DATE OF OPERATION: MM/DD/YYYY

PREOPERATIVE DIAGNOSES: Chronic otitis media with hearing loss and chronic adenoiditis.

POSTOPERATIVE DIAGNOSES: Chronic otitis media with hearing loss and chronic adenoiditis.

PROCEDURES PERFORMED:
1. Adenoidectomy.
2. Bilateral myringotomy and tube.

ANESTHESIA: General.

BLOOD LOSS: Not significant.

DESCRIPTION OF PROCEDURE: The patient was placed on the operating table and given mask induction without problems. The IV was started. The patient was intubated. The operating microscope was brought into position. The right ear was examined.

An anterior-superior quadrant myringotomy incision was made and thick fluid was suctioned from the middle ear space. An Activent tube was inserted in the tympanic membrane. Ciprodex drops were placed in the canal.

A similar procedure was undertaken on the left side. The ear was cleaned of cerumen. An anterior-superior quadrant myringotomy incision was made and thick fluid was suctioned from the middle ear space. The same type of tube was inserted in the tympanic membrane. Ciprodex drops were placed in the canal.

The bed was turned 90 degrees. The McIvor mouth gag was placed in the oral cavity with a #2 blade. There was crusted purulent mucus in the nasal cavity. Culture of the nasopharynx was performed. The red rubber catheters were used to retract the palate.

Adenoids were moderately hypertrophic. Adenoid tissue was removed with the Coblation wand with a setting of 6 and 5 and suction Bovie cauterization was used to control bleeding. Intravenous Decadron was given at the start of the procedure.

The pharynx was irrigated and suctioned. The patient tolerated the procedure well. He was discharged to home on Augmentin, Orapred, Ciprodex and Tylenol or Motrin. Followup in the office will be within the next two weeks.

Myringotomy and Tube Medical Transcription Operative Sample Report #2

DATE OF OPERATION: MM/DD/YYYY

PREOPERATIVE DIAGNOSIS: Chronic otitis media with hearing loss, left ear.

POSTOPERATIVE DIAGNOSIS: Chronic otitis media with hearing loss, left ear.

PROCEDURE PERFORMED: Left myringotomy and tube.

ANESTHESIA: General.

BLOOD LOSS: Not significant.

DESCRIPTION OF PROCEDURE: The patient was placed on the operating table and given intravenous induction without problems. She was mask ventilated. The left ear was examined with an operating microscope. There were signs of chronic otitis media with tympanic membrane tympanosclerosis.

The previously inserted Touma T-tube was removed and granulation tissue around the ostial opening of the tube was removed.

The incision was enlarged with a #7120 Beaver blade and the same type of Touma T-tube was inserted in the tympanic membrane. Ciprodex drops were placed in the canal. The patient will follow up in the office within the next 7 to 10 days. Water precautions are to be maintained. The patient is to finish her present course of Levaquin.

DATE OF OPERATION: MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1. Left vocal cord lesion.
2. History of tobacco use.
3. Right middle ear effusion with conductive hearing loss.

POSTOPERATIVE DIAGNOSES:
1. Left vocal cord lesion.
2. History of tobacco use.
3. Right middle ear effusion with conductive hearing loss.

OPERATION PERFORMED:
1. Microlaryngoscopy with excision and biopsy of left vocal cord lesion.
2. Right myringotomy and tube placement.

SURGEON: John Doe, MD

SEDATION: General endotracheal anesthesia.

PROCEDURE FINDINGS: Polypoid lesion of the left vocal cord, excised. Right serous middle ear effusion.

INDICATIONS FOR OPERATION: The patient is an (XX)-year-old female with a history of chronic hoarseness and right-sided hearing loss. She has a history of ongoing tobacco use. Office evaluation with flexible fiberoptic laryngoscopy revealed a polypoid lesion of the left vocal cord and a right serous middle ear effusion. There was no nasopharyngeal lesion. The risks, benefits and alternatives of right myringotomy and tube with microlaryngoscopy and left vocal cord biopsy were discussed with the patient, with emphasis on the risks of otorrhea, persistent perforation, retained myringotomy tube, persistent or worsened hoarseness and dental injury. The patient verbalized understanding of these risks and consented to the procedure.

DESCRIPTION OF OPERATION: After obtaining informed consent, the patient was brought to the operating room and placed supine on the operating table. General anesthesia with endotracheal intubation was induced without difficulty. The eyes were protected with ointment and tape. The table was turned 90 degrees.

