid was removed off of the trachea. The left thyroid fossa was irrigated with warm normal saline. Meticulous hemostasis was obtained. The pyramidal lobe was removed in continuity with the isthmus. The specimen was submitted to the pathologist.

The strap muscles were approximated in the midline with a running suture of 3-0 PDS. The platysmal layer was closed with interrupted sutures of 5-0 PDS. The skin was closed with subcuticular sutures of 6-0 Prolene. A quarter inch Steri-Strip tape was applied and ice bag placed over the anterior neck.

The patient tolerated the procedure well and was transferred to the recovery room in stable condition. Estimated blood loss was 15 cc. Sponge, needle, and instrument counts were correct.

ENT Medical Transcription Operative Sample Report #3

PROCEDURES PERFORMED:

A. Right tympanoplasty with ossicular chain reconstruction.

B. Fascial graft.

C. Microdissection with the use of operative microscope throughout the procedure.

D. Facial nerve monitoring.

DETAILS OF PROCEDURE: The patient was taken to the operating room and was placed supine on the operating room table. After adequate general anesthesia had been obtained via endotracheal intubation, attention was then turned to the patient’s right ear. The patient was then appropriately positioned and padded on the operating room table. Lidocaine 1% with 1:100,000 epinephrine was injected into the postauricular crease. Facial EMG electrodes were placed in the orbicularis oris and orbicularis oculi muscles. Facial nerve monitoring was used throughout the procedure. There were no abnormal EMG potentials. The patient’s right ear was then prepped and draped in the standard surgical fashion. The operative microscope was used throughout the procedure. The patient’s ear canal was cleaned. The patient was with normal tympanic membrane and middle ear space. Lidocaine 1% with epinephrine was injected into the 4 quadrants of the ear canal. A 2 cm stab incision was made in the postauricular crease. This was carried down to the level of the mastoid, periosteum, and temporalis fascia. A fascial graft was harvested, pressed, and passed off the table. Hemostasis was obtained in the postauricular incision and it was closed with absorbable sutures. Attention was then once again turned to the ear canal. A vertical incision was made at 12 o’clock and 6 o’clock followed by a connecting incision 6 mm lateral to the annulus. A tympanomeatal flap was elevated. The annulus was identified and elevated and the middle ear space was entered. The caroticotympanic nerve was identified and preserved throughout the remainder of the procedure. The posterosuperior canal was then curetted due to prominent overhang. This fully exposed the entire ossicular chain. Upon palpation of the malleus, it was noted to be mobile. The incus was noted to be significantly eroded. The long process tapered down onto a remnant of the head of the stapes. The stapedius tendon was present. The entire superstructure of the stapes was missing. There was not a single remnant of it present on the footplate. The footplate was noted to be mobile. The distance between the malleus and the stapes was measured. The ossicular chain was then reconstructed with a Kartush incus-stapes strut. This had to be trimmed further to fit. The strut was placed on the footplate and along the handle of the malleus. There was noted to be good mobility upon palpation of the malleus of the entire strut and footplate. Gelfoam was packed around the strut to support its position. A micrograft was used laterally at the level of the malleus to hold the strut’s position. The prior fascial graft was then placed in an underlay fashion along the unilateral aspect of the strut. This was used as a buffer to prevent extrusion of the prosthesis. The tympanomeatal flap was then returned to its normal anatomical position along the posterior canal wall. Saline-soaked Gelfoam was used to pack the lateral one-half of the ear canal. This was followed by bacitracin ointment to the remainder of the ear canal. Bacitracin ointment was also placed along the postauricular incision. Facial EMG electrodes were then removed. The patient was then awakened by the anesthesia service, extubated and taken to the recovery room in a stable condition. Postoperatively, the patient had normal facial function. There were no intraoperative complications.

ENT Medical Transcription Operative Sample Report #4

PROCEDURE PERFORMED: Bilateral otoplasty.

DETAILS OF PROCEDURE: The patient was brought to the operating room and was placed supine on the operating room table under general anesthesia. Her face and ears were prepped with Betadine solution and draped sterilely. The ears were marked appropriately and then infiltrated with 1% Xylocaine with epinephrine to improve hemostasis. A triangle of skin was removed posteriorly and the otoplasty rasps were inserted to score and release the pull of the antihelix cartilages. After this was softened with the otoplasty rasp, which was placed through a subcutaneous tunnel anteriorly, #4-0 wide Mersilene sutures were then placed in a horizontal suture fashion tacking the ear to the mastoid periosteum. The tension was adjusted to bring the ears back into proper anatomical position, after which interrupted #4-0 Vicryl was used to approximate the skin edges. A #5-0 running Vicryl Rapide was then used to close the skin. Identical procedure was carried out bilaterally, except on the left ear a small darwinian tubercle was removed and shaved down through a helical incision. The excess cartilage was properly excised and the skin closed with the running interrupted #5-0 Vicryl Rapide. Postoperatively, a damp cotton mold was applied to the ear to hold it in proper position after which a wraparound light fluffy head dressing was applied. The patient was then transferred from the operating table to the recovery area having tolerated the procedure without difficulty.

