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CASE 13-12 Operative Report, Myringotomy and Tympanostomy The patient’s bilateral nasolacrimal duct obstruction is congenital. LOCATION: Outpatient, Hospital PATIENT: Karen Vince SURGEON: Jeff King, MD PREOPERATIVE DIAGNOSIS: 1. Bilateral nasolacrimal duct obstruction 2. Bilateral cerumen impaction 3. Right otitis media with effusion with nonfunctional pressure equalization tube POSTOPERATIVE DIAGNOSIS: 1. Bilateral nasolacrimal duct obstruction 2. Bilateral cerumen impaction 3. Acute right otitis media with effusion with nonfunctional pressure equalization tube PROCEDURE PERFORMED: 1. Bilateral nasolacrimal duct dilation 2. Left endoscopic nasal examination with inferior turbinate fracture 3. Bilateral microscopic ear examination with cleaning of the left and right ear 4. Right myringotomy with tympanostomy tube placement ANESTHESIA: General endotracheal anesthesia INDICATION: A 10-year-old female with bilateral nasolacrimal duct obstruction (congenital). The patient is now here for treatment. She has very narrow nasal anatomy. She also has bilateral cerumen impactions that do not allow for ease of access for examination of her ears for the status of her PE (pressure equalization) tubes. DESCRIPTION OF PROCEDURE: After consent was obtained, the patient was taken to the operating room and placed on the operating table in a supine position. After an adequate level of general endotracheal anesthesia was obtained, the patient was draped in an appropriate manner and the nasolacrimal duct dilation performed, bilaterally. The nose was packed with cotton pledgets soaked with 0.25% Neo-Synephrine. Attention was first focused on the left eye. The left nasal cavity was examined endoscopically. The turbinate was infractured to allow access to the inferior meatus. The turbinate was then repositioned to its normal position and the nose packed with the pledgets soaked with the Neo-Synephrine solution. Attention was then focused on the right. A similar procedure was performed; however, endoscopic examination and turbinate outfracture were not necessary on that side. The right side was then packed with the pledgets soaked with the Neo-Synephrine solution. Attention was then focused on the ears. Using the ear speculum and microscope, the left ear canal was cleared of cerumen. It was functional, and there were no abnormalities on that side. Attention was then focused on the right side, where the ear canal was again cleared of cerumen impaction. Subsequent examination showed an extruded PE tube lying on the tympanic membrane with surrounding cerumen and squamous debris. This was removed. Subsequently, a myringotomy incision was placed in the anterior-inferior quadrant. A large amount of mucoid effusion was suctioned. A bobbin tympanostomy tube was then placed without difficulty. Corticosporin Otic suspension and a cotton ball were then placed in the right ear. The nasal packs were then removed. There was no bleeding. The patient tolerated the procedure well. There was no break in technique. The patient was extubated and taken to the postanesthesia care unit in good condition. FLUIDS ADMINISTERED: 50 cc (cubic centimeter) of RL ESTIMATED BLOOD LOSS: Less than 20 cc PREOPERATIVE MEDICATION: 4 mg (milligram) of Decadron IV (intravenous) SERVICE CODE(S): _______________________________________ ICD-10-CM DX CODE(S): ____________________________
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