The operating microscope was brought in. A #3 otologic speculum was used to examine the right external auditory canal. Cerumen was cleared with a Billeau loop. The ear canal was irrigated with alcohol, which was suctioned and allowed to dry.

A radial incision was made in the anterior-inferior quadrant of the tympanic membrane and serous middle ear effusion was suctioned.

A collar-button myringotomy tube was inserted into the incision and Ciprodex Otic drops instilled into the external auditory canal. A shoulder roll was placed. A head drape was placed. A slimline laryngoscope was used to examine the oral cavity, oropharynx and hypopharynx, which were all normal. The supraglottis was normal. The endolarynx was visualized and the patient was placed into suspension.

A 0 degree telescope was passed through the glottis and used to examine the subglottis, which was normal. The left vocal cord lesion was visualized. It was grasped with microcup forceps.

A mucosal incision was made using microscissors, with care not to disturb normal vocal cord mucosa. The entire polyp was removed and sent for routine pathology.

Hemostasis was obtained by applying cotton pledgets soaked in oxymetazoline. The patient tolerated the procedure well and without complication.

PREOPERATIVE DIAGNOSIS:

Right-sided mixed hearing loss, likely from right chronic otitis media.

POSTOPERATIVE DIAGNOSES:

1. Right-sided mixed hearing loss, likely from right chronic otitis media.

2. Dense adhesions involving the right middle ear preventing ossicular mobility, particularly of the incudostapedial joint and the stapes bone.

OPERATIONS PERFORMED:

1. Right middle ear exploration.

2. Lysis of adhesions with restoration of ossicular mobility.

3. Microdissection.

4. Facial nerve monitoring.

SURGEON: John Doe, MD

ASSISTANT: Jane Doe, MD

ANESTHESIA: General.

ANESTHESIOLOGIST: Jean Doe, MD

COMPLICATIONS: None.

ESTIMATED BLOOD LOSS: Minimal.

DESCRIPTION OF OPERATION: The patient was taken to the operating room, placed supine on the operating table. After general anesthesia had been obtained via endotracheal intubation, the patient was appropriately positioned and padded.

Attention was then turned to the patient’s right ear. Monitoring electrodes were placed into the orbicularis oculi and orbicularis auris muscles. The facial nerve monitoring system was noted to be appropriately functioning and was then used throughout the procedure. The patient’s right ear was then prepped and draped in the standard surgical fashion. The operative microscope was used throughout the entire length of the procedure.

Next, the ear canal was suctioned and cleaned. Lidocaine 1% with 1:100,000 epinephrine was then injected into the 4 quadrants of the ear canal. The postauricular crease was similarly injected. A 2-cm incision was made in the postauricular crease and carried down to the level of the mastoid periosteum. A small segment of fascia tissue was harvested. This was passed off the table to dry. Hemostasis was obtained in the postauricular incision and this was closed with absorbable sutures.

Attention was then turned to the ear canal and 6 o’clock and 12 o’clock vertical incisions were made followed by horizontal connecting incision 8 mm lateral from the annulus. The tympanomeatal flap was elevated. The middle ear space was entered. The posterosuperior canal wall was then alternately drilled and curetted away. This fully exposed the ossicular chain. There was noted to be multiple dense adhesions present throughout the posterior quadrant of the middle ear, in particular involving the posterosuperior quadrant. There was noted to be poor mobility of the ossicular chain upon palpation of the malleus. Entire stapes bone was obscured with granulation tissue.

With the use of a CO2 lasered 5-watt single, these adhesions were gently lysed. Chorda tympani nerve was noted to be significantly adherent to these adhesions. To prevent a traction injury on the nerve, the chorda tympani nerve was sharply suctioned. This allowed improved exposure and allowed lysis of the remaining adhesions, particularly involving the superior portion of the stapes at the region of the tympanic segment of the facial nerve. The incudostapedial joint was separated to prevent noise trauma.

The remainder of the adhesions were then carefully dissected circumferentially around the stapes bone. Facial nerves of the bony canal were noted to be completely intact without dehiscences. This was stimulated easily at 0.5 mA to the region of the oval window. After all adhesions had been carefully lysed, the entire ossicular chain was noted to regain its normal mobility. The incudostapedial joint was replaced in its normal anatomical position. A microdrop of Dermabond was placed on the joint to allow for reapproximation.

