Consent, Endoscopic Sinus Surgery

PLEASE READ THIS SHEET BEFORE YOU CONSENT FOR YOUR PROCEDURE

This information sheet provides general information to a person having an Endoscopic Sinus Surgery. It does not provide advice to the individual. It is important that the content is discussed between the patient and the concerned doctors who understand the level of fitness and medical condition.

What are the “sinuses”?

The sinuses are spaces filled with air in some of the bones of the skull. Air passes in and out of these spaces, and mucus drains through them and out of the nose. They also reduce the weight of the skull and give our voices a nicer sound.

There are four main pairs of sinus openings, sometimes called sinus cavities, in the face:
* Maxillary - in the cheekbones
* Ethmoid - between the eye sockets
* Frontal - in the forehead and above the eyebrows
* Sphenoid - deep in the head at the back of the nose

 What is Endoscopic Sinus Surgery?

Endoscopic sinus surgery - also called endoscopy or sinoscopy - is a procedure used to remove blockages in the sinuses (the spaces filled with air in some of the bones of the skull). These blockages cause sinusitis, a condition in which the sinuses swell and become clogged, causing pain and impaired breathing.
A thin, lighted instrument called an endoscope is inserted into the nose, and the doctor looks inside through an eyepiece. Much like a telescope with a wide-angle camera lens, the endoscope beams light into different parts of the nose and sinuses, allowing the doctor to see what is causing blockages. Surgical instruments can then be used along with the endoscope to remove the blockages and improve breathing.

This surgery does not involve cutting through the skin, as it is performed entirely through the nostrils.

Therefore, most people can go home the same day.

When is it indicated?

Endoscopic sinus surgery is used to treat:
* Sinusitis
* Deviated septum
* Polyps
* Tumors

How does a doctor determine if surgery is necessary?

The first thing a doctor will do is take a detailed medical history and make note of all symptoms, as well as how long the symptoms have been present. The doctor will need to know any medications being taken, as well as any other conditions such as high blood pressure, eye diseases or bleeding disorders.
* If there is another course of treatment besides surgery that has not yet been tried, the doctor may prescribe new medications.
* If surgery appears to be the best course of action, a CT scan, which is a special type of x-ray, is usually taken so that the doctor can see all of the sinuses prior to using the endoscope. The CT scan serves as a kind of road map for the endoscopic examination.
* Before the endoscopic examination, a nasal spray is used to shrink and anesthetize sinus tissues. The doctor will then insert the endoscope into the nostrils to determine what is causing the sinusitis symptoms, such as thick mucus, swelling, small openings, deviated septum, or polyps.
* The doctor will only perform surgery if the examination shows problems that can be surgically corrected.

What are the advantages of this surgery?

There are other types of surgeries that can correct blockages in the nose and sinuses, but endoscopic sinus surgery is becoming the procedure of choice for more and more doctors. It is:
* Is less painful
* Leaves no visible scars
* Causes less bleeding
* Creates less discomfort after surgery
* Requires less packing in the nose after surgery
* Has a faster recovery period
* Has a higher success rate

How do I prepare for this surgery?

Prior to endoscopic sinus surgery, your doctor may recommend that you do the following:
* Discontinue taking any pain relievers that contain aspirin for at least two weeks prior to surgery, as aspirin thins the blood and promotes bleeding.
* Discontinue taking any other medications the day of surgery.
* Do not drink or eat anything after midnight the night before surgery.

What happens during the procedure?


The surgery itself lasts 60 to 90 minutes, after which the patient spends an hour or two in a recovery room.
A simple clearing of the intersection between the two sides of the nose is often all that is needed to relieve symptoms. In this case, a local anesthetic, where the patient remains awake during the procedure, is enough. Some crunching sounds may be heard and a sensation of tightness may be felt during the surgery, but there is no pain.
If there are several blockages deeper in the sinuses or polyps to be removed, a general anesthetic, where the patient is fully asleep, is recommended. The doctor typically begins by clearing the ethmoid sinuses, followed by the sphenoid sinuses, the frontal sinuses, and finally the maxillary sinuses, if necessary.
 Endoscopic sinus surgery is carried out with the use of an endoscope, which is a small telescope. This telescope, inserted through the nostrils, provides the surgeon with a magnified view of the nose and sinuses. A camera is attached to the eyepiece of the endoscope and the image from the eyepiece is then projected onto a video screen. The surgeon is then able to operate by looking at the video screen while holding the endoscope with one hand and using the other to insert various instruments through the nostril (see below).

Once the procedure is completed, nasal packing may or may not be used, depending on the risk of bleeding. Nasal packing can take on many different forms, including a gauze strip (a long string of gauze coated with an ointment), as well as a variety of pre-made and commercially available packs of varying shape and size.

 What happens after surgery?

* The nose is usually covered with a gauze dressing that will need to be changed whenever it becomes dirty or wet.
* A packing is placed in the nose after surgery, which requires breathing through the mouth for a short time during the healing process. The packing usually has to be worn for only a few days, and the doctor will advise when it can be removed. It may have a bad odor, however, or cause bad breath.
* Nose blowing should be avoided entirely for at least a week after surgery.
* Sleep on at least two pillows to keep the head elevated.
* It is not uncommon to experience discomfort in the nose and face for a short time after surgery. Mild headaches are also normal.
* Do not take pain relievers containing aspirin without consulting a doctor. Aspirin can promote bleeding and cause problems after surgery.
* Keep the nose as free from dry crusting as possible. A saline spray may be used six to eight times per day to keep the nose moist. Sometimes, the doctor will want to take care of cleaning the area in the office two to three times a week.
* Keep activities to a minimum for a couple of weeks, as too much activity can increase the chances of bleeding.
* Do not lift heavy objects, swim, scuba dive, or fly for a few weeks following surgery.
* Avoid caffeine, alcoholic beverages, spicy foods, and medications, which can cause drying of the sinus passages.
* Do not use decongestant nasal sprays unless prescribed by a doctor, as these sprays can become addictive after a few days of continuous use.
* Avoid eating dairy products, which can promote excess mucus production.
* Avoid anything that causes allergic reactions.
* Do not smoke, and avoid secondhand smoke.
* Drink plenty of fluids, especially water.
* Use a humidifier, if necessary, to moisten dry air.
* Finish all prescribed antibiotic medication.
* Within a week after surgery, the doctor will set an appointment to check the progress of healing.

