DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Left otosclerosis.
2. Left conductive hearing loss.
POSTOPERATIVE DIAGNOSES:
1. Left otosclerosis.
2. Left conductive hearing loss.
OPERATION PERFORMED:
Left laser stapedectomy, intraoperative facial nerve monitoring x1 hour, fascia graft, microsurgery.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal anesthesia.
ANESTHESIOLOGIST: Jane Doe, MD
DESCRIPTION OF OPERATION: After informed 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 head was turned to the right, exposing the left ear. The left 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. The operating microscope was next brought in. Throughout the case, the operating microscope and microsurgical technique was used. The microscope was used for improved illumination and magnification. The left ear was examined. The tympanic membrane was normal. The ear canal was somewhat stenotic. An appropriately-sized speculum was placed. The ear canal was injected with 1% lidocaine with epinephrine. A tympanomeatal flap was created using a sickle knife and 7200 Beaver blade.
Next, a small postauricular incision was made. A piece of fascia was harvested, pressed and set aside under a heating lamp for later use. Hemostasis was achieved with bipolar cautery. The wound was closed using 5-0 fast-absorbing gut. The fascia, once dry, was trimmed into small pieces to seal the piston in place. The ear was examined again with the microscope. The speculum was held in place with a speculum holder attached to the bed. The tympanomeatal flap was elevated and the middle ear was entered. The chorda tympani nerve was identified and preserved. The ossicular chain was palpated and found to be rigidly fixed. The scutum was taken down using the Skeeter drill. This was done until the stapes superstructure was easily seen. The incudostapedial joint was separated. Using the OmniGuide CO2 laser at a setting of 4 watts, the stapedius tendon was sectioned. The posterior crus was removed with the laser. The anterior crus was down-fractured and removed. The distance from the footplate to the incus was measured and found to be 4.30 mm. The footplate itself appeared quite thick. Using the CO2 laser, a rosette was created in the footplate. The char was removed. There was additional bone present. Again, the laser was used to create another rosette. The char was again removed. Repeating this procedure many times, laser drill out of footplate was performed. Eventually, the vestibule was opened. An oval window rasp was used to remove the char at the edges. A Medtronic Big Easy 4.30 x 0.5 titanium and platinum MRI-compatible piston was next brought onto the field. This was placed from the incus to the fenestra. It was crimped in placed using a crimper. The ossicular chair was palpated and found to move normally. The piston was sealed in place using the previously harvested fascia. The tympanic membrane and tympanomeatal flap were returned to their normal position. The tympanic membrane was intact.
The lateral surface was packed with antibiotic ointment. The ear was dressed with antibiotic ointment and a cotton ball. 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. The facial nerve was covered in bone. In the recovery room, the patient’s facial nerve function was normal. Estimated blood loss was minimal. Sponge and needle counts were correct.