Next, the tympanomeatal flap was then replaced into its normal anatomical position. Gelfoam with saline was then packed lateral to the drum. Medial one-half of the ear canal was packed in this fashion. Lateral one-half of the ear canal Imak was packed with bacitracin ointment.

Next, the facial nerve monitoring electrodes were removed. The patient was then awakened by the anesthesia service, extubated, and taken in the recovery room in stable condition. In the recovery room, the patient had normal cranial nerve VII function bilaterally.

DATE OF OPERATION: MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1. Multinodular goiter.
2. Hashimoto thyroiditis.

POSTOPERATIVE DIAGNOSES:
1. Multinodular goiter.
2. Hashimoto thyroiditis.

OPERATIONS PERFORMED:
1. Total thyroidectomy.
2. Continuous laryngeal nerve integrity monitoring x2.5 hours.

SURGEON: John Doe, MD

ANESTHESIA: General.

ESTIMATED BLOOD LOSS: Less than 50 mL.

COMPLICATIONS: None.

INDICATIONS FOR OPERATION: This is a patient with compressive symptoms from a multinodular goiter with evidence of Hashimoto thyroiditis. After discussion of the risks and benefits, including alternative treatment options, the patient elected to proceed with total thyroidectomy under general anesthesia understanding the need for postoperative thyroid hormone replacement therapy. Additionally, the patient was noted to have borderline elevated serum calcium and PTH levels with plans for parathyroid exploration at the time of thyroidectomy.

DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in the supine position after induction and intubation per Anesthesia. The patient was intubated with 7.0 Xomed nerve integrity monitoring endotracheal tube. Direct laryngoscopy was performed to confirm accurate placement of the EMG contact electrodes of the vocalis muscles and endolarynx bilaterally. Subdermal ground electrodes were placed. All electrodes were hooked up to the nerve monitor, which was turned on and set for continuous laryngeal nerve monitoring for the remainder of the 2.5 hour procedure. Only short-acting muscle relaxant was used for intubation. No further muscle relaxant was given and no topical laryngeal anesthetic was used.

After confirming the correct patient and procedure using standard time-out technique, the neck was prepped and draped in standard sterile fashion. A horizontal skin incision was made in the previously identified skin crease. Dissection was carried down to the subplatysmal plane. The flaps were elevated and strap muscles were divided in the midline and retracted laterally on the left. There was extensive fibrosis making the surgery much more difficult than usual resulting from the underlying thyroiditis. The left lobe of the thyroid was noted to be massively enlarged. This was mobilized medially, and attention was turned to the superior pole.

The cricothyroid muscle and superior laryngeal nerve were identified medially and preserved. The integrity of the nerve was confirmed with the nerve stimulator monitor. The superior pole vasculature was taken with the Harmonic scalpel in such a way as to preserve the integrity of this nerve. This allowed better mobilization of the thyroid gland medially. The recurrent nerve was identified, its integrity confirmed with the nerve stimulator monitor. The inferior and superior parathyroid glands were noted to be grossly normal in appearance and were preserved along with their blood supply. The recurrent nerve was followed to its insertion near the cricothyroid membrane. Berry’s ligament was sharply transected. Attention was turned to the contralateral side.

Dissection on the right proceeded as described on the left. Again, the dissection was made extremely difficult due to the extensive fibrosis from the underlying thyroiditis. Specifically, the superior and recurrent laryngeal nerves were identified and preserved, and the integrity confirmed with a nerve stimulator monitor. The inferior and superior parathyroid glands were noted to be grossly normal in appearance and were preserved along with their blood supply. The recurrent nerve was followed to its insertion near the cricothyroid membrane, Berry’s ligament sharply transected, and the thyroid gland was passed off the field and sent for final histologic diagnosis. Hemostasis was obtained. The wound was closed in layers over a suction drain after the integrity of the recurrent nerves was confirmed bilaterally at 0.5 mA stimulus.

DATE OF OPERATION: MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1. Primary hyperparathyroidism.
2. Osteoporosis.

POSTOPERATIVE DIAGNOSES:
1. Primary hyperparathyroidism.
2. Osteoporosis.

OPERATIONS PERFORMED:
1. Minimally invasive video-assisted parathyroidectomy.
2. Continuous laryngeal nerve integrity monitoring x3 hours.

SURGEON: John Doe, MD

ANESTHESIA: General.

ESTIMATED BLOOD LOSS: Less than 50 mL.

COMPLICATIONS: None.

OPERATIVE FINDINGS: 600 mg hypercellular left inferior parathyroid probable adenoma, grossly normal-appearing left and right superior parathyroid glands. Right inferior parathyroid gland was not localized.

INDICATIONS FOR OPERATION: This is an elderly female with severe progressive osteoporosis and primary hyperparathyroidism. After discussion of risks and benefits, including alternate treatment options, the patient elected to proceed with parathyroidectomy through a minimally invasive approach under general anesthesia. Preoperative ultrasound and sestamibi both suggested a probable left inferior parathyroid adenoma. Both imaging studies were present intraoperatively to assist with surgical localization.

DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in the supine position induced and intubated per Anesthesia. The patient was intubated with 7.0 Xomed nerve integrity monitoring endotracheal tube. Direct laryngoscopy was performed to confirm accurate placement of the EMG contact electrodes to the vocalis muscles and endolarynx bilaterally. Subdermal ground electrodes were placed. All electrodes were hooked up to the nerve monitor, which was turned on and set for continuous laryngeal nerve monitoring for the remainder of the two-hour operative procedure. Electrode impedance was confirmed. A short-acting muscle relaxant was given for intubation. No further muscle relaxant was given and no topical laryngeal anesthetic was used.

After confirming the correct patient and procedure using the standard time-out technique, a 3 cm horizontal skin incision was made through a previously identified skin crease. Dissection was carried down to the subplatysmal plane. The strap muscles were divided midline and retracted laterally on the left. The thyroid gland was mobilized medially using the 5 mm 30-degree endoscope with video assistance, and a large left inferior parathyroid was immediately identified. The recurrent laryngeal nerve was identified, its integrity confirmed with the nerve stimulator and monitor.

The left inferior parathyroid was gently dissected using blunt technique and was removed and sent for frozen histologic diagnosis, which was consistent with a 600 mg hypercellular parathyroid. Intraoperative PTH levels were sent at preincision, pre-removal and 5 and 10 minutes post removal. These came back at 170, greater than 500, 160 and 118 respectively. Due to concern for possible multigland disease, the decision was made to perform bilateral exploration.

The left superior parathyroid gland was grossly normal in appearance. The right superior parathyroid gland was likely grossly normal. The right inferior parathyroid gland could not be identified. The right recurrent laryngeal nerve integrity was preserved and confirmed using the nerve stimulator and monitor. A biopsy was performed of the right superior parathyroid gland, which was questionably hypercellular. A 30-minute post removal of the left inferior parathyroid PTH level came back at 42.

Based upon this information and the lack of second adenoma being localized, the decision was made to terminate the procedure. Hemostasis was obtained. The integrity of the recurrent nerves was confirmed bilaterally, and the wound was closed in layers over a suction drain. The patient was taken to the recovery room in good condition awake and extubated.

CHIEF COMPLAINT: Oropharyngeal bleeding.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male on cardiopulmonary support following non-ST-elevation MI with ejection fraction of 60%. Of note, he is on heparin as well and has low platelets of 70,000. He was seen yesterday by Dr. John Doe, and both nasal cavities were packed as well as his oral cavity, as he was found to have an abrasion/laceration of the soft palate as well. We were called to the ICU by the patient’s nurse with complaints of severe continued oropharyngeal bleeding.

PAST MEDICAL HISTORY: Atherosclerosis of aorta, arteriosclerotic heart disease, cardiomyopathy, chronic kidney disease, epistaxis, hyperlipidemia, oropharyngeal laceration, palpitations, peripheral vascular disease, polyneuropathy, and spinal stenosis.

MEDICATIONS: Heparin, Ancef, as well as multiple other medications.

ALLERGIES: No known drug allergies.

SOCIAL HISTORY: The patient denies alcohol, drugs, tobacco usage.

FAMILY HISTORY: Noncontributory.

REVIEW OF SYSTEMS: A complete 12-point review of systems is otherwise negative.

PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 37.6, pulse 94, blood pressure 98/62.
GENERAL: The patient is sedated and intubated.
HEENT: There is a Rhino Rocket in the right nasal cavity with no active bleeding. There is Merocel in the left nasal cavity with no active bleeding noted. Merocel appears to be dry. Oral cavity reveals an extremely large packing above the indwelling endotracheal tube and orogastric tube. This appears to be saturated with blood clot and bright red blood as well. The packing was removed and an abrasion/small laceration was seen in the soft palate area, which appears to be actively bleeding.
NECK: Supple. Full range of motion. No lymphadenopathy or masses.
LUNGS: Clear to auscultation bilaterally.
HEART: Regular rate and rhythm. No murmurs, rubs or gallops.
ABDOMEN: Soft, nontender, nondistended. Normoactive bowel sounds.
EXTREMITIES: No cyanosis, clubbing or edema.
NEUROLOGIC: Grossly nonfocal.

LABORATORY DATA: Reveal a white blood cell count of 11.6, hematocrit 26.2, and platelet count of 74,000. Packed red blood cells and platelets are currently being transfused. Sodium is 140 and potassium 4.2.

PROCEDURE: Control of oropharyngeal bleeding was done at the bedside. A large oral cavity packing consisting of 4 x 4s and Xeroform as well as Surgicel was removed. No active bleeding was seen in the hard palate. An approximately 1.5 cm partial thickness laceration avulsion was seen of the left soft palate with active bleeding. FloSeal hemostatic sealant was placed in this area with direct pressure over this area for approximately 5 minutes. The area was re-examined and found to be free from any further bleeding. Large clots were removed from the oronasopharynx. No active bleeding was seen from the nasopharynx. No other bleeding was seen.

IMPRESSION: Oropharyngeal hemorrhage in a patient on cardiopulmonary support, on heparin.

PLAN: We recommend the nasal packing and 4 x 4 in the mouth, to be left in until Sunday or Monday. The patient is to be continued on Ancef. The platelets should be transfused to keep the platelet count around 100,000. If possible, we would recommend minimizing the patient’s heparin drip, if okay with Cardiac Surgery.

PREOPERATIVE DIAGNOSES:
1.  Nasal fracture.
2.  Nasal airway obstruction.

POSTOPERATIVE DIAGNOSES:
1.  Nasal fracture.
2.  Nasal airway obstruction.

OPERATION PERFORMED:
1.  Closed reduction, nasal fracture.
2.  Nasal airway reconstruction.

ANESTHESIA: General endotracheal.

BLOOD LOSS: 20 mL.

COMPLICATIONS: None.

OPERATIVE FINDINGS: Nasal dorsal deviation to the left severely with convex left nasal bone, concave right nasal bone, and convoluted nasal septum obstructing both left and right nasal airways with hypertrophic turbinates.

DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in the supine position. After successful general endotracheal anesthesia was established, an oropharyngeal pack was placed. Cocaine and 1% Xylocaine with 1:100,000 epinephrine was placed bilaterally intranasally. The patient was draped.

We began by injecting 3 mL of saline to the hypertrophic left inferior turbinate and then delivered 300 joules of radiofrequency energy posteriorly and 300 joules anteriorly. On the contralateral side of the nose, we injected 3 mL of saline to the hypertrophic inferior turbinate and placed 300 joules of radiofrequency energy posteriorly and 300 joules anteriorly. We then made a standard left Killian incision in the mucoperichondrium. Mucoperiosteal flaps were elevated. The quadrangular cartilage was disarticulated from the bony septum posteriorly, and the obstructing portion of bony septum was conservatively resected. A thin strip of inferior quadrangular cartilage was resected conservatively. Superior relaxing incisions were made. Both inferior turbinates were laterally outfractured. These maneuvers greatly improved the patient’s airway. Plain suture around a Keith needle was used circumferentially to reapproximate the mucoperichondrial flaps. Two of these sutures were placed.

The Killian incision was closed with 4-0 chromic in a running fashion. We then, with digital manipulation, infractured the left nasal bone, outfractured the right nasal bone, serving to bring the nasal dorsum to a more normal midline position. Denver splint was placed externally. A mustache dressing was placed externally. Telfa and bacitracin were internally placed. The oropharyngeal pack was removed. Blood loss was estimated at 20 mL. There were no surgical complications.

PREOPERATIVE DIAGNOSIS: Left substernal thyroid mass with tracheal compression.

POSTOPERATIVE DIAGNOSIS: Left substernal thyroid mass with tracheal compression.

OPERATION PERFORMED:
1. Left substernal hemithyroidectomy.
2. Parathyroid reimplantation.

SURGEON: John Doe, MD

ASSISTANT: Jane Doe, MD

ANESTHESIA: General endotracheal tube.

