Tplasty Lata

DEPARTMENT OF E.N.T. AND HEAD AND NECK SURGERY, K.E.
M HOSPITAL
DISCHARGE CARD HEAD OF UNIT:- DR NILAM SATHE
NAME: LATA KRISHNA KOTEKAR AGE: 42 YRS SEX: FEMALE

RES: 3/8/31,INDIRA NAGAR, J.R BORICHA MARG. JACOB CIRCLE , Mumbai 400011, Maharashtra
IPD NO – 24/6830 PH NO.- 7304631039 OPD NO- G/1535
Date of admission: 9/2/2024 Date of surgery: 10/2/2024 Date of discharge: /2/2024
Diagnosis: Left inactive mucosal chronic otitis media with left moderately severe conductive hearing loss with Right
minimal hearing loss with no evidence of any complications
Surgery: Left type II B Tympanoplasty with Ossiculoplasty under Local anaesthesia and intravenous sedation d/b Dr
Nilam Sathe a/b Dr Davish on 10/2/2024
HOPI- C/o– left ear discharge since 1 year, insidious in onset, gradually progressive ,mucopurulent, non foul
smelling, non blood stained, associated with upper respiratory tract infection, partially relieved with medications
-H/o eardrops reaching throat present
-H/o left ear decreased hearing, insidious in onset, gradually progressive, such that patient prefers right ear for
telephonic conversation
-No H/o giddiness/tinnitus
-No H/o Ototoxic drug use/loud noise exposure/trauma
-No H/o Facial asymmetry
-No H/o pre or post aural swelling
-No h/o fever with vomiting/ altered sensorium/ seizures
-No H/o nasal obstruction /recurrent rhinitis
-No H/o Recurrent sore throat
-No H/o of any other ENT complaints
-no H/o MMI/MSI
-No h/o HTN/DM/BA/TB/TBC
Clinical Examination:
GENERAL: Fair, conscious oriented
EAR: Right Left. TFT Right Left
PRE AURICULAR 256hz

PINNA 512hz
POST AURICULAR 1024hz
EAC Weber
TM ABC
NO Facial asymmetry/Mastoid Tenderness/Nystagmus

NOSE : Air blast Equal, No sinus tenderness
ARS- Deviated nasal septum to left
THROAT : Mouth opening adequate
Posterior pharyngeal wall – within normal limits
INVESTIGATIONS:
PTA: Right – Right minimal hearing loss
Left – moderately severe Conductive hearing loss
Xray Mastoid – Right – sclerosed
Left – sclerosed
HRCT TEMPORAL BONE: Chronic mastoiditis sequelae, mild soft Tissue in left middle ear cavity partly abutting the
Ossicles
OT NOTES – Left type II B Tympanoplasty with Ossiculoplasty under Local anaesthesia and intravenous sedation d/b
Dr Nilam Sathe a/b Dr Davish on 10/2/2024
(Steps 1-8 and 15-17 d/b Dr Davish, steps 9-15 d/b Dr Nilam Sathe)
-Patient taken under intravenous sedation
-All aseptic precautions taken, parts painted and draped.
1)local infiltration done using 30 ml NS with 0.6cc adrenaline
2)Left post aural William Wilde’s incision taken.
3)Temporalis fascia graft harvested
4)Deep periosteal incision taken.
5)Posterior meatotomy done, and Examination under microscope- Subtotal central perforation present 6)Margins
freshened and edges undermined
7) 12 o’clock and 6 o’clock incision taken
8)Tympanomeatal flap elevated And Middle ear entered
9) Granulations tissue present in region of Eustachian tube opening – removed
10) Canaloplasty done stapes head visualised
11) incus long process erosion present – removed and drilling done over body of incus to create facet for Malleus head
12) Temporalis fascia graft kept over handle of malleus
13) Incus kept between Malleus and stapes
14)Dry Gelfoam placed at the edges of graft assembly and around cartilage.
15)External auditory canal packed with medicated gelfoam.
16)Suturing done in layers
17)Sterile mastoid dressing given.
18)Immediate post op uneventful
COURSE IN THE WARD: Inj. Advent 1.2g IV BD x 5 days
ADVICE ON DISCHARGE: Avoid coughing sneezing and straining with closed mouth
TREATMENT:
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FOLLOW UP IN E.N.T. OPD 107 – MON /WED/FRI AT FOR SR / DRESSING/ FOLLOW UP
HOUSEMAN REGISTRAR

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Tplasty Lata

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DEPARTMENT OF E.N.T. AND HEAD AND NECK SURGERY, K.E.

DISCHARGE CARD HEAD OF UNIT:- DR NILAM SATHE

NAME: LATA KRISHNA KOTEKAR AGE: 42 YRS SEX: FEMALE

PRE AURICULAR 256hz

NO Facial asymmetry/Mastoid Tenderness/Nystagmus

COURSE IN THE WARD: Inj. Advent 1.2g IV BD x 5 days

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