ENT Medical Transcription Operative Sample Report #5

OPERATION PERFORMED: Tonsillectomy and adenoidectomy.

DESCRIPTION OF OPERATION: The patient was brought into the operating room and placed on the operating room table in supine position. After intubation and adequate anesthesia was given, the patient was cleaned, prepped, and set up for tonsillectomy and adenoidectomy. Used the McIvor mouth gag to retract the tongue and endotracheal tube inferiorly, giving good exposure to the oropharynx. The tonsils were seen. The adenoids were directly palpated and indirectly visualized. A Foley catheter was used to retract the soft palate, and the adenoids were freely curetted out of the nasopharynx using adenoid curettes. A tonsil sponge was placed into the nasopharynx to control any bleeding. Attention was then focused toward the tonsils.

The right tonsil was grasped with a curved Allis, retracted medially, and dissected from superior to inferior pole using the coblator scalpel with settings of 7 and 4. In a similar fashion, the left tonsil was grasped with a curved Allis, retracted medially, and dissected from the superior to inferior pole using the coblator scalpel at settings of 7 and 4. All bleeding was controlled at the time of dissection using a coblator scalpel.

Attention was then refocused back towards the nasopharynx. The tonsil sponge was removed and any remaining bleeding was controlled with the handheld suction Bovie. Under indirect visualization of the adenoid mirror, nasopharynx and oropharynx were then copiously irrigated with saline and suctioned free. An orogastric tube was passed down the esophagus and into the stomach to remove any gastric contents. Then, 0.25% Marcaine was injected into each tonsillar fossa for postoperative pain. The patient was then awakened, extubated, and transferred to recovery room in stable condition. All postoperative instructions were given.

ENT Medical Transcription Operative Sample Report #6

PROCEDURE PERFORMED: Uvulopalatopharyngoplasty with tonsillectomy.

DETAILS OF PROCEDURE: The patient was brought to the operating room and correctly identified. General anesthesia was induced using mask intubation followed by endotracheal tube intubation. IV steroids and IV antibiotics were administered. The table was turned to 90 degrees and the patient placed in slight reverse Trendelenburg. The patient was then draped in the usual sterile fashion following injection of 8 mL of 1% lidocaine with 1:100,000 epinephrine into the nose followed by placement of Afrin pledgets.

Following sufficient time for vasoconstrictive purposes, a hemitransfixion incision was created along the left side. A mucoperichondrial followed by mucoperiosteal flap was then elevated. A bone spur was noted posteriorly following separation of the bony cartilaginous junction. The mucosa was elevated on both sides of the bony spur and controlled cuts were made using heavy Mayo. A Takahashi was then used to extract the bony spur. The septum was noted to be well in the midline following this procedure. The inferior turbinates were then dressed. The #15 blade was used to create an incision along the anterior face of the inferior turbinate on both sides. A Freer was then used to elevate the mucoperiosteal flap along the medial surface. A suction Bovie was placed into this pocket and a reduction of the tissue was then performed.

Following this, a Boies elevator was used to outfracture the inferior turbinates. The hemitransfixion incision was then reapproximated using interrupted catguts.

Following this, a Crowe-Davis mouthgag was used to expose the oral cavity. There was evidence of +4 tonsils. The soft palate was palpated and found to be normal. A red rubber catheter was introduced through the nose into the oropharynx to retract the soft palate superiorly. Following this, each tonsil was individually grasped with a curved Allis and removed using Bovie cautery. There was noted to be a poorly defined tracheal tonsillar plane, and the tissue was sent for intraoperative frozen diagnosis. There was no evidence of any lymphoma.

Following this, under direct visualization with a laryngeal mirror, an adenoid curette was used to remove +3 adenoids. Tonsil packs were then placed, placed for temporary hemostasis. These were removed and suction Bovie was used to control and maintain hemostasis. Following this, the nasopharynx and oropharynx were irrigated and suctioned out with copious amounts of normal saline. Any noted bleeding was then controlled in the oropharynx using the suction Bovie.

The mouthgag was released and resuspended after several minutes with no evidence of any active bleeding. Following this, anterior pharyngeal tissue as well as the uvula and a small cuff of palate was then removed using Bovie cautery. There was no evidence of any active bleeding. The anterior and posterior pillars of the pharyngeal tissue were then reapproximated using interrupted #3-0 Vicryl suture.

