DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Right chronic otitis media.
2. Right tympanic membrane perforation.
3. Right conductive hearing loss.
POSTOPERATIVE DIAGNOSES:
1. Right chronic otitis media.
2. Right tympanic membrane perforation.
3. Right conductive hearing loss.
OPERATION PERFORMED:
1. Right tympanoplasty with intact canal wall mastoidectomy.
2. Intraoperative facial nerve monitoring x1 hour.
3. Microsurgery.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal.
OPERATIVE FINDINGS: A right near total tympanic membrane perforation was present. This was repaired using an over-under tympanoplasty technique. The ossicular chain was intact and mobile. The chorda tympani nerve was identified and preserved. Intact canal wall mastoidectomy was performed. The mastoid was clean. Facial nerve was covered in bone.
DESCRIPTION OF PROCEDURE: After proper consent was obtained, the patient was brought to the operating room and placed on the table in the supine position. General endotracheal anesthesia was administered. With the patient asleep, the bed was turned 180 degrees. The patient’s head was turned to the left, exposing the right ear. The right ear was then prepped in the usual manner. It was injected with 1% lidocaine with epinephrine. Intraoperative facial nerve monitoring electrodes were placed by the operating surgeon. These were placed in the orbicularis oris and orbicularis oculi. They were connected to the nerve integrity monitor. The monitor’s proper functioning was confirmed by performing a tap test and by checking electrode impedances. The ear was then cleansed with Betadine paint and covered with sterile drapes.
Next, the operating microscope was brought in. Throughout the case, the operating microscope and microsurgical technique was used. The right ear was examined. There was a near total tympanic membrane perforation. The ear was injected with 1% lidocaine with epinephrine. A tympanomeatal flap was created using a sickle knife and 7200 Beaver blade. The ear canal was packed with topical epinephrine.
Next, a postauricular incision was made. This was carried down to the temporalis fascia and mastoid periosteum. A piece of temporalis fascia was harvested, pressed and set aside under a heating lamp for later use. A T-shaped periosteal incision was made and the mastoid cortex was exposed. Self-retaining retractors were placed. An intact canal wall mastoidectomy was next performed. This was done using a high-speed otologic drill with continuous suction irrigation. Progressively, smaller cutting and diamond burs were used. Dissection was carried back to the sigmoid sinus, superior to the tegmen, inferiorly to the mastoid tip and anterior thinning the bony canal wall. The antrum was opened. The mastoid was clear of disease.
Next, ear canal was examined. The posterior skin was elevated forward. The edges of the tympanic membrane were freshened using a Rosen needle. The tympanomeatal flap was elevated with a weapon knife and the middle ear space was entered. Chorda tympani nerve was identified and preserved. The malleus periosteum was incised and the tympanic membrane was elevated forward off of the malleus. The middle ear was healthy. The eustachian tube orifice was palpated with a gimmick. It was mildly stenotic but with gentle pressure opened. The facial nerve was covered in bone. The ear was copiously irrigated with saline.
Next, the previously harvested temporalis fascia was trimmed. It was brought in place and put under the anterior annulus lateral to the malleus and up the posterior canal wall. The middle ear space was packed with Xeroform soaked with saline. The lateral graft and drum was packed with Gelfoam soaked with ciprofloxacin. The mastoid periosteum was closed using 3-0 interrupted Vicryl. The lateral ear canal was examined. It was packed with Gelfoam soaked with ciprofloxacin. The postauricular wound was then closed in layers using 3-0 interrupted Vicryl and 5-0 fast absorbing gut. The ear was dressed with antibiotic ointment and Glasscock ear dressing.
Throughout the case, intraoperative facial nerve monitoring was performed. The monitor was personally observed and controlled by the operating surgeon. At no point during the case was there spontaneous activity to suggest injury to the nerve. At the end of the case, the patient was awakened and extubated. The patient was transferred to the recovery room in stable condition. Estimated blood loss minimal. Sponge and needle counts correct. In the recovery room, the patient’s facial nerve function was normal.
