ENT - Otolaryngology
Sample Name: Bilateral Myringotomies - 1
Description: Bilateral myringotomies with Armstrong grommet tubes, Adenoidectomy, and Tonsillectomy.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSES: OM, chronic, serous, simple or unspecified. Adenoid hyperplasia. Hypertrophy of tonsils.
POSTOPERATIVE DIAGNOSIS: Same as preoperative diagnosis.
OPERATION: Bilateral myringotomies with Armstrong grommet tubes, Adenoidectomy, and Tonsillectomy.
CONSENT: The procedure, benefits, and risks were discussed in detail preoperatively. The parentsagreed to proceed after all questions were answered.
TECHNIQUE: The patient was brought to the operating room and placed in the supine position. After general mask anesthesia was adequately obtained, the right external auditory canal was cleaned out under the microscope. Serous fluid was aspirated from the middle ear space. An Armstrong grommet tube was placed down through the incision and rotated into place. The opposite ear was then cleaned out under the microscope. Serous fluid was aspirated from the middle ear space. An Armstrong grommet tube was placed down through the incision and rotated into place. Cortisporin suspension was placed in both ear canals.
Then the patient was intubated. A Crowe-Davis mouth gag was placed into the mouth and extended and hung on the Mayo stand. The red rubber catheter was placed down through the nose and brought out through the mouth to retract the palate. The adenoid fossa was visualized with the mirror. The adenoids were removed using the microdebrider. Two adenoid packs were placed. The packs were removed one by one. Using mirror and suction bovie, adequate hemostasis was achieved.
The stomach was evacuated with the nasogastric tube. The patient was then awakened in the operating room, extubated and taken to the recovery room in satisfactory condition.
Keywords: ent - otolaryngology, adenoid hyperplasia, om, adenoidectomy, tonsillectomy, auditory canal, serous fluid, crowe-davis mouth gag, tonsils, adenoidectomy and tonsillectomy, armstrong grommet tubes, bovie electrocautery, tonsillar pillar, bilateral myringotomies, armstrong, tubes, grommet, tonsillar, bilateral, myringotomies, tenaculum,