ENT Medical Transcription Operative Sample Reports For Medical

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DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left vallecular lesion.
POSTOPERATIVE DIAGNOSIS: Left vallecular lesion.
OPERATIONS PERFORMED:
1. Direct laryngoscopy with biopsy.
2. Rigid esophagoscopy.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal.
ANESTHESIOLOGIST: Jill Doe, MD
FINDINGS: A 1.5 cm spherical left vallecula/base of tongue lesion, which
was biopsied. There was a small left epiglottic cyst on the lingual surface.
There were no other lesions seen in the patient's oral cavity, oropharynx,
hypopharynx or larynx. There were no mucosal lesions seen on rigid
esophagoscopy. There was no palpable cervical lymphadenopathy or floor of
mouth lesions.
INDICATION: The patient is a (XX)-year-old lady who presents with a left
vallecula/base of tongue lesion noted on fiberoptic examination. Therefore,
direct laryngoscopy with biopsy was indicated. The patient was consented.
DESCRIPTION OF OPERATION: The patient was brought to the operating
room and positioned supine on the operating room table. After induction of
anesthesia, the patient's head and neck were prepped and draped in the
usual sterile fashion. The larynx was exposed with an anterior commissure
laryngoscope. There were no laryngeal lesions seen. Right epiglottic cyst
was noted. A left vallecula/base of tongue round lesion was noted, and
biopsies were taken with the cup forceps. Hemostasis was achieved with
epinephrine-impregnated cottonoid pledgets.

Rigid esophagoscopy was performed with no visible esophageal mucosal

lesion. There were no palpable cervical lymphadenopathies or floor of
mouth lesions or base of tongue lesion other than the one noted. The
patient tolerated the procedure very well. The patient was awakened,
extubated, and taken to the recovery room in stable condition. There was
minimal blood loss. The patient received preoperative antibiotics. There
were no perioperative complications.
Endoscopic Ethmoidectomy MT Sample Report
-----------------------------DATE OF OPERATION:
PREOPERATIVE DIAGNOSES:
1. Otosclerosis.
2. Vertigo, rule out perilymphatic fistula.
POSTOPERATIVE DIAGNOSES:
1. Otosclerosis.
2. Right perilymphatic fistula, round window.
OPERATIONS PERFORMED:
1. Right exploratory tympanotomy with revision stapedectomy.
2. Right perilymphatic fistula repair.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal.
ANESTHESIOLOGIST: Jill Doe, MD
FINDINGS:
1. Right round window perilymphatic fistula.
2. Slightly displaced right stapedectomy prosthesis, which was revised.
3. Some erosion of right long process of the incus.
INDICATION: The patient is a (XX)-year-old lady who underwent right
stapedectomy with initial good hearing. Subsequently, however, she
developed vertigo 2 months postoperative with suspected prosthesis
displacement and perilymphatic fistula. Therefore, exploratory
tympanotomy with possible revision surgery and fistula repair was

indicated. The patient was consented.

DESCRIPTION OF OPERATION: The patient was brought to the operating
room and positioned supine on the operating room table. After induction of
anesthesia, the patient's head and neck were prepped and draped in the
usual sterile fashion. Ear canal was irrigated with copious Betadine and
flushed with saline solution. A tympanomeatal flap was then elevated and
the middle ear was exposed quite easily due to previous surgery. Round
window fistula was evident with very gentle suction with fine suction tip.
Some scar tissue was noted around the previously placed stapedectomy
prosthesis. Erosion of the long process was noted. The prosthesis was
replaced with a 4.0 mm x 0.6 mm, which was a platinum ribbon, which was
firmly clipped onto more proximal end of the incus. A small piece of adipose
tissue was harvested from posterior earlobe and it was used to repair the
round window perilymphatic fistula. Additional fatty tissue was used to seal
around the prosthesis piston into the oval window. Middle ear was impacted
for Gelfoam pledgets impregnated with saline solution. Tympanomeatal flap
was replaced. Ear canal was then packed in usual fashion.
Post earlobe fatty tissue donor site was closed with mild chromic 6-0 suture.
The patient tolerated the procedure very well. The patient was awakened
and taken to the recovery room in stable condition. There was minimal
blood loss. The patient received preoperative antibiotics. There were no
perioperative complications.
Total Laryngectomy Sample Report
------------------------------

DATE OF OPERATION: MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1. Bilateral nasal airway obstruction, worse on the right side.
2. Right hemifacial headaches.
3. Right nasal septal deviation.
4. Bilateral inferior turbinate hypertrophy.
5. Right maxillary sinus mucocele.
POSTOPERATIVE DIAGNOSES:
1. Bilateral nasal airway obstruction, worse on the right side.
2. Right hemifacial headaches.
3. Right nasal septal deviation.
4. Bilateral inferior turbinate hypertrophy.

