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Report 5
Name: Jose Beliz
#050105
Date of Operation:
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Department:
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Surgeon: A. Jones, MD
Assistant Surgeons: D. Patel, MD, R. Snow, MD
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS
Cholesteatoma, left ear.
POSTOPERATIVE DIAGNOSIS
Same.
PRIMARY PROCEDURE
TYMPANOPLASTY WITH MASTOIDECTOMY, LEFT EAR.
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ANESTHESIA
General via endotracheal tube.
FINDINGS
1. Malleus and incus present with erosion of the long process of the incus.
2. Stapes intact and mobile.
3. Cholesteatoma present in the middle ear and epitympanum.
4. Mastoid sclerotic.
5. Small area of mastoid cholesteatoma.
6. Several areas of cholesterol granuloma in the mastoid.
7. Malleus and incus fixed.
PROCEDURE
The patient was brought into the operating room and placed on the operating table in the supine
position. An intravenous line had been established, and general endotracheal anesthesia was
induced to a satisfactory level. The periauricular area was shaved. Lidocaine 1% with
epinephrine 1:100,000 was injected in the postauricular area and posterior canal wall. The patient
was then prepped and draped in the usual fashion for ear surgery.
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Using the operating microscope, the aural speculum was inserted and the external canal cleaned.
The canal was then injected with lidocaine 1% with epinephrine 1:100,000 to all 4 quadrants of
the cartilaginous canal. This was forced medially with the speculum. Good blanching in the
medial canal and TM was noted. After adequate time for vasoconstriction, the #1 knife was used
to create vascular strip incisions along the tympanomastoid and tympanosquamous suture lines.
These were brought out laterally.
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A #2 knife was used to elevate the vascular strip slightly. The Beaver blade was then used at the
junction of the bony cartilaginous canal to complete the circumferential cut, leaving the vascular
strip intact. Cotton ball with local solution was placed in the canal.
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Postauricular incision was then made with the #15 blade carried down through the skin and
subcutaneous tissue. Hemostasis was achieved with electrocautery. The self-retaining retractor
was used to expose the temporalis fascia and a right-angle retractor used to increase exposure.
Overlying tissue was cleaned and the temporalis fascia identified. A piece of temporalis fascia
was harvested for grafting in the usual fashion. This was flattened, cleaned and set aside to dry
for use at the end of the case. Hemostasis was good at the graft donor site. Attention was then
turned toward the mastoid periosteum. This was incised with the #15 blade posterior and parallel
to the zygomatic root. This was then dropped down toward the mastoid tip and the mastoid
periosteum elevated with a Lempert. Further elevation and retraction via the vascular strip was
then reflected and held underneath the self-retaining retractor. The canal skin and epithelial layer
of the TM were also removed.
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The bony canal was somewhat small, so was enlarged using a rotating cutting bur under constant
suction, irrigation and magnification. Care was taken to remain outside of the
temporomandibular joint. After appropriate opening of the canal, the entire annulus could be
seen.
The areas of diseased TM were then dissected and the middle ear entered. The region of the
eustachian tube was seen to have diseased mucosa but no cholesteatoma. The TM remnant was
carefully dissected off the malleus. Because of the extent of the disease, the entire TM was
removed and the annulus left. Malleus was found to be fixed, and long process of the incus was
not present.
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Cholesteatoma was seen primarily in the mesotympanum, leading up into the epitympanum.
Granulation tissue and cholesteatoma were seen in the region of the oval window. The stapes
could not be visualized at this time. There was no pus present.
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Attention was then turned to the mastoid. Mastoidectomy was begun with large rotating cutting
bur with suction and irrigation. The mastoid cortex was removed, and the sclerotic mastoid air
cells were noted. Care was taken to maintain dissection high and anterior, in order to increase
exposure in the area of the epitympanum. The region of the dural angle was opened. The middle
fossa plate was skeletonized.
The sigmoid sinus and antrum were identified. The zygomatic root cells were dissected out. The
area of the chorda tympani was identified. The facial nerve was identified as it came from its
horizontal portion, turning at the genu into the vertical portion. The facial nerve remained intact
throughout this portion of the dissection. The area of the lateral semicircular canal was identified,
and there was no evidence of fistula. Dissection and removal of cholesteatoma was performed
during this procedure. Dissection continued in the region of the promontory toward the stapes
capitellum. The crura were present. The stapes was mobile. The incus and malleus were
removed. A thick, reinforced piece of Silastic, 0.04 inches, was then shaped appropriately and
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then placed in the middle ear with the tongue extending into the eustachian tube area and coming
out through the facial recess. The graft was placed and trimmed. Gelfoam was placed in the main
portion of the middle ear and the epitympanum. The temporalis fascial graft was placed and
redraped so that it abutted the anterior canal wall. The canal skin was then placed back in its
native position. The medial canal was packed with Gelfoam. The ear was reflected back to its
native position and held in place with a single Dexon suture at the periosteum. The remainder of
the ear canal was then packed with Gelfoam soaked in Coly-Mycin.
The postauricular incision was closed. Skin was closed with interrupted subcuticular Dexon
sutures. A dry cotton ball was placed in the meatus. The skin was then prepped with benzoin, and
Steri-Strips were applied. A mastoid dressing was placed in the usual fashion.
The patient was awakened from anesthesia, having tolerated the procedure well. Sponge and
needle counts were correct at the end of the case. The patient was transferred to the PAR in
stable condition. EBL: 30 mL. Specimens from the mastoid and middle ear were sent to
pathology for routine studies. There were no drains or complications.
____________________________________
Anne Jones, MD
D:
T:
AJ:
Footnotes
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Write out date here per Rule 64.
Department is required. Flag the doctor.
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All caps per format.
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Vertical numbered list per Rule 58.
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Doctor forgets which number she was on, and dictates “next.” Continue numbering.
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Rule 28.
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Doctor dictates “epi 1:100” here. This is slang. Edit per 61. NOTE: To research this dosage, you must research this
as lidocaine with epinephrine. This is a combination medication. Researching by the individual med names will not
yield the dosage dictated.
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This blade name, Beaver, sounds very similar to another medical blade name, Deaver. By researching the Beaver
blade, you will find that Beaver blades are used in ENT surgery, which helps you confirm which name is correct.
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Rule 22.
10
Doctor dictates “was” here. Edit for grammar.
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Rule 27.
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Rule 28.
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Doctor dictates “was” here. Edit for grammar.
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Rule 28.
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Add a zero before the decimal point per Rule 9.
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Comma per Rule 28.
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PAR stands for postanesthesia recovery.
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Rule 2.
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