General Risks of having the procedure:

These have been mentioned in the “Anesthesia Consent Form.” Please discuss this with your Anesthetist before signing the Anesthesia Consent Form.

What are the risks of the procedure?

While majority of patients have an uneventful procedure and recovery, few cases may be associated with complications. These are seen infrequently and not all the ones listed below are applicable to one individual. However it is important that you are aware of the complications/risks that may arise out of this procedure which are as below:
There are some risks/ complications, which include:
(a) Bleeding. This may occur either at the time of surgery or in the first few weeks after surgery. Bleeding at the time of surgery may require termination of the procedure and nasal packing.
Bleeding after surgery may require packing of the nose under local anesthesia or may require another operation to stop the bleeding.
A blood transfusion may be necessary depending on the amount of blood lost
(b) Eye injury. This may lead to bruising or swelling around the eye. Rarely, permanent damage causing double vision or partial or complete loss of vision.
(c) Brain injury. CSF (brain / spinal fluid) leak, meningitis or brain abscess may occur. Further surgery to repair the CSF leak may be necessary
(d) Tear duct injury with tearing of the eye can occasionally occur and may be ongoing.
(e) Infection of the nose and sinuses. Usually temporary but may be ongoing which requires antibiotic therapy
(f) Altered taste and smell which may be permanent.
(g) Scar tissue may grow inside the nose which may need sinus drainage requiring further surgery
(h) Hole in the partition inside the nose. This does not usually cause any problems. Sometimes it may cause whistling, crusting or bleeding and may require further surgery to close the hole.
This may cause disfigurement.
(i) The disease may not be cured or may come back. This may need further medical or surgical treatment.

Consent Acknowledgement:

* The doctor has explained my medical condition and the proposed surgical procedure.
* I understand the risks of the procedure, including the risks that are specific to me, and the likely outcomes. The doctor has explained other relevant treatment options and their associated risks, the prognosis and the risks of not having the procedure.
* I have been given an Anesthesia Informed Consent Form.
* I have been given a Patient Information Sheet about the Condition, the Procedure, and associated risks.
* I was able to ask questions and raise concerns with the doctor about my condition, the procedure and its risks, and my treatment options.
* My questions and concerns have been discussed and answered to my satisfaction.
* I understand that the procedure may include a blood / blood product transfusion.
* I understand that if organs or tissues are removed during the surgery, that these may be retained for tests for a period of time and then disposed of sensitively by the hospital.
* The doctor has explained to me that if immediate life-threatening events happen during the procedure, they will be treated as appropriate.
* It has been explained to me, that during the course of or subsequent to the Operation/Procedure, unforeseen conditions may be revealed or encountered which may necessitate urgent surgical or other procedures in addition to or different from those contemplated. In such exigency, I further request and authorize the above named Physician / Surgeon or his designee to perform such additional surgical or other procedures as he or they consider necessary or desirable.

On the basis of the above statements,
I REQUEST TO HAVE THE PROCEDURE.
Name of Patient/Substitute Decision Maker…………………………………………….
Relationship …………………………………….
Signature………………………………………
Date………………………………………………
Name of the Witness…………………………
Relationship/Designation………………………
Signature………………………………………..
Date……………………………


INFORMED CONSENT: ENDOSCOPIC SINUS SURGERY


Patient Identification Label to be affixed here





A. INTERPRETER
An interpreter service is required.Yes______________No_______________
If Yes, is a qualified interpreter present.Yes_____________No___________

B. CONDITION AND PROCEDURE
The doctor has explained that I have the following condition:
(Doctor to document in patient’s own words)
_______________________________________________and I have been advised to undergo the following treatment/procedure____________________________________________________________________________________________________________________________________________________________
 
See patient information sheet- “Endoscopic Sinus Surgery” for more
C.ANAESTHETIC
Please see your “Anesthesia Consent Form”. This gives you information of the General Risks of Surgery. If you have any concern, talk these over with your anesthetist.

D.RISKS OF THIS PROCEDURE
While majority of patients have an uneventful surgery/procedure and recovery, few cases may be associated with complications. These are seen infrequently and not all the ones listed below are applicable to one individual. However it is important that you are aware of the complications/risks that may arise out of this procedure which are as below:

There are some risks/ complications, which include:
(a) Bleeding. This may occur either at the time of surgery or in the first few weeks after surgery. Bleeding at the time of surgery may require termination of the procedure and nasal packing.
Bleeding after surgery may require packing of the nose under local anesthesia or may require another operation to stop the bleeding.
A blood transfusion may be necessary depending on the amount of blood lost
(b) Eye injury. This may lead to bruising or swelling around the eye. Rarely, permanent damage causing double vision or partial or complete loss of vision.
(c) Brain injury. CSF (brain / spinal fluid) leak, meningitis or brain abscess may occur. Further surgery to repair the CSF leak may be necessary
(d) Tear duct injury with tearing of the eye can occasionally occur and may be ongoing.
(e) Infection of the nose and sinuses. Usually temporary but may be ongoing which requires antibiotic therapy
(f) Altered taste and smell which may be permanent.
(g) Scar tissue may grow inside the nose which may need sinus drainage requiring further surgery
(h) Hole in the partition inside the nose. This does not usually cause any problems. Sometimes it may cause whistling, crusting or bleeding and may require further surgery to close the hole.
This may cause disfigurement.
(i) The disease may not be cured or may come back. This may need further medical or surgical treatment.