The stomach contents were then suctioned out using an orogastric tube. There was evidence of fluid within the stomach contents. The nasal passages were reevaluated. There was no evidence of any active bleeding. A Doyle splint was placed and bacitracin ointment was then placed and secured anteriorly using a #3-0 nylon suture through the membranous portion of the septum. The patient was then returned to anesthesia and awoken without incident. There were no complications. Estimated blood loss was less than 100 cc.

ENT Medical Transcription Operative Sample Report #7

PROCEDURE PERFORMED: Bilateral myringotomy and tympanostomy tube placement.

DETAILS OF PROCEDURE: The patient was brought to the operating room and identified. He was placed in the operating room table in supine position. General mask anesthesia was then administered. After adequate prepping, both ears were examined using binocular operating room microscope; the above findings were noted. Previously extruded tympanostomy tubes were removed using alligator forceps. Cerumen was removed using Buck curette. Myringotomies were then made in the anterior, inferior aspects of the tympanic membranes. Scant fluid effusions were then evacuated. New Armstrong beveled PE tubes were then placed through the myringotomies bilaterally. Floxin drops were then instilled in the ears. The patient’s anesthesia was reversed and the patient was sent to the recovery room. There were no complications.

ENT Medical Transcription Operative Sample Report #8

PROCEDURE PERFORMED: Bilateral myringotomy with tubes.

DETAILS OF PROCEDURE: The patient was brought to the operating room and put on the operating room table in a supine position. After adequate anesthesia was given, the patient was then set up for myringotomy with tubes. Using the operating microscope with 250 mm lens and ear speculum, the left ear canal was cleared of any debris giving good exposure to the tympanic membrane. A myringotomy incision was made in the anterior-inferior quadrant. An Armstrong grommet tube was passed into the myringotomy incision. Mild amount of mucoid fluid was suctioned from behind the eardrum and Ciprodex drops were put into the left ear canal. The patient was then repositioned for right myringotomy. Using the operating microscope with 250 mm lens and ear speculum, the right ear canal was cleared of any debris giving exposure to the tympanic membrane. A myringotomy incision was then made in the anterior-inferior quadrant. An Armstrong grommet tube was put into the myringotomy incision. Mild amount of mucoid fluid was suctioned from behind the eardrum using #2 suction. Ciprodex drops were put into the ear canal. The patient was then awakened and transferred to the recovery room in stable condition.

ENT Medical Transcription Operative Sample Report #9

PROCEDURE PERFORMED: Bilateral upper and lower eyelid blepharoplasty.

DETAILS OF PROCEDURE: After identification of the patient and obtaining informed consent, she underwent the following procedure. In the preoperative holding area, the patient was marked; marked out the supratarsal creases, marked out planned excision of the skin in the upper eyelids, which is approximately 5 mm in greatest width, marked up the planned subciliary incisions with planned excision of the skin of about 3 mm in each lower eyelid. Marked out the level of the supraorbital rim bilaterally. The patient was taken to the operative suite and placed on the table in supine position. After induction and intubation, achieving full anesthesia, antibiotic prophylaxis given with Ancef and eye was lubricated with ophthalmic antibiotic ointment. Upper and lower eyelids anesthetized with 1% lidocaine with epinephrine.

Upper eyelid incision was performed in the skin with 15 blade scalpel. Symmetrically, the skin was excised using tenotomy scissors. Symmetrically, the redundant orbicularis muscle excised using electrocautery. Fat pads from the medial and central fat compartments in the upper eyelids were identified, teased out with Q-tips and then cauterized at the base and excised with electrocautery removing symmetrical amounts of the redundant tissue. Then, attention made towards hemostasis. Incision was closed in layers using 5-0 Vicryl sutures subdermally and subcuticular pullout sutures and 6-0 Novofil along the skin edges.

Addressing the lower eyelids, performed subciliary incisions and elevated skin and orbicularis muscle as flaps down to the level of the orbital rim. Identified the redundant fat pad compartments in the lateral, medial, and central areas of each lower eyelid. Tenotomy scissor was used to make incision in the septum. Fat pad compartments identified, teased out with Q-tips, and cauterized and divided at the bases with electrocautery and removed in symmetrical fashion. Attention was made to hemostasis with cautery. Incisions closed after removal of the redundant skin with tenotomy scissors using 5-0 Vicryl subdermally and 6-0 Novofil in subcuticular pullout fashion. Eyes could close completely without any undue tension and there was no sign of any eyelid ectropion. The patient was dressed with antibiotic ointment. Extubated and taken to recovery in stable condition.

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