EXAMPLE
Donald W. Burt, Jr., M.D.
OPERATIVE REPORT
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PREOPERATIVE DIAGNOSIS: Chronic bilateral otitis media with
effusion refractory to medical management.
POSTOPERATIVE DIAGNOSIS: Chronic bilateral otitis media with
effusion refractory to medical management.
PROCEDURES PERFORMED:
1. Right tympanostomy with insertion of ventilation tube.
2. Left tympanostomy with insertion of ventilation tube.
SURGEON: Donald W. Burt, Jr., M.D.
ASSISTANT: None.
ANESTHESIOLOGIST: Amitabh M. Mathur, M.D.
ANESTHESIA: General via mask.
BRIEF HISTORY: This 11-month-old child is a patient of
Dr. Kawaljeet Bhatia, who referred this patient to my office. He
has a history of chronic ear infections since birth. He has been
on multiple antibiotic regimens without resolution of the
symptoms. The effusion within the ear had never resolved. He
complains of pain and does not sleep well, and has required some
Tylenol With Codeine to control the pain.
Examination in the office showed bilateral bulging, inflamed
tympanic membranes with mucoid fluid filling the middle ear
spaces. The external auditory canals were clear. With this in
mind, the findings, the diagnosis, treatment options to include
doing nothing, to doing medical or surgical management, as well
as the attendant risks, benefits, complications of performing or
not performing any of these modalities were discussed with the
patient's mother and she indicated her acceptance and
understanding, and desire to proceed with surgery at
this time.
FINDINGS: Glue-like mucoid material filling both middle ear
spaces with mild middle ear mucosal polypoid changes.
DESCRIPTION OF PROCEDURE: The patient was brought into the
operating room, placed on the operating room table in the dorsal
lithotomy position. General anesthesia via mask was begun. Once
an adequate level of anesthesia had been achieved, the patient
was draped in the usual manner.
The operating microscope was then brought into the field and an
ear speculum placed into the left ear canal, while the head was
gently rotated to the right. Cerumen was then removed from the
external auditory canal. The tympanic membrane was noted to be
intact and bulging. An incision was made in the anteriorinferior quadrant and thick mucoid glue-like material was
suctioned from the middle ear space. The middle ear mucosa
appeared mildly polypoid throughout. An Armstrong ventilation
tube was inserted in the incision and placement was found to be
good. The ear speculum was then removed.
The patient was approached from the opposite side of the table
and his head gently rotated to the left. Again, an ear speculum
placed and using the microscope, cerumen was removed from the
external auditory canal. The tympanic membrane was noted to be
bulging. An incision was made in the anterior-inferior quadrant
and a large amount of thick glue-like mucoid material was
suctioned from the middle ear space. The middle ear mucosa
appeared mildly polypoid throughout. An Armstrong ventilation
tube was inserted in the incision and placement was found to be
good. The ear speculum was then removed.
The patient was then allowed to awaken and taken to the post
anesthesia care unit in satisfactory condition.
CLOSURE: None.
ESTIMATED BLOOD LOSS: None.
COMPLICATIONS: None.
DRAINS AND PACKS: Bilateral Armstrong ventilation tubes.
NEEDLE AND SPONGE COUNT: None used.