SIGNIFICANT RISKS AND RELEVANT TREATMENT OPTIONS:F. SIGNIFICANT RISKS AND
The doctor has explained any significant risks and problems specific to me, and the likely outcomes if complications occur.
The doctor has also explained relevant treatment options as well as the risks of not having the procedure.
(Doctor to document in Medical Record if necessary. Cross out if not applicable. )

PATIENT CONSENT: CONSENT
I acknowledge that:
 
* The doctor has explained my medical condition and the proposed procedure. I understand the risks of the procedure, including the risks that are specific to me, and the likely outcomes.
* The doctor has explained other relevant treatment options and their associated risks. The doctor has explained my prognosis and the risks of not having the procedure.
* I have been given a Patient Information Sheet on Anesthesia.
* I have been given the patient information sheet regarding the condition, procedure, risks and other associated information.
* I was able to ask questions and raise concerns with the doctor about my condition, the procedure and its risks, and my treatment options. My questions and concerns have been discussed and answered to my satisfaction.
* I understand that the procedure may include a blood transfusion.
* I understand that if organs or tissues are removed during the surgery, that these may be retained for tests for a period of time and then disposed of sensitively by the hospital.
* The doctor has explained to me that if immediate life-threatening events happen during the procedure, they will be treated accordingly.
* I understand that photographs or video footage maybe taken during my operation. These may then be used for teaching health professionals. (You will not be identified in any photo or video).
* I understand that no guarantee has been made that the procedure will improve the condition, and that the procedure may make my condition worse.

On the basis of the above statements,
I hereby authorize Dr……………………………………………………………………and those he may designate as associates or assistants to perform upon me the following medical treatment, surgical operation and / or diagnostic / therapeutic procedure…………………………………………………………..

I REQUEST TO HAVE THE PROCEDURE

Name of Patient/Substitute Decision Maker…………………………………………….
Relationship …………………………………………………………………………………….
Signature……………………………………………Date……………………………………….

Name of the Witness…………………………………………………………………………
Relationship/Designation………………………………………………………………………
Signature……………………………………………Date………………………………………
FERENCES
INTERPRETER’S STATEMENT:
I have given a translation in……………………………………………………………………
Name of interpreter…………………………………………………………………………….
Signature……………………………………………Date………………………………………

DOCTOR’S STATEMENTS
I have explained
* The patient ‘s condition
* Need for treatment
* The procedure and the risks
* Relevant treatment options and their risks
* Likely consequences if those risks occur
* The significant risks and problems specific to this patient

I have given the Patient/ Guardian an opportunity to:
* Ask questions about any of the above matters
* Raise any other concerns, which I have answered as fully as possible.

I am of the opinion that the Patient/ Substitute Decision Maker understood the above information.

Name of doctor…………………………………………………………………………..
Designation………………………………………………………………………………
Signature………………………………………Date……………………………………

ENDOSCOPIC SINUS SURGERY

Happy New year

Wishing all of you a happy prosperous new year 2011.

Consent, tonsillectomy

CONSENT INFORMATION – PATIENT COPY

TONSILLECTOMY

PLEASE READ THIS SHEET BEFORE YOU CONSENT FOR YOUR PROCEDURE

This information sheet provides general information to a person having a Tonsillectomy. It does not provide advice to the individual. It is important that the content is discussed between the patient and the concerned doctors who understand the level of fitness and medical condition.

What are the “Tonsils”?

The tonsils are two oval lumps of tissue. They sit on either side of the back of your throat behind your tongue. The tonsils are involved in helping your body fight infection but they are not essential to your health.

What is “Tonsillectomy”?

A tonsillectomy is an operation to remove the tonsils. The operation may be necessary for people who get repeated or very severe bouts of tonsillitis that interfere with normal life.

Why have a tonsillectomy?

Sometimes the tonsils can become infected, either with a virus or with bacteria, causing symptoms such as a sore throat, painful swallowing, headache and fever. This is called tonsillitis.

The majority of people who get tonsillitis do not need an operation. Your surgeon will usually only suggest it for people who have had:
* at least five bouts of tonsillitis in the past year
* frequent ear infections because of swollen tonsils
* swollen tonsils that make it harder to breathe or swallow
* sore throats that stop you, or your child, getting on with everyday life (such as finding it hard to sleep or your child missing school)

What are the alternatives?

Many children "grow out" of tonsillitis over a year or so and do not need any treatment at all. There are treatments for tonsillitis that don't involve surgery, such as painkillers to help reduce discomfort. Antibiotics are the only other treatment that is used to try to treat sore throats in the long-term.

Sometimes, a long-term course of antibiotics is prescribed to try and avoid the need for a tonsillectomy. Tonsillitis that is caused by bacteria often responds well to this treatment. However, the most common type of tonsillitis is caused by a virus, and cannot be treated in this way.
Your doctor will discuss the available options with you.

 What happens before tonsillectomy?

Your surgeon will discuss how to prepare for the operation.
It is unlikely that your surgeon will perform a tonsillectomy if a person has an infection. This is because an infection can increase the chance of chest problems. You should advise the hospital if you, or your child, has a sore throat or cold in the week before the operation date as it may need to be postponed.

What to expect in hospital

Before surgery you will talk to your surgeon about the operation and you will be asked to sign a Consent Form either for yourself, or on behalf of your child. This confirms that you understand the risks, benefits and possible alternatives to the procedure and have given your permission for it to go ahead.
Fasting instructions must be followed before a general anesthetic. Typically, you must not eat or drink for about six hours. However, some anesthetists allow occasional sips of water until two hours beforehand.

The operation

The tonsillectomy is often performed under a general anesthesia, which means that people are asleep throughout the procedure and feel no pain.
A tonsillectomy generally takes about half an hour and an overnight stay in hospital is usually necessary.
Once the anesthesia has taken effect, your mouth is held open so that the surgeon can see into your throat. No cuts are made in the skin.
There are a number of different methods that your surgeon can use to remove the tonsils.
* The tonsils can be cut away with special scissors. Dissolvable stitches are then used to close the wound and to stop the bleeding.
* Lasers, ultrasound and freezing can also be used to take out tonsils. They are newer methods and aren't commonly used.
* Diathermy - an instrument that heats to a temperature of about 100°C can also be used. The heated instrument cuts away the tonsils and seals up the area where they have been removed from.
* Coblation (or cold ablation) uses a lower temperature (about 60°C) to cut away the tonsils.