5. Right maxillary sinus mucocele.

OPERATIONS PERFORMED:
1. Septoplasty.
2. Submucosal reduction of bilateral inferior turbinates.
3. Right-sided maxillary antrostomy with removal of contents.
SURGEON: John Doe, MD
DESCRIPTION OF OPERATION: The patient was taken to the operating
room and placed in the supine position. The patient was induced and
intubated by the anesthesia team without complications. The left eye was
taped and Lacri-Lube was placed in the right eye. The head of the bed was
turned 90 degrees in a counter-clockwise fashion and the patient was
draped in the usual fashion. Pledgets soaked in 0.25% Afrin were placed
bilaterally. After several minutes, the pledgets were removed and the right
nasal cavity was examined using a 0-degree telescope. I then passed the 0degree nasal telescope through the left nasal cavity and there appeared to
be no evidence of mass, polyps or purulence. The septum appeared to be
straight. At this juncture, I decided to proceed with septoplasty. I injected
approximately 3 mL of 1% lidocaine with 1:100,000 epinephrine along the
caudal edge of the septum and along the left and right sides of the septum.
I then made a left-sided hemitransfixion incision using a #15 blade and
raised the left-sided mucoperichondrial and mucoperiosteal flaps. The area
of right nasal septal deviation appeared to involve the cartilaginous portion
of the septum in the mid to inferior aspect of the septum as well as a portion
of the maxillary crest. Therefore, I outlined the deviated portion of the
cartilaginous septum using a caudal instrument. Right-sided
mucoperichondrial flaps were raised carefully. Next, with the cartilage freed
up from all of its edges, I removed it using the Takahashi forceps. There
appeared to be a remaining portion of deviated maxillary crest to the right
side, and therefore, I used a 4-mm osteotome to remove this portion of the
deviated bone. At this point, the septum appeared to be significantly
straighter and further documentation was performed through the right nasal
cavity to document this. The left-sided hemitransfixion incision was closed
with 4-0 chromic suture.
I then proceeded with submucous reduction of bilateral inferior turbinates
and anterior 1 cm incision was made along the right inferior turbinate.
Submucosal flaps were raised along the entire length of the inferior
turbinate. A small portion of bone was removed anteriorly. The inferior
turbinate was then lateralized using a Boies instrument. I then made an
incision in the anterior aspect of the left inferior turbinate measuring
approximately 1 cm. Again, mucoperiosteal flap was raised along the entire

length of the inferior turbinate. A small portion of bone was removed

anteriorly and the bone was lateralized using a Boies instrument. I then
directed my attention towards performing the right-sided maxillary
antrostomy. The middle turbinate was medialized using a Freer. I then
injected approximately 2 mL of 1% lidocaine with 1:100,000 epinephrine in
the region of the agger nasi. An uncinectomy was performed using a caudal
knife and this specimen was sent for permanent pathological analysis. I was
then able to visualize the right-sided maxillary antrum, and it measured
approximately 5 x 5 mm in size. I enlarged it posteriorly and using a
straight through-cutting forceps and anteriorly using a side-biting forceps.
Careful attention was directed towards not enlarging the maxillary ostium
too far anteriorly past the anterior portion of the middle turbinate in order to
avoid injury to the nasolacrimal duct. Furthermore, the edges of the
maxillary ostium were enlarged using the 4 mm Xomed debrider. I then
visualized the interior of the right maxillary sinus using a 30-degree
telescope, and indeed, there appeared to be two raised areas of mucosa
filled with cystic-like fluid in a portion of the anterolateral maxillary sinus.
Pictures were taken. Using dural forceps, these cysts were decompressed
and some of the mucosa overlying the cysts were removed and sent for
permanent pathological analysis. The contents of the right maxillary sinus
were then suctioned out and there appeared to be no further evidence of
masses, polyps or purulence.
At this point, endoscopic sinus surgery was deemed satisfactory. There was
no evidence of disease involving the ethmoid or sphenoid sinuses requiring
attention. Therefore, I proceeded with irrigation using 16 mL of normal
saline. I then placed Doyle splints impregnated in Bactroban bilaterally and
sutured in to the caudal septum using a 3-0 nylon suture. An orogastric
tube was placed and the contents of the stomach were suctioned. The
patient was turned over to the anesthesia team and emerged from general
anesthesia without complications.

