CHAPTER 16 Medical Record

Medical Record Chronic Suppurative Otitis Media with Large Conductive Hearing Loss

and Perforated Tympanic Membrane

FINDINGS: This 14-year-old girl had a near-total tympanic membrane perforation.

The small remnant of the tympanic membrane superiorly had tympanosclerosis, so

a total perforation was created.

MUCOSA: The middle ear mucosa was mildly inflamed. There was no active infection.

EUSTACHIAN TUBE: The eustacian tube was not visually obstructed. Furthermore, I was able to easily

pass #00, #0, and #1 lacrimal probes without difficulty. A #2 lacrimal probe had too much tension to pass

easily.

OSSICLES: I was concerned about her ossicular chain since the amount of hearing

loss is more than I would usually anticipate with just a perforation alone. On close

examination of the ossicular chain, the malleus was partially immobilized, but this

improved considerably with removal of the tympanosclerosis surrounding the neck

of the malleus and handle of the malleus. The incus long process was slightly

eroded, but there was good continuity. The stapes was intact and mobile.

OPERATIVE DESCRIPTION: The patient was placed in the supine position on the operating table.

General endotracheal anesthesia was administered. A small amount of hair was shaved from the

postauricular region. The left ear was prepped and draped in the usual fashion.

The skin of the left ear canal was carefully cleaned of dead skin, cerumen, and hardened purulent debris.

Using an angled and straight Beaver blade, a posterior canal flap was incised and elevated from the bone

of the external auditory canal.

CANAOPLASTY: A peritympanic incision was made. The tympanic membrane remnant was reflected

inferiorly off the handle of the malleus. Diseased portions of the tympanic membrane (i.e.,

tympanosclerosis and mucosa) and fibrosis at the perforation edge were resected using a microscissors.

Following placement of saline-soaked gelfoam to support the graft, the grafts were placed underneath the

medial canal skin and tympanic membrane remnant. Polysporin ointment was instilled into the ear canal.

Weitlander retractors were removed. Hemostasis was obtained using an electrocautery. The mastoid

fascia was approximated using interrupted 3-0 Vicryl sutures. Wound care and dressings were carried out.

The patient was brought to the recovery room in stable condition. There were no intraoperative

complications. Blood loss was negligible.

FUTURE PLAN: The patient's conductive hearing loss will be reevaluated over the next 6 to 18 months

to determine if there is any significant residual conductive loss. She will have to be followed to determine

if tympanosclerosis will re-fix the ossicular chain.

Medical Terminology (HIT-120-01 )