Sample Type / Medical Specialty: ENT - Otolaryngology
Sample Name: Myringotomy/Tube Insertion - 2
Description: Bilateral myringotomies with insertion of Santa Barbara T-tube.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSES: Tympanic membrane atelectasis and chronic eustachian tube dysfunction.
POSTOPERATIVE DIAGNOSES: Tympanic membrane atelectasis and chronic eustachian tube dysfunction.
OPERATIVE PROCEDURE: Bilateral myringotomies with insertion of Santa Barbara T-tube.
ANESTHESIA: General mask.
FINDINGS: The patient is an 8-year-old white female with chronic eustachian tube dysfunction and TM atelectasis, was taken to the operating room for tubes. At the time of surgery, she has had an extruding right Santa Barbara T-tube and severe left TM atelectasis with retraction. There was a scant amount of fluid in both middle ear clefts.
The attention was then directed to the left side where severe TM atelectasis was identified. With a mask anesthetic, the eardrum elevated. A radial incision was made in the inferior aspect of the tympanic membrane and middle ear fluid aspirated. A Santa Barbara T-tube was then inserted without difficulty and 5 drops Ciloxan solution applied. Anesthesia was then reversed and the patient taken to recovery room in satisfactory condition.
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