After the operation

As the anesthesia wears off, the throat or ears, or both, will feel sore and the jaw may be stiff. Painkillers will be given to help relieve any discomfort.
After about 12 hours, a white or yellowish membrane (thin skin) will appear where the tonsils were. This is nothing to worry about and is not a sign of infection. It's just new skin growing over the wound.
People are encouraged to begin to drink and eat as soon as they feel ready, starting with clear fluids such as water or apple juice.
Most patients stay in hospital for one night. In some hospitals tonsil surgery is done as a day-case, which means you can have the operation and go home the same day. Either way, the hospital will only let a patient go home when he or she is eating and drinking and feeling well enough to go home.
However, due to the general anesthetic, you will need to arrange for a friend or relative to drive you home and stay with you for the next 24 hours.

 Recovering from a tonsillectomy

Once home, more painkillers can be taken if needed, as advised by your surgeon or nurse.
Eating will be difficult to start with, and soft or liquid foods will be less uncomfortable. Although it may be painful, swallowing solid food like toast and cereal will help healing by scraping away dead tissue. Taking a dose of painkillers half an hour before meals may help to ease any discomfort.
The teeth may be brushed as normal.
It is advisable to stay at home for 7-14 days after the operation, avoiding (where possible) contact with people who have colds, coughs or other infections. Strenuous activities should also be avoided during this time.
Complete recovery can take two weeks.

General Risks of having the procedure:

These have been mentioned in the “Anesthesia Consent Form.” Please discuss this with your Anesthetist before signing the Anesthesia Consent Form.

What are the risks of the procedure?

While majority of patients have an uneventful procedure and recovery, few cases may be associated with complications. These are seen infrequently and not all the ones listed below are applicable to one individual. However it is important that you are aware of the complications/risks that may arise out of this procedure which are as below:
There are some risks/ complications, which include:
(a) Bleeding. This may either at the time of surgery or in the first 2 weeks after surgery. Delayed bleeding may require readmission to hospital and may require another operation to stop the bleeding. A blood transfusion may be necessary depending on the amount of blood lost.
(b) Burns from the equipment used to seal off bleeding areas during the operation.
(c) Infection. Persistent bad breath, worsening throat discomfort or delayed bleeding may indicate an infection. This is usually treated with antibiotics. Delayed bleeding is treated as outlined above.
(d) Pain. Moderate throat pain is common during the first 2 weeks after surgery, requiring regular analgesia. Rarely, pain in the area back of the tongue or back of the throat.
(e) Injury to the teeth, lips, gums or tongue. There can also be a temporary change in sensation to tongue.
(f) Abnormal scarring may rarely occur causing narrowing or stenosis of the throat or strange sensations in the throat.
10. Consent Acknowledgement:
* The doctor has explained my medical condition and the proposed surgical procedure.
* I understand the risks of the procedure, including the risks that are specific to me, and the likely outcomes. The doctor has explained other relevant treatment options and their associated risks, the prognosis and the risks of not having the procedure.
* I have been given an Anesthesia Informed Consent Form.
* I have been given a Patient Information Sheet about the Condition, the Procedure, and associated risks.
* I was able to ask questions and raise concerns with the doctor about my condition, the procedure and its risks, and my treatment options.
* My questions and concerns have been discussed and answered to my satisfaction.
* I understand that the procedure may include a blood / blood product transfusion.
* I understand that if organs or tissues are removed during the surgery, that these may be retained for tests for a period of time and then disposed of sensitively by the hospital.
* The doctor has explained to me that if immediate life-threatening events happen during the procedure, they will be treated as appropriate.
* It has been explained to me, that during the course of or subsequent to the Operation/Procedure, unforeseen conditions may be revealed or encountered which may necessitate urgent surgical or other procedures in addition to or different from those contemplated. In such exigency, I further request and authorize the above named Physician / Surgeon or his designee to perform such additional surgical or other procedures as he or they consider necessary or desirable.

On the basis of the above statements,
I REQUEST TO HAVE THE PROCEDURE.
Name of Patient/Substitute Decision Maker…………………………………………….
Relationship …………………………………….
Signature………………………………………
Date………………………………………………

Name of the Witness…………………………
Relationship/Designation………………………
Signature………………………………………..
Date……………………………

INFORMED CONSENT: TONSILLECTOMY


Patient Identification Label to be affixed here






A. INTERPRETER
An interpreter service is required.Yes______________No_______________
If Yes, is a qualified interpreter present.Yes_____________No___________

B. CONDITION AND PROCEDURE
The doctor has explained that I have the following condition:
(Doctor to document in patient’s own words)
_______________________________________________and I have been advised to undergo the following treatment/procedure____________________________________________________________________________________________________________________________________________________________
See patient information sheet- "Tonsillectomy” for more
C.ANAESTHETIC
Please see your “Anesthesia Consent Form”. This gives you information of the General Risks of Surgery. If you have any concern, talk these over with your anesthetist.

D.RISKS OF THIS PROCEDURE
While majority of patients have an uneventful surgery/procedure and recovery, few cases may be associated with complications. These are seen infrequently and not all the ones listed below are applicable to one individual. However it is important that you are aware of the complications/risks that may arise out of this procedure which are as below:

There are some risks/ complications, which include:
(a) Bleeding. This may either at the time of surgery or in the first 2 weeks after surgery. Delayed bleeding may require readmission to hospital and may require another operation to stop the bleeding. A blood transfusion may be necessary depending on the amount of blood lost.
(b) Burns from the equipment used to seal off bleeding areas during the operation.
(c) Infection. Persistent bad breath, worsening throat discomfort or delayed bleeding may indicate an infection. This is usually treated with antibiotics. Delayed bleeding is treated as outlined above.
(d) Pain. Moderate throat pain is common during the first 2 weeks after surgery, requiring regular analgesia. Rarely, pain in the area back of the tongue or back of the throat.
(e) Injury to the teeth, lips, gums or tongue. There can also be a temporary change in sensation to tongue.
(f) Abnormal scarring may rarely occur causing narrowing or stenosis of the throat or strange sensations in the throat.

