PAKISTAN INSTITUTE OF MEDICAL SCIENCES DEPARTMENT OF OTOLARYNGOLOGY & HEAD & NECK SURGERY THE OTOLOGICAL SURGERY DATA

Patient's Name: _____________ Age/Sex: ___________________ PCN: ______________________ Surgeon: _____________ Procedure: ____________ Anesthesia: ___________

History: Previous Ear Surgery: Audiology: PTA (dB) AIR BONE RIGHT LEFT

Tympanic Membrane (please draw):

SPEECH AUDIOMETRY SRT (dB) SDS (%)

RIGHT

LEFT

RADIOLOGY
X-RAY MASTOID CT SCAN (if done) CELLULAR [ ] SCLEROTIC [ ] OTHER:

PER-OPERATIVE DATA
INCISION EAC TM MIDDLE EAR Mucosa Cholesteatoma Ossicles Post-auricular Normal [ Intact [ Marginal [ [ ] ] ] ] Endaural [ Polyp [ Retracted [ Granulations [ Thick [ ] Present [ ] Eroded [ ] ] ] ] ] Per-meatal [ Granulations [ Perforated [ Cholesteatoma [ ] ] ] ] Other: Other: Central [ ] Other: Polypoidal [ ] Non-Encap. [ ]

Normal [ ] Absent [ ] Intact [ ]

Granulations [ ] Encapsulated [ ] If Eroded Then Specify:

FACIAL NERVE MASTOID MASTOID CAVITY CANAL WALL

Covered Cellular Open Intact

[ [ [ [

] ] ] ]

Dehiscent Sclerotic Closed Taken Down

[ [ [ [

] ] ] ]

Anomalous [ ] Cholesteatoma [ ] Obliterated [ ]

RECONSTRUCTION FASCIAL GRAFTING MEATOPLASTY CHORDA TYMPANI

Autograft [ ];Specify: Overlay [ ] Not Done [ ] Preserved [ ]

Synthetic [ ];Specify: Underlay [ ] Done [ ] (Cartilagenous [ ],Osseous [ ] ) Excised [ ]

COMPLICATIONS:

Resident: Date: