Example Procedure Template from ENT

Septal Perforation

Patient: 

Account #:     

Date:

OPERATIVE NOTE:

Pre-Op Diagnosis:.  Nasal obstruction, septal perforation

Post-Op Diagnosis:.  Same

Indication for Surgery:.  Longstanding nasal obstruction, recurrent nasal crusting, recurrent nasal bleeding, associated with a large septal perforation.  She has had attempts by other physicians in the past at repair which were unsuccessful

Procedure:. 

1.  Repair of septal perforation with internal nasal advancement flaps

2.  Bilateral surgical nasal endoscopy

Technique:.  After informed consent was obtained, the patient underwent general endotracheal anesthesia. Injection of 1% lidocaine with epinephrine was performed into the septum. The area was prepped and draped in the usual and sterile fashion.

Bilateral surgical nasal endoscopy was performed to evaluate the nasal cavity and the perforation.

Patient had a very large anterior septal perforation with significant crusting and bleeding.  The perforation was too large to completely close.  The goal was to reduce the size of the perforation and any remaining perforation was to be as posterior as possible.

An incision was made at the anterior aspect of the nasal septum and a sub mucoperichondrial plane was followed posteriorly and superiorly.  A superior incision was made at the highest aspect of the nasal vault and a large section of mucosa was freed.  This mucosa was kept in contact with its posterior blood supply and was flipped on itself to fill in the septal defect.  This was successful in covering a large amount of the anterior aspect of the septal perforation.  This flap was sewn in position using multiple chromic sutures.  The remaining septal perforation was posterior and small.

Post Procedure Instructions:.  Instruction sheet was given.

Prescription:.  Prescriptions were given.