SIGNIFICANT RISKS AND RELEVANT TREATMENT OPTIONS:F. SIGNIFICANT RISKS AND
The doctor has explained any significant risks and problems specific to me, and the likely outcomes if complications occur.
The doctor has also explained relevant treatment options as well as the risks of not having the procedure.
(Doctor to document in Medical Record if necessary. Cross out if not applicable. )

PATIENT CONSENT: CONSENT
I acknowledge that:
* The doctor has explained my medical condition and the proposed procedure. I understand the risks of the procedure, including the risks that are specific to me, and the likely outcomes.
* The doctor has explained other relevant treatment options and their associated risks. The doctor has explained my prognosis and the risks of not having the procedure.
* I have been given a Patient Information Sheet on Anesthesia.
* I have been given the patient information sheet regarding the condition, procedure, risks and other associated information.
* I was able to ask questions and raise concerns with the doctor about my condition, the procedure and its risks, and my treatment options. My questions and concerns have been discussed and answered to my satisfaction.
* I understand that the procedure may include a blood transfusion.
* I understand that if organs or tissues are removed during the surgery, that these may be retained for tests for a period of time and then disposed of sensitively by the hospital.
* The doctor has explained to me that if immediate life-threatening events happen during the procedure, they will be treated accordingly.
* I understand that photographs or video footage maybe taken during my operation. These may then be used for teaching health professionals. (You will not be identified in any photo or video).
* I understand that no guarantee has been made that the procedure will improve the condition, and that the procedure may make my condition worse.

On the basis of the above statements,
I hereby authorize Dr……………………………………………………………………and those he may designate as associates or assistants to perform upon me the following medical treatment, surgical operation and / or diagnostic / therapeutic procedure…………………………………………………………..

I REQUEST TO HAVE THE PROCEDURE

Name of Patient/Substitute Decision Maker…………………………………………….
Relationship …………………………………………………………………………………….
Signature……………………………………………Date……………………………………….

Name of the Witness…………………………………………………………………………
Relationship/Designation………………………………………………………………………
Signature……………………………………………Date………………………………………
FERENCES
INTERPRETER’S STATEMENT:
I have given a translation in……………………………………………………………………
Name of interpreter…………………………………………………………………………….
Signature……………………………………………Date………………………………………

DOCTOR’S STATEMENTS
I have explained
* The patient ‘s condition
* Need for treatment
* The procedure and the risks
* Relevant treatment options and their risks
* Likely consequences if those risks occur
* The significant risks and problems specific to this patient

I have given the Patient/ Guardian an opportunity to:
* Ask questions about any of the above matters
* Raise any other concerns, which I have answered as fully as possible.

I am of the opinion that the Patient/ Substitute Decision Maker understood the above information.

Name of doctor…………………………………………………………………………..
Designation………………………………………………………………………………
Signature………………………………………Date……………………………………

Few questions for ENT Surgeons?

How many of ENT Surgeon will prefer to remove Angiofibroma pack under GA?

Will you prefer to get X-Ray for Adenoids with mouth closed or open?

Will you prescribe nasal decongestant in hypertensive epistaxis?

Which Tracheostomy tube you prefer to put after total laryngectomy? like Lary tube or Portex no. 10 tube and why?

In case of Adenoidectomy with myringotomy, which surgery will you perform first?

The advantage of doing Adenoidectomy first is that a pack can be left in nasopharynx which will get more time to stop bleeding by pressure as it will be removed after completion of myringotomy.

But by doing adenoidectomy first, we may be converting a clean myringotomy into iatrogenic ASOM.


so better do Myringotomy with Grommet insertion first.

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In any case of neck swelling especially for surgery, better to get a CT or MRI

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Case of nasal bleed especially in a medically complicated cases or on oral anticoagulants, better to take up patients for  cauterization of bleeding points under general anesthesia.

Care of the discharging ears

   1. Avoid moisture in ear :  Plug ear with Vaseline smeared cotton plug during shampoo, head wash, shower or bathing. Remove these after drying hair with towel.
   2. Avoid oil in ear :  It causes fungal infection by preventing evaporation of moisture.
   3. Avoid colored ear drops : It makes subsequent examination and evaluation difficult.
   4. Avoid Scratching ears with ear buds, hair –pin, finger nail, crochet, knitting needle, pencil, pin, toothpick, match stick etc.
   5. Avoid feeding the baby or young child in lying down position. Prop him up. The feeds may enter the ear via Eustachian tube (ventilation tube of the ear). Thus bottle feeding should also be avoided in children having discharging ears.
   6. If you catch a cold, take prompt treatment. Do not blow the nose during a cold – nasal discharge must not be forced up to the ear Avoid contact with people having cold.
   7. Avoid swimming – do not bathe in a river, lake, sea or swimming pool.
   8. Avoid air travel during episode of cold.

SENSORY NEURAL HEARING LOSS (NERVE DEAFNESS)

Your detailed examination shows that you are suffering from verve type of hearing loss. There is no medical or surgical treatment available to improve the hearing in these cases. The aim of our management is to prevent further hearing loss and try to make the best use of the hearing which you have.
       The circumstances mentioned below are known to cause hearing defeat in susceptible individuals. It is in your interest to observe the following precautions, otherwise your trouble may get worse.
      
1.    You should avoid the use of following medicines :

       Please show this pamphlet to your family doctor when you seek his advice for any future illness.

A. DEFINITELY OTOTOXIC:
i. Aminoglycoside antibiotics e.g. Streptomycin, Dihydrostreptomycin (not used now a days), Neomycin,Viomycin Framycetin, Vancomycetin, Kanamycin, Ristocetin, Polymixin B, Gentamycin, Tobramycin, Amikacin, Chloramphenicol Erythromycin.
ii. Anti-Protozoal drugs-Quinine, Choroquine (reversible at early stages), Chimopodium may also cause deafness.
iii. Salicylates, Aspirin (reversible at early stage).

B. OTOTOXICITY AND IDIOSYNCRASY:
i. Cytotoxic drugs –Nitrogen mustard, Cisplatin, Bleomycin.
ii. Thalidomide (cause congenital abnormality).
iii. Tetanus antitoxin
iv. Topical drugs-chlorhexadine (Hibitane) in spirit
v. Heavy metals used in allopathic and indigenous drugs e.g. arsenic in the form of salvarsam, mercury, lead and gold etc., used as “Bhasmas” in Ayurvedic and “Kushtas” in Unani Systems.