ESTIMATED BLOOD LOSS: 60 mL.

OPERATIVE FINDINGS:
1.  Large multinodular left substernal thyroid crossing midline and extending into the chest and right above the subclavian artery. This returned as follicular lesion, deferred to permanent frozen section.
2.  Left recurrent laryngeal nerve identified and preserved throughout the case.
3.  Left superior parathyroid identified and preserved.
4.  Left inferior parathyroid reimplanted in the left sternocleidomastoid muscle anteriorly.

SPECIMENS: Left hemithyroid sent to Pathology.

COMPLICATIONS: None.

INDICATION FOR OPERATION: The patient is a (XX)-year-old female with slowly growing, large left substernal thyroid mass with calcifications and tracheal compression. Informed consent was obtained after explaining the risks, benefits, and alternatives to the procedure.

DESCRIPTION OF OPERATION: The patient was taken to the operating room. Under general endotracheal tube anesthesia with recurrent laryngeal nerve, endotracheal tube placed by the anesthesia staff and confirmed using the GlideScope. With the neck extended, a lower neck skin crease incision was marked with the marking pen and injected with 1% lidocaine with 1:100,000 epinephrine. Appropriate surgical time-outs were called x2. The neck and chest were prepped with Betadine solution and scrubbed and draped sterilely.

A skin incision was made sharply and carried down through platysma with Bovie electrocautery. Subplatysmal flaps were elevated superiorly and inferiorly. The strap muscles were split in the midline. The left sternohyoid muscles were split superiorly to allow for better exposure. The middle thyroid vein was identified and divided with Harmonic scalpel and tied distally with 3-0 silk suture. Dissection proceeded inferiorly, staying in close proximity to the surface of the capsule of the gland. The inferior pole vessels were divided with Harmonic scalpel and tied distally with 3-0 silk suture. The recurrent laryngeal nerve was identified just lateral to the tracheoesophageal groove and dissected toward its entry point at the cricothyroid membrane.

Large substernal extension was dissected bluntly and reflected into the neck. Dissection then proceeded towards the isthmus. The large left-sided mass was seen to be crossing the midline. The isthmus was dissected bluntly away from the trachea and then divided with the Harmonic scalpel. Dissection then proceeded superiorly, staying in close proximity to the surface of the capsule of the gland. The superior parathyroid gland was seen and dissected free from the undersurface of the gland and kept intact with its blood supply intact. The superior pole vessels were divided with Harmonic scalpel and tied distally with 2-0 silk suture. Berry’s ligaments were then divided with Harmonic scalpel with the recurrent laryngeal nerve under direct visualization. The left hemithyroid was then sent off the table to Pathology as a specimen, which returned as follicular lesion, deferred to permanent on frozen section.

Meticulous bipolar cautery was used for hemostasis after the bed was copiously irrigated. A 7-French closed suction drain was brought through a separate stab incision and secured to the skin with 2-0 nylon. The strap muscles were reapproximated with 3-0 Vicryl. The platysma was reapproximated with 3-0 Vicryl. The skin was closed with 4-0 Vicryl and Dermabond. A pressure dressing was applied. The patient was then awoken from anesthesia and extubated and taken to the recovery room in stable and awake condition. Prior to skin closure, left inferior parathyroid gland that was seen to be somewhat dusky following dissection was minced and reinserted into the left sternocleidomastoid muscle and marked with a 4-0 Prolene suture. Sponge and needle counts were reported to be correct by the nursing staff. The patient was then awoken from anesthesia and extubated and taken to the recovery room in stable and awake condition.

PREOPERATIVE DIAGNOSES:
1. Nasal septal deviation.
2. Bilateral inferior turbinate hypertrophy.
3. External nasal valve collapse.

POSTOPERATIVE DIAGNOSES:
1. Nasal septal deviation.
2. Bilateral inferior turbinate hypertrophy.
3. External nasal valve collapse.

OPERATION PERFORMED:
1. External nasal valve reconstruction bilaterally.
2. Septoplasty.
3. Bilateral inferior turbinate coblation with outfracture.

SURGEON: John Doe, MD

ANESTHESIA: General endotracheal tube.

ESTIMATED BLOOD LOSS: 30 mL.

OPERATIVE FINDINGS:
1. External nasal valve collapse bilaterally.
2. Right nasal septal deviation with inferior and posterior spurs.
3. Bilateral inferior turbinate hypertrophy causing variable nasal obstruction.

