ASSISTANT:
ANESTHESIOLOGIST:
PROCEDURE:
1. Adenotonsillectomy, CPT 42830.
2. Right myringotomy with insertion of ventilation tube,
CPT 69436.
3. Left myringotomy with insertion of ventilation tube,
CPT 69436.
PREOPERATIVE DIAGNOSIS:
1. Recurrent otitis media with effusion with hearing loss
not responding to medication.
2. Adenoid hypertrophy with obstruction nonresponsive to
medication.
POSTOPERATIVE DIAGNOSIS:
1. Recurrent otitis media with effusion with hearing loss
not responding to medication.
2. Adenoid hypertrophy with obstruction nonresponsive to
medication.
ANESTHESIA:
General endotracheal intubation anesthesia.
ESTIMATED BLOOD LOSS:
Less than 1 mL.
INDICATIONS FOR PROCEDURE: The patient is a 6-year-old
female who was referred to me with recurrent ear infection
and hearing loss not responding to medication for three
years, but had been monitored while on the medication. Her
mother stated her daughter had chronic mouth breathing,
loud snoring, and bad teeth grinding for several years
nonresponsive to medication.
Risks, benefits and alternatives of surgery, general
anesthesia, bleeding, infection, scarring, nasal synechiae,
decrease in smell, chronic postnasal drip, hyponasality,
recurrent otitis media and external TM perforation, chronic
otorrhea, worsening of hearing loss and recurrence of ear
infection and no guarantee of final outcome, including the
need for any further medical or surgical intervention were
fully explained to the patient's mother. She fully
understood and consented her daughter to undergo the
procedures.
DESCRIPTION OF PROCEDURE:
The patient was identified and
taken back to the OR suite, where he was administered
general anesthetic.
Then the right ear prepped and draped in the usual clean
manner. Right ear speculum was inserted into the right ear
canal. The microscope was brought into view at that time.
The tympanic membrane was noted to be dull and retracted.
Myringotomy knife was used to make an incision in the
anterior inferior quadrant and a small amount of serous
fluid was aspirated. The metallic Reuter-Bobbin
ventilation tube was placed at the myringotomy site and the
ear speculum was removed from the ear canal. A similar
procedure was performed with similar findings in the right
ear canal to the left ear.
McIvor mouth gag was inserted into the mouth and suspended
on a Mayo stand. At the time, no bifid uvula, submucous
cleft, or V-notched palate appreciated. The laryngeal
mirror was used to visualize the nasopharynx. Adenoids
were noted to be 4+ and cryptic and blocking the
nasopharynx. The adenoids were completely removed with the
suction Bovie and good nasopharyngeal airway was
established. The McIvor mouth gag was removed from the
mouth.
The patient tolerated the procedure well and subsequently
was transferred to the PACU stable in satisfactory
condition. She was sent home on amoxicillin, Claritin,
Tylenol Elixir with Codeine and Phenergan suppositories for
postop pain. Next appointment she was given was for 1 week
from now.