ENT Medical Transcription Operative Sample Reports For Medical Transcriptionists

ENT Medical Transcription Operative Sample Report #1

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.

ENT Medical Transcription Operative Sample Report #2

DATE OF OPERATION: MM/DD/YYYY

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.

ENT Medical Transcription Operative Sample Report #3

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 0-degree 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.

ENT Medical Transcription Operative Sample Report #4

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.

ENT Medical Transcription Operative Sample Report #5

DATE OF OPERATION: MM/DD/YYYY

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.

ENT Medical Transcription Operative Sample Report #6

DATE OF OPERATION: MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1. Obstructive sleep apnea.
2. Nasal obstruction with turbinate hypertrophy.

POSTOPERATIVE DIAGNOSES:
1. Obstructive sleep apnea.
2. Nasal obstruction with turbinate hypertrophy.

OPERATIONS PERFORMED:
1. Tonsillectomy.
2. Uvulopharyngopalatoplasty.
3. Submucosal turbinate resection.

SURGEON: John Doe, MD

ESTIMATED BLOOD LOSS: Less than 50 mL.

COMPLICATIONS: None.

ANESTHESIA: General.

DESCRIPTION OF OPERATION: The patient was brought to the operating room, placed in supine position, and induced and intubated per Anesthesia. The table was turned. A Crowe-Davis mouth gag was atraumatically inserted into the oropharynx. A standard electrosurgical tonsillectomy was performed. Hemostasis was obtained.

The soft palate was palpated to ensure no submucous clefting and to determine the amount of soft tissue resection while minimizing risk of velopharyngeal insufficiency. The soft palate was injected with 1% lidocaine with 1:100,000 epinephrine. An anterior mucosal incision was made with a 12 blade with removal of anterior soft palatal mucosa with submucosal fibrofatty tissue with preservation of all underlying pharyngeal musculature, including the palatopharyngeus and uvular muscle down to the base of the uvula. The uvula was then transected at its base. All posterior soft palate mucosa was preserved. Hemostasis was obtained and multilayer closure was performed to open up the uvulopharyngeal airway. Hemostasis was obtained. The orogastric tube was passed with stomach contents suctioned. The Crowe-Davis mouth gag was removed. Attention was turned to the nasal turbinates.

The inferior turbinates were injected with 1% lidocaine with 1:100,000 epinephrine bilaterally. A 15 blade was used to make a mucosal incision. Submucosal resection was performed using the endoscopic shaver and turbinate shaver blade. Hemostasis was obtained. The turbinates were outfractured laterally. The patient was taken to the recovery room in good condition awake and extubated.