Sample Transcribed Reports:

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Edited Sample Report

This patient is an ***-year-old gentleman who developed a firm swelling in the upper part of the right auricle about two months ago. In 1940, after being involved in the sport of boxing, he developed a hematoma in the upper part of the right pinna, but nothing has happened since then.

On Exam: There is a small hematoma in the right upper auricle. Ear canals and eardrums are normal.

Aspiration of this lesion revealed 1.5 cc of serous fluid mixed with some blood.

Impression:  Initial hematoma auris which later turned into a seroma.

The lesion is benign and after the aspiration the patient felt better. There is no need for further treatment.


Edited Sample Report

This patient is a ***-year-old gentleman who underwent ligation of the right ethmoid artery and the right internal maxillary artery four years ago for control of a severe posterior epistaxis. Since then, he has been complaining about paresthesia or a numbness sensation on the right mid-face and the right forehead. He also has chronic nasal obstruction since he recovered from the surgery.

On Exam:  There is a synechia between the medial surface of the inferior turbinate and the septum. There is also a small polyp located in the left middle meatus. The postnasal space is clear. X-rays of the sinuses revealed cloudiness of the frontal as well as the ethmoid sinuses. The right maxillary antrum is opaque. There is a small of air-fluid level in the left maxillary antrum, indicating apparent sinusitis.

Diagnoses: 1) Paresthesia of the right face, probably due to injury to the infraorbital nerve and the supraorbital nerve, during the last surgery for control of epistaxis.
                  2) Pan-sinusitis with left-sided nasal polyp.
                  3) Synechia of the right nasal cavity.

The patient will have a CT scan of the paranasal sinus and will come back to discuss the finding with a view to doing some endoscopic sinus surgery to remove the polyps as well as to release the adhesion in the right nasal cavity.

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Edited Sample Report

This patient is an ***-year-old patient who has a history of ankylosing spondylitis, affecting her spine. For a few years now, she has been having dizziness which is aggravated by any neck movement or head-turning, such as flexion-extension of the neck or lateral rotation of the neck. She has had to learn to walk with a very stiff neck. Sometimes, she might fall if she is not careful.

A parotid tumour was removed from the left side about 30 years ago.

On Exam:  Revealed normal eardrums. There is no spontaneous or positional nystagmus. Audiogram demonstrated bilateral high-tone sensorineural hearing loss at 8,000 Hz which is compatible with her age. Auscultation of the carotid artery system revealed no abnormal vascular noise.

The patient seems to have a vertebroarterial insufficiency which seems to be aggravated by the osteoarthritis of the cervical spine. I do not think she has any significant inner-ear disorder.

Diagnosis:  Vertebroarterial insufficiency.

The patient's condition may improve by having physiotherapy to the neck muscles or by wearing a soft cervical collar to stabilize the cervical spine.

Edited Sample Report

This patient is a ***-year-old diabetic who has been on insulin for a year now. Before, she was on oral anti-diabetic medication for 10 years. The patient was hospitalized a month ago because of severe preauricular pain and jaw pain. She was thought to have had a heart attack. She was in ICU for five days. Eventually, angiogram demonstrated there was no obstruction of the coronary artery. While in the hospital in ICU one day, she was half asleep and she heard a big banging noise in her left ear which woke her up. She also feels the left ear is somewhat stuffy since she came out of hospital. She has no tinnitus or dizziness. She had a dental checkup and there is no evidence of dental sepsis. She still has occasional pain along the left jaw and the submandibular area and she takes Tylenol analgesic for that.

On Exam:  Both eardrums are normal. There is no middle-ear effusion. Audiogram and tympanogram were all within normal limits. Flexible fibreoptic endoscopy showed the nasal cavity, nasopharynx, hypopharynx, and laryngeal openings to be normal. Palpation of the major salivary glands were all normal. Palpation of the floor of mouth was unremarkable.

The cause of this left periauricular pain is still unclear. I did not see any sign of middle ear or external ear pathology.

Edited Sample Report

This patient developed an acute onset of dizziness, nausea, and vomiting a few months ago and was seen in the Emergency Room and was diagnosed as having inner-ear viral involvement. This happened in May. Since then, she has been suffering from occasional imbalance and dizzy spells, particularly when she bends down and gets up. She takes medicine for control of hypertension.

On Exam:  The right eardrum is normal. The left eardrum has an atrophic tympanic membrane on the posterior half of the drum surface. There is no sign of middle-ear effusion. Nose and throat examination was normal. Audiogram demonstrated bilateral sensorineural hearing loss, somewhat worse in the left ear. Tympanogram was normal. Speech reception thresholds were 20 dB in the left ear and 10 dB in the right ear.

Clinically, there is no spontaneous or positional nystagmus. Her gait and stance with eyes closed were quite normal. There is no cerebellar sign.

I suspect the patient is just recovering from a bout of viral labyrinthitis which struck her in May this year, and she still has some residual balance problem. I expect a further recovery in the very near future. There is no need to pursue further investigations.

Diagnosis:  Resolving viral labyrinthitis.

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