C. REVERSIBLE OTOTOXICITY:
i. Beta-adrenergic receptor blocking agent, Protocol (withdrawn), Propranolol, Atenolol, Metoprolol, Oprenotol.
ii. Antiheparinising agents viz Hexadimethrine bromide.
iii. Loop-Diuretics-Ethacrynic acid, Lasix (Frusemide)

D. MISCELLANEOUS:
i. Oral Contraceptives
ii. Nicotine, Tobacco, Marijuana

E. DOUBTFUL OTOTOXICITY:
i. Drugs for control of diabetes, antithyroid drugs.
ii. Atropine
iii. Barbiturates, Dilantin
iv. Librium

       It has been proved that very often the severe ototoxic damage to the hearing organ is irreversible and treatment with any amount of drugs like B-complex, Vit-E, Vit-A etc. will not improve the hearing. If there is any impairment of hearing after consumption of the above mentioned drugs, the same should be stopped immediately with the approval of the treating physician. During the treatment with ototoxic drug if there is any tinnitus (noise in the ear) the patient should immediately report to the doctor since it may precede the onset of deafness.

2.    Avoid prolonged exposure to noisy surroundings e.g. those of lathe machines, vacuum cleaner, factory machines, discotheques etc. Exposure to high frequency noise like jet engines or firing of ammunition, Diwali crackers etc. is very harmful. Even a sudden loud sound from the telephone can damage the ear in susceptible individuals.
3.    Avoid smoking, tobacco-chewing and alcohol
4.    Avoid using hair pins, match-sticks and other sharp objects in the ear
5.    Please do not pour oil (warm/cold) into the ear unless you suspect that an insect has entered your ear and an immediate medical care is not available.
6.    Do not blow the nose hard during a cold.
7.    Get your blood pressure, blood sugar etc. checked by your family doctor periodically for diagnosis and control of hypertension, diabetes and other chronic ailments.
8.    Get your Audiometry repeated once in a year.

       Use a Hearing Aid in the better hearing ear. Practice lip reading by paying attention to people’s lips when they are talking. Buy a book of poems. Read any poem 3 to 4 times. Then as a friend to read out one line of the poem mouthing the words with his lips but not speaking them aloud. You should be able to repeat the line after him just by paying attention to his lips, without having heard the words. Practice this for ½ to 1 hour daily for 3-4 months. Just by looking at the lips of the person who is talking, you should be able to understand what he is saying without hearing a word, provided you know the gist of the conversation.

Consent Information-Thyroidectomy (Total or Partial)

CONSENT INFORMATION - PATIENT COPY

THYROIDECTOMY (Total or Partial)

PLEASE READ THIS SHEET BEFORE YOU CONSENT TO YOUR SURGERY

This information sheet provides general information to a person having a Thyroid Surgery (Total or Partial). It does not provide advice to the individual. It is important that the content is discussed between you and your doctor who understands your level of fitness and your medical condition.


1. What is a Thyroidectomy?
A thyroidectomy is a surgical procedure for removing all or part of the thyroid gland.

2. When is it done?
A thyroidectomy may be done for patients who have a variety of thyroid conditions, including both cancerous and benign (non cancerous) thyroid nodule (lump) in your thyroid gland, large thyroid glands (goiters), and overactive thyroid glands.

3. Why do I need an operation?
The most common reason a patient is referred for Thyroid surgery is after an evaluation for a thyroid nodule which usually includes a Fine Needle Aspiration Cytology (FNAC) or biopsy. Surgery may be recommended for the following biopsy results: a) Diagnosed Cancer b) Possible cancer c) Benign (non malignant).
Surgery is also an option for Hyperthyroidism, large multinodular goiters and for any symptomatic goiter that has failed to be controlled by medication or radioactive iodine.

4. How do I prepare for the surgery?
Plan for your care and recovery after the operation. Find someone to drive you home after the surgery. Allow for time to rest and try to find other people to help you with your day-to-day duties.
Follow your health care provider's instructions about not smoking before and after the procedure. Smokers heal more slowly after surgery. They are also more likely to have breathing problems during surgery. For this reason, if you are a smoker, you should quit at least 2 weeks before the procedure. It is best to quit 6 to 8 weeks before surgery. Also, your wounds will heal much better if you do not smoke after the surgery. Follow any other instructions your provider gives you. Eat a light meal, such as soup or salad, the night before the procedure. Do not eat or drink anything after midnight and the morning before the procedure. Do not even drink coffee, tea, or water.

5. The Operation:

This means removing my thyroid gland completely or nearly completely. Under a general anaesthetic, the surgeon makes a cut in along a skin crease in the lower part of the neck and lifts upper and lower flaps of skin and underlying tissues to give a good view of the thyroid gland. The lymph glands associated with the thyroid are inspected and any that are suspicious may be removed and sent for microscopic examination. The blood vessels to the thyroid are tied off and the gland gradually freed, while the surgeon looks for and protects two important structures nearby – the nerves that control the vocal cords (recurrent laryngeal nerves) and the parathyroid glands that help control the body’s calcium.

When the gland is free, it is sent for microscopic examination. Any bleeding points are sealed and a fine suction drain is often left in each side of the neck to remove any secretions. These will be removed after a day or two. The skin wound is closed.

How much of my thyroid glands needs to be removed?

Patients should discuss with the surgeon what operation on the thyroid is to be performed, such as lobectomy or total thyroidectomy, and the reasons why such a procedure is recommended. For patients with papillary or follicular thyroid cancer many, but not all, surgeons recommend total or near-total thyroidectomy when they believe that subsequent treatment such as that with radioactive iodine might be beneficial. For patients with large (>1.5 cm) primary tumors and for any medullary thyroid cancer, more extensive lymph node dissection is necessary to remove possibly involved lymph node metastases.

6. After the Operation:
* You may be in the hospital for about 2 or 3 days. You will have a scar on the front of your neck.
* You may have a small drain tube from the incision, which will be removed 1 or 2 days after surgery. This may cause your throat to be sore.
* If the surgeon removed all or a large part of the thyroid gland, you will have to take thyroid hormone medicine for the rest of your life.
* If you have a cancer, you may be advised to take a radioactive iodine medicine to destroy any remaining thyroid tissue and cancerous cells.
* Vigorous sports such as swimming and activities that involve lifting of heavy weights should be delayed for at least 3 weeks.
* Ask your health care provider what steps you should take and when you should come back for a checkup.

