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

M HOSPITAL

DISCHARGE CARD
HEAD OF UNIT:- DR NILAM SATHE ASSISTANT PROFFESOR :- DR KAMINI CHAVAN

NAME: NAZRIN AKRAM AKRAM SHAIKH AGE: 25 YRS SEX: FEMALE

RES: – A 3/5, GROUND FLOOR, SHANTI NAGAR, SANGAM NAGAR, NEAR REHAN MADICAL STORE,
WADALA EAST, Mumbai - 400037 , MAHARASHTRA
IPD NO – 24/4885 PH NO.- 9702709206 OPD NO- 24/10134
Date of admission: 29/1/2024 Date of surgery: 30/1/2024 Date of discharge: 5/2/202

Diagnosis:

Surgery: Left Revision mastoidectomy with TORP under General anaesthesia d/b Dr Nilam Sathe a/b
Dr Saad on 02/12/2023

HOPI- C/o– left ear discharge since 2 months, insidious in onset, gradually progressive, mucopurulent ,
non foul smelling, non blood stained, profuse, temporarily relieved with medications
-H/o left ear decreased hearing since 2 months such that patient prefers right ear for telephonic
conversation
-No H/o trauma
-No H/o Facial asymmetry/post aural swelling
-No H/o tinnitus/giddiness/fever with chills/headache/altered sensorium
-No h/o ototoxicity/loud noise exposure
-No H/o of any other ENT complaints
-No H/o HTN/DM/BA/TB/TBC/any other medical complaints
-o/c/o left atticoantrostomy with lateral wall reconstruction with PORP on 13/05/23
Clinical Examination:
GENERAL: Fair, conscious oriented
EAR: Right Left. TFT Right Left

PRE AURICULAR 256hz

PINNA 512hz
POST AURICULAR 1024hz
EAC Weber
TM

NOSE : Air blast Equal , No sinus tenderness

ARS :Deviated nasal Septum to left
THROAT : Posterior pharyngeal wall – within normal limits

INVESTIGATIONS:
PTA: Right – minimal hearing loss
Left – Moderately-severe mixed hearing loss
Xray Mastoid – Right -sclerosed
Left -sclerosed
HRCT TEMPORAL BONE: Left shrunken middle ear cavity with destruction of the ear ossicles and
irregular thickening of tympanic membrane suggestive of infective etiology
OT NOTES – Left Revision mastoidectomy with TORP under General anaesthesia d/b Dr Nilam Sathe
a/b Dr Saad on 02/12/2023
-Patient taken under general anaesthesia
-All aseptic precautions taken, parts painted and draped.
-Local infiltration done using 30 ml NS with 0.6cc adrenaline
-Left post aural William Wilde’s incision taken over the previous scar .
-Temporalis fascia graft harvested
-Deep periosteal incision taken.
-Previous mastoidectomy with atticoantrostomy with cartilage reconstruction noted, reconstruction intact. Mastoid healthy.
-Posterior meatotomy done.
-12 o’clock and 6 o’clock incision taken
-Tympanomeatal flap elevated
-Middle ear entered
-PORP found to be displaced, removed
-Cartilage that was kept over PORP was displaced, removed.
-Extra piece of cartilage that was used for reconstruction of scutum found blocking Aditus, removed
-Atticoantral patency achieved
-Footplate visualised , overhanging facial canal present, but not dehiscent
-TORP kept over the footplate ,
-Cartilage that was previously removed kept over TORP
-Temporalis fascia kept over assembly
-Gelfoam placed at the edges of graft assembly and around cartilage.
-External auditory canal packed with medicated gelfoam.
-Suturing done in layers
-Sterile mastoid dressing given.
-Immediate post op uneventful
-Weber to operated ear
COURSE IN THE WARD: Inj. Supacef 1.5g IV BD x 4 days

ADVICE ON DISCHARGE:TREATMENT:
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FOLLOW UP IN E.N.T. OPD 107 – MON /WED/FRI AT FOR SR / DRESSING/ FOLLOW UP

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