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Canal Wall Up Tympanomastoidectomy Medical Transcription Operative Sample Report / Example

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Right-sided recalcitrant chronic otitis media.

POSTOPERATIVE DIAGNOSIS:  Right-sided recalcitrant chronic otitis media.

OPERATIONS PERFORMED:
1.  Right canal wall up tympanomastoidectomy.
2.  Microdissection.
3.  Right-sided facial nerve neural monitoring.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

ESTIMATED BLOOD LOSS:  Less than 50 mL.

COMPLICATIONS:  None.

SPECIMENS:  Middle ear tympanic membrane for pathology. Middle ear and mastoid contents were sent for culture and sensitivity including aerobic, anaerobic, fungal and TB.

IMPLANTS:  None.

DRAINS:  None.

OPERATIVE FINDINGS:  Inflamed and mucosalized tympanic membrane with perforation along with mucopus coming through the perforation. In addition, the middle ear mucosa was noted to be inflamed.

DESCRIPTION OF OPERATION:  The patient was taken to the operating room and placed supine on the operating table. After adequate general anesthesia had been obtained by endotracheal intubation, the patient was appropriately positioned and padded on the table. Attention was then turned to the right ear and right face. Facial nerve monitoring electrodes were placed into the orbicularis oculi and orbicularis oris muscles on the right side. The facial nerve monitoring and EMG system was then used throughout the procedure. There were never any abnormal or traumatic EMG potentials. Stimulating dissecting instruments were used when dissecting on the facial nerve. There were never any traumatic potentials. Lidocaine 1% with 1:100,000 epinephrine was injected into the postauricular region. The patient's right ear was then prepped and draped in standard surgical fashion. The operative microscope was used throughout the vast majority of the procedure except for the skin incision and skin closure. The patient's ear canal was cleaned. There was noted to be mucopus coming out through a tympanic membrane perforation in the inferior quadrant. In addition, the tympanic membrane was noted to be mucosalized and inflamed. Lidocaine 1% with 1:100,000 epinephrine was injected into the four quadrants of the ear canal.

A postauricular incision was then made 1 cm outside the postauricular crease. This was carried down to the level of the mastoid periosteum. Superiorly, temporalis fascia was identified and harvested for later grafting. A T-shaped mastoid periosteal incision was made and the entire mastoid cortex exposed. Elevation was carried into the ear canal. Canal incisions were then made 8 mm lateral to the annular rim. The ear canal was exposed. A tympanomeatal flap was elevated and the middle ear space was entered. Mucopus was then cultured and sent for culture and sensitivity. The chorda tympani nerve was preserved throughout the procedure. There was noted to be granulation tissue around the incus and the stapes, which was dissected free. Palpation of the malleus revealed the malleus and incus were noted to be mobile and it appeared the stapes was mobile, though view was limited secondary to granulation tissue around the base of it. The mucosalized portion of the tympanic membrane was resected, which left a large perforation on the drum. The periosteum of the malleus was incised and the tympanic membrane elevated off the malleus. The CO2 laser at 5 watt single pulse was used to help with dissection along with the release of some middle ear adhesions.

With a drill, a canal wall up mastoidectomy was performed. The tegmen was noted to be intact; sigmoid covered. Lateral semicircular canal intact. Mastoid air cells had mucus along with mucopus and thin granulation tissue and adhesions were present. Adhesions within the epitympanum were lysed. At this point, there was noted to be free flow of fluid within the mastoid and the middle ear space. Specimens were sent from mastoid for culture and sensitivity. The wound was copiously irrigated with bacitracin solution. There was noted to be good hemostasis. At this point, Gelfoam soaked in Ciprodex was packed in the middle ear cleft. A fascia graft was then trimmed.  It was placed in an over-under fashion over the handle of the malleus but underneath the tympanic membrane. There was noted to be good coverage of the large perforation. The grafted tympanomeatal flap was then redraped along the posterior ear canal. Further Gelfoam soaked in Ciprodex was packed lateral to this flap. The lateral meatal flap was realigned along the ear canal, followed by further Gelfoam and Ciprodex packing. Laterally, an ear pack was used.

The postauricular incision was then closed in three layers. Dermabond was used for the superficial skin closure. A sterile mastoid dressing applied. Facial nerve monitoring electrodes were removed. The patient was then awakened by the anesthesia service, extubated and taken to the recovery room in stable condition. There were no intraoperative complications and the patient tolerated the procedure well.