7. Will I be normal after having surgery?
Yes. Once you have recovered from the effects of thyroid surgery, you will usually be able to doing anything that you could do prior to surgery. Many patients become hypothyroid following thyroid surgery, requiring treatment with thyroid hormone. This is especially true if you had surgery for thyroid cancer. In addition, your doctor may recommend follow-up therapy with radioactive iodine if you have thyroid cancer prior to starting thyroid hormone therapy.

8. Benefits of Having the Surgery:
* Cosmetically, a large gland visible on the neck is removed and looks better.
* Prevents pressure effects on wind pipe and food pipe.
* If a cancer is detected, its further treatment can be advocated.
* Goiter associated with hyperthyroidism usually is benefited by surgery as medical treatment has been known to lead to high rates of relapse.

9. Risks of Not having the Surgery:
* Malignancy may remain undetected.
* Hemorrhage within the gland may cause acute respiratory obstruction.
* Growing goiter can produce pressure effects.
* Goiter may become hypersecrete thyroid hormone which per se will require surgery.

10. Alternative Treatments:

Please note that some alternative treatments may not be available or suitable to everyone

Alternatives to this procedure are:
* Choosing not to have treatment while recognizing the risk that a cancer may go untreated
* Choosing to have repeat exams over many months or years and having surgery if a nodule grows (there is some risk of spread if a nodule turns out to be malignant).
* You should ask your health care provider about these choices

11. After the surgery contact your doctor if:
* You develop a fever over 100°F (37.8°C).
* You have trouble breathing.
* You have tingling or muscle cramping in your face or cramping (muscle spasms) in your hands.

12. Specific Risks of this procedure:
While majority of patients have an uneventful surgery and recovery, few cases may be associated with complications. These are seen infrequently and not all the ones listed below are applicable to one individual. However it is important that you are aware of the complications/risks that may arise out of this procedure which are as below:

(a) Increased risk in obese people of wound infection, chest infection, heart and lung complications and thrombosis.
(b) Increased risk in smokers of wound and chest infections, heart and lung complications and thrombosis.fRe8
(c) Possible bleeding in the tissues of the neck which may result in swelling about the wound or a fluid discharge, or on rare occasions, pressure in the wind pipe which may cause breathing problems. This may require emergency surgery.
(d) Rarely an important nerve in the area of the back of the thyroid may be damaged which could result in a permanent hoarse voice, or difficulty with the higher pitch of the voice. It is very common to have a temporary hoarse voice for a few days as this operation is near the larynx. If both of these nerves were damaged, severe breathing difficulty may occur with the need for respiratory support. This may be permanent.
(e) Rarely a small gland behind the thyroid, called the parathyroid, may be damaged and this may result in tingling of the fingers and spasms of the hands and toes. This is usually a temporary problem but occasionally long term calcium supplements are necessary.
(f) After removal of part of the gland the function of the thyroid may decrease and you may need a test of thyroid function in the next few months and possible treatment for under activity of the thyroid. With total removal of the gland, life long medication is required.
(g) In some people healing of the wound may be abnormal and the wound can be thickened and red and may be painful.
(h) Other extremely rare risks/complications.
. Recovering from your operation

13. Consent Acknowledgement:
* The doctor has explained my medical condition and the proposed surgical procedure. I understand the risks of the procedure, including the risks that are specific to me, and the likely outcomes. The doctor has explained other relevant treatment options and their associated risks, the prognosis and the risks of not having the procedure.
* I have been given an Anaesthesia Informed Consent Form.
* I have been given a Patient Information Sheet about the procedure and its risks.
* I was able to ask questions and raise concerns with the doctor about my condition, the procedure and its risks, and my treatment options.
* My questions and concerns have been discussed and answered to my satisfaction.
* I understand that the procedure may include a blood / blood product transfusion.
* I understand that if organs or tissues are removed during the surgery, that these may be retained for tests for a period of time and then disposed of sensitively by the hospital.
* The doctor has explained to me that if immediate life-threatening events happen during the procedure, they will be treated as appropriate.
* It has been explained to me, that during the course of or subsequent to the Operation/Procedure, unforeseen conditions may be revealed or encountered which may necessitate urgent surgical or other procedures in addition to or different from those contemplated. In such exigency, I further request and authorize the above named Physician / Surgeon or his designee to perform such additional surgical or other procedures as he or they consider necessary or desirable.
On the basis of the above statements,

I REQUEST TO HAVE THE PROCEDURE.
Name of Patient/Substitute Decision Maker………………………………………
Relationship ………………………………
Signature…………………………………
Date………………………………………


Name of the Witness
Relationship/Designation………………
Signature…………………………………
Date………………………………………REFERENCES

INFORMED CONSENT: THYROIDECTOMY (SUB OR TOTAL)


Name________________________Age_______Yrs______Sex M______F_____

Registration No.___________Consultant____________________Bed No._____


A. INTERPRETER

An interpreter service is required Yes____No_______

If Yes, is a qualified interpreter present Yes_____No______

B. CONDITION AND PROCEDURE
The doctor has explained that I have the following condition:
(Doctor to document in patient’s own words)…………………………………………..
………………………………………………………………………………………………and
I have been advised to undergo the following treatment/ procedure………............
……………………………………………………………………………………………………..
See patient information sheet- "Thyroidectomy (Sub or Total)" - for more
Operation: Removal of part or all of the thyroid gland through a cut along the necklace line of the neck.

C.ANAESTHETIC
Please see your “Anesthesia Consent Form”. This gives you information of the General Risks of Surgery. If you have any concern, talk these over with your anaesthetist.