DATE OF OPERATION: MM/DD/YYYY

PREOPERATIVE DIAGNOSIS: Chronic hypertrophic obstructive adenotonsillitis.
POSTOPERATIVE DIAGNOSIS: Chronic hypertrophic obstructive adenotonsillitis.
OPERATION PERFORMED: Adenotonsillectomy.
SURGEON: John Doe, MD

ANESTHESIA: General.
INDICATIONS: The patient is a very nice (XX)-year-old female with a
history of chronic hypertrophic adenotonsillitis with obstructive symptoms,
scheduled for surgery. The risks, benefits and possible complications were
discussed including bleeding, infection and soreness.
DESCRIPTION OF OPERATION: The patient was taken to the operating room in
the care of Anesthesia, placed in supine position, premedicated and given general
anesthesia, prepped and draped in a sterile manner. The mouth retractor was placed in the
mouth and hung from the Mayo stand in the usual fashion. The tonsils were found to be at
4+. The right tonsil was grasped with a hemostat. Mucosal incision made in medial border
of the anterior pillar, exposing the tonsillar capsule. Dissection continued near the tonsillar
capsule to the superior muscle until the tonsil was completely removed in a superior to
inferior direction. No bleeding was noted but a few areas were lightly cauterized with
suction electrocautery.

Similarly, the left tonsil was removed in a similar fashion, grasping it

medially. Mucosal incision was made in the medial border of the anterior
pillar, exposing the tonsillar capsule. Dissection continued near the tonsillar
capsule to the superior muscle until the tonsil capsule was completely
removed in a superior to inferior direction. No bleeding was noted but a few
areas were lightly cauterized with suction electrocautery. The palate was
palpated. No notching of the hard palate. No widening of the median raphe.
No evidence of a submucous cleft palate.
A red rubber catheter was placed through the nostril and out the oral cavity,
hemostated to the head drape, elevating the soft palate. The adenoids were
found to be 4+ with thick mucoid drainage. The drainage was suctioned and
the adenoids were removed with the St. Clair-Thompson forceps, until all
visible adenoid tissue was removed. Posterior carina could be seen well.
Tonsillar sponges were placed for 5 minutes and removed. A few areas were
lightly cauterized with suction electrocautery.
The patient was awakened from anesthesia. Stomach was suctioned. The
patient awakened from anesthesia, extubated and taken to the recovery
room in stable and satisfactory condition.
Sphenoidotomy Ethmoidectomy Polypectomy Sample
------------------------------

DATE OF OPERATION:
PREOPERATIVE DIAGNOSIS: Bilateral deafness.

POSTOPERATIVE DIAGNOSIS: Bilateral deafness.

OPERATION PERFORMED: Left cochlear implant.
SURGEON: John Doe, MD
ASSISTANT: None.
ANESTHESIA: General.
ANESTHESIOLOGIST: Jane Doe, MD
FINDINGS: The patient has had a previous implant that had been removed
due to infection. The mastoid was still open as well as the cochleostomy
once the scar tissue was removed.
DESCRIPTION OF OPERATION: The patient was taken to surgery. After
induction of general anesthesia, 1% Xylocaine with epinephrine was
infiltrated in the left external auditory canal and the postauricular area. The
ear was then prepped and draped in a sterile manner. A #15 blade was
used to make a postauricular incision. This was carried up into the hairline.
The soft tissue was elevated posteriorly. The mastoid was entered
anteriorly. The facial recess was opened and the cochleostomy was
identified. This was able to be opened using a joint knife. There was no
scar tissue identified medial into the cochlea.
At this point, attention was then directed posteriorly where a flap was
elevated and the trough was made in the bone to set the high-resolution
cochlear implant. Once this was done, a 2-mm diamond bur was used to
make tie holes in 4 quadrants around the implant. A #0 silk was placed
through the tie holes and the implant was then placed and tied into place.
There was no motion. The leftward ray was then passed into the cochlea
without any difficulty. All 16 electrodes were implanted. Fascia was placed
around the cochleostomy and muscle was placed in the facial recess.
The skin flap was then closed in layers using #4-0 Vicryl deep in the
subcutaneous tissue and #4-0 nylon in the skin. Mastoid dressing was
applied, and the patient was awakened and taken to the recovery room in
good condition.