SPECIMENS: None.

COMPLICATIONS: None.

INDICATIONS FOR OPERATION: The patient is a (XX)-year-old male with longstanding nasal obstructive symptoms refractory to medical therapy. Informed consent was obtained after explaining the risks, benefits, and alternatives to the procedures.

DESCRIPTION OF OPERATION: The patient was taken to the operating room. Under general endotracheal tube anesthesia, in the supine position, after appropriate surgical time-outs were called x2, the nose was prepped with Betadine solution and scrubbed and draped sterilely. The nasal septum and both inferior turbinates were injected with 1% lidocaine with 1:100,000 epinephrine. The bilateral intercartilaginous areas were similarly injected.

A right hemitransfixion incision was made sharply and carried down to cartilage. Under direct vision, bilateral mucoperichondrial and mucoperiosteal flaps were elevated to the bony vomer. Taking care to preserve a 1 cm L-strut for good tip support, all deviated anterior quadrangular cartilage and posterior bone was taken down in a through-cutting fashion with open Jansen-Middleton forceps after an approximately 1 x 1 cm window of cartilage was removed to be later used for alar batten grafts. A very significant left inferior spur with disarticulation from the maxillary crest was taken down along its lateral aspect with a V-gouge osteotome. The septum was inspected and palpated and found to be free from further points of obstruction. The hemitransfixion incision was closed with interrupted through-and-through 3-0 chromic sutures. Both inferior turbinates were then coblated at a setting of 6 for 10 seconds each x3 and then outfractured with a Boies elevator.

Next, external nasal valve reconstruction was undertaken. Bilateral intercartilaginous incisions were made sharply. A pocket overlying the piriform aperture was made with Converse scissors. Approximately 1.5 x 0.5 cm alar batten grafts were placed into this pocket. The mucosa was then sutured with 4-0 chromic sutures and a through-and-through 4-0 nylon suture was placed to the graft, woven in place. This was done bilaterally. Bilateral Doyle splints coated in bacitracin were then placed and secured to the septum with 2-0 nylon. The patient’s oronasopharynx were copiously suctioned. The patient was then awoken from anesthesia and extubated and taken to the recovery room in stable and awake condition.

PREOPERATIVE DIAGNOSIS: Right neck abscess.

POSTOPERATIVE DIAGNOSIS: Right neck abscess.

PROCEDURE PERFORMED: Incision and drainage of right neck abscess.

SURGEON: John Doe, MD

ANESTHESIA: General endotracheal anesthesia.

PROCEDURE FINDINGS: Twenty mL of purulent material expressed from right-sided neck abscess.

INDICATIONS FOR PROCEDURE: The patient is a (XX)-month-old male who presented via his primary care physician’s office with several days of worsening right-sided submandibular mass. He was admitted and placed on IV antibiotics and enjoyed an initial improvement. When his neck mass worsened yesterday, he started to spike fevers.

A followup ultrasound and CT scan of the neck was performed. The CT scan of the neck was suggestive of right sided neck abscess.

The risks, benefits, and alternatives of incision and drainage were discussed with the patient’s parents with an emphasis on the risks of anesthesia, bleeding, and need for repeat drainage or cranial nerve injury. They verbalized understanding of these risks and consented to the procedure.

DESCRIPTION OF PROCEDURE: After obtaining informed consent, the patient was brought to the operating room and placed supine on the operating table. General anesthesia with endotracheal intubation was induced without difficulty. The eyes were protected with ointment and tape. Shoulder roll was placed. The skin of the right neck was prepped and draped in a sterile fashion.

A 1.5 cm transverse cervical incision was made in the posterior triangle over the most fluctuant area. Sharp dissection was used only to incise the skin. After the skin incision, blunt dissection was used to dissect into the center of the abscess. A large amount of purulent material was expressed and sent to microbiology.

Blunt dissection was used to spread in all directions with external pressure to break up and drain any loculation. The abscess cavity was then copiously irrigated with saline. A 1/4 inch Penrose drain was inserted into the abscess cavity.

The incision was partially closed with interrupted 4-0 chromic sutures. An anchoring stitch was placed through the drain at the posterior apex of the incision. Antibiotic ointment and Telfa gauze were applied. A bulky neck dressing was then applied to collect any drainage. The patient tolerated the procedure well without complication.