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ENT Procedure Medical Transcription Transcribed Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Deviated nasal septum, left.
2.  Nasal obstruction.
3.  Turbinate hypertrophy with no response to topical nasal decongestant.
4.  Rhinitis, pharyngitis and halitosis.

POSTOPERATIVE DIAGNOSES:
1.  Deviated nasal septum, left.
2.  Nasal obstruction.
3.  Turbinate hypertrophy with no response to topical nasal decongestant.
4.  Rhinitis, pharyngitis and halitosis.

OPERATIONS PERFORMED:
1.  Nasoseptoplasty.
2.  Submucosal resection, right inferior turbinate.
3.  Outfracture, bilateral inferior turbinates.

SURGEON:  John Doe, MD

ANESTHESIA:  General and local, 4 mL of 1% Xylocaine with 1:100,000 epinephrine and 2 mL of 1% Xylocaine 1:1 with saline.

SPECIMENS:  Portion of nasoseptal cartilage and bone.

ESTIMATED BLOOD LOSS:  Less than 25 mL.

DESCRIPTION OF OPERATION:  After the patient was identified, he was taken to the operating room and placed on the operating table in a flat supine position.  The anesthesiologist was present for monitoring as well as administration of anesthesia.  The patient received IV induction and gas ventilation maintenance via an oral endotracheal tube.  Once the patient was adequately anesthetized, he was placed in a semi-seated reverse Trendelenburg position.  Neo-Synephrine-impregnated cottonoids were placed in the nasal cavity and allowed to take effect.  Topical Neo-Synephrine was applied in the preoperative holding area as well.  Local was infiltrated along the nasal septum using hydraulic dissection technique bilaterally, Betadine prep was completed, and the patient was sterilely prepped and draped in routine fashion.

A modified Killian curvilinear incision was made on the left.  Mucoperichondrium, periosteum carefully elevated using caudal elevator, Freer elevator and Freer knife.  A swing-door technique was employed and the contralateral mucoperichondrium, periosteum also elevated.  Evaluation of the septum is as noted under the findings.  Gorney scissors, Freer knife, Freer elevator were employed on the deviated portion of the nasal septal cartilage and bone was taken down leaving an adequate caudal as well as dorsal strut.  Vertical strips were placed along the superior remaining cartilage to allow for additional medialization.  An island of cartilage was removed near the more superior deflexion of the septum in the region of the middle turbinate on the left.  A 6-0 Prolene suture was used to reapproximate the cut edge of the nasal septum after additional trimming was taken down to reduce the redundancy that was obtained after the resection was completed.  A mallet and chisel were required to remove the bony component of deflexion to the left without entry into the neurovascular bundle.  The modified Killian incision was closed using chromic suture.  Running horizontal mattress was used to reapproximate the mucoperichondrium, periosteum along the length of the dissection.  At the conclusion, the septum took on a midline position.  There were no perforations, tears or rents in the mucoperichondrium, periosteum bilaterally.

Outfracture of the inferior turbinates was completed.  There still remained significant prominence of the right inferior turbinate due to its hypertrophy.  Local with saline mixture was infiltrated and allowed to take effect.  A probe was entered into the tissue with a setting of 6 and submucosal resection was completed with a routine 12-second dissection with the coblator.  There was an immediate response of the tissue improving the airway further.

Neiman splints impregnated with Bactroban were placed bilaterally and fixed to the septum using a 4-0 nylon suture.  Suction was completed.  An NG tube was passed orally.  The stomach and esophagus were suctioned and clot and debris were removed from nasopharynx, oropharynx and hypopharynx.  The patient was awakened, extubated, and then taken to the recovery room in stable condition.  The specimen sent to pathology for routine evaluation included the portion of the nasoseptal cartilage and bone that was resected.  At the conclusion of the procedure, there was significant improvement in nasal airway bilaterally.

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