D.RISKS OF THIS PROCEDURE
While majority of patients have an uneventful surgery and recovery, few cases may be associated with complications. These are seen infrequently and not all the ones listed below are applicable to one individual. However it is important that you are aware of the complications/risks that may arise out of this procedure which are as below:

(a) Increased risk in obese people of wound infection, chest infection, heart and lung complications and thrombosis.
(b) Increased risk in smokers of wound and chest infections, heart and lung complications and thrombosis.fRe8
(c) Possible bleeding in the tissues of the neck which may result in swelling about the wound or a fluid discharge, or on rare occasions, pressure in the wind pipe which may cause breathing problems. This may require emergency surgery.
(d) Rarely an important nerve in the area of the back of the thyroid may be damaged which could result in a permanent hoarse voice, or difficulty with the higher pitch of the voice. It is very common to have a temporary hoarse voice for a few days as this operation is near the larynx. If both of these nerves were damaged, severe breathing difficulty may occur with the need for respiratory support. This may be permanent.
(e) Rarely a small gland behind the thyroid, called the parathyroid, may be damaged and this may result in tingling of the fingers and spasms of the hands and toes. This is usually a temporary problem but occasionally long term calcium supplements are necessary.
(f) After removal of part of the gland the function of the thyroid may decrease and you may need a test of thyroid function in the next few months and possible treatment for under activity of the thyroid. With total removal of the gland, life long medication is required.
(g) In some people healing of the wound may be abnormal and the wound can be thickened and red and may be painful.
(h) Other extremely rare risks/complications.

E.SIGNIFICANT RISKS AND RELEVANT TREATMENT OPTIONS
The doctor has explained any significant risks and problems specific to me, and the likely outcomes if complications occur.
The doctor also has explained relevant treatment options as well as the risks of not having the procedure.
(Doctor to document in medical record if necessary. Cross out if not applicable)

F.PATIENT CONSENT
I acknowledge that:
* The doctor has explained my medical condition and proposed procedure. I understand the risks of the procedure including the risks that are specific to me, and the likely outcomes.
* The doctor has explained other relevant treatment options and their associated risks. The doctor has also explained the risks of not having the procedure.
* I have been given the Anesthesia informed consent form.
* I have been given the Patient Information sheet related to the procedure and the risks.
* I was able to ask questions and raise concerns with the doctor the procedure and its risks, and my treatment options. My questions and concerns have been discussed and answered to my satisfaction.
* I understand that the procedure may include a blood/blood product transfusion.
* I understand that a doctor other than the consultant surgeon may conduct the procedure I understand this could be a doctor undergoing further training.
* I understand that if organs or tissues are removed during the surgery that these may be retained for tests for a period of time and then disposed of sensitively by the hospital.
* The doctor explained to me that if immediate life-threatening events happen during the procedure, they will be treated accordingly.
* It has been explained to me, that during the course of or subsequent to the Operation/Procedure, unforeseen conditions may be revealed or encountered which may necessitate urgent surgical or other procedures in addition to or different from those contemplated. In such exigency, I further request and authorize the above named Physician / Surgeon or his designee to perform such additional surgical or other procedures as he or they consider necessary or desirable.
* I understand that no guarantee has been made that the procedure will improve the condition and that the procedure may make my condition worse.
On the basis of the above statements,
I hereby authorize Dr……………………………………………………………………and those he may designate as associates or assistants to perform upon me the following medical treatment, surgical operation and / or diagnostic / therapeutic procedure………………..
……………………………………………………………………………………………………..
I REQUEST TO HAVE THE PROCEDURE

Name of Patient/Substitute Decision Maker…………………………………………….
Relationship ………………………………………………………………………………..
Signature…………………………………………………………………………………….
Date………………………………………………………………………………………….

Name of the Witness………………………………………………………………………
Relationship/Designation…………………………………………………………………
Signature……………………………………………………………………………………
Date………………………………………………………………………………………….
REFERENCES
G.INTERPRETER’S STATEMENT
I have given a translation in……………………………………………………………………
Name of interpreter……………………………………………………………………..
Signature……………………………………………………………………………………
Date………………………………………………………………………………………….

H. DOCTOR’S STATEMENTS
I have explained
* The patient ‘s condition
* Need for treatment
* The procedure and the risks
* Relevant treatment options and their risks
* Likely consequences if those risks occur
* The significant risks and problems specific to this patient
I have given the Patient/ Guardian an opportunity to:

* Ask questions about any of the above matters
* Raise any other concerns,
which I have answered as fully as possible.

I am of the opinion that the Patient/ Substitute Decision Maker understood the above information.

Name of doctor………………………………………………………………
Designation………………………………………………………………….
Signature…………………………………………………………………….
Date…………………………………………………………………………

Consent - Division of Tongue Tie

CONSENT INFORMATION – PATIENT COPY

DIVISION OF TONGUE TIE

PLEASE READ THIS SHEET BEFORE YOU CONSENT FOR YOUR PROCEDURE

This information sheet provides general information to a person having a Division of tongue tie. It does not provide advice to the individual. It is important that the content is discussed between the patient and the concerned doctors who understand the level of fitness and medical condition.

What is “Tongue tie”?

 Tongue-tie (ankyloglossia) is a congenital condition in which the lingual frenulum is abnormally short and may therefore restrict mobility of the tongue tip. The lingual frenulum is a normal structure that is present in all babies. If it is short and restricts the movement and function of the tongue, it is called tongue-tie. Not all tongue-ties require release - the division of the lingual frenulum - and these may be considered a normal variant unless there are clearly identified feeding problems.

What is “division of tongue tie”?

Division of tongue tie is the division of the band of tissue tethering the tongue.

Why divide tongue ties?

Tongue-tie can interfere with a baby's ability to suckle efficiently at the breast. This may lead to nipple pain and trauma, poor breast milk intake and a decrease in milk supply over time.

 What are the symptoms?

The good news is that lots of babies with tongue-tie experience no problems at all, either with feeding or speech. However, some babies will have problems with breastfeeding because they won't be able to use their tongue to massage their mother's nipple and areola. If they can't stick their tongue out beyond their lower gum they won't get enough milk. Any of the following can be symptoms of tongue-tie:
(1) failure to latch on
(2) slipping off the breast while feeding
(3) Sore nipples, mastitis and/or blocked ducts
(4) continuous feeding
(5) colic
(6) slow weight gain

Remember, a baby with tongue-tie may not have all of the above symptoms and some babies will have these symptoms, but not have a tongue-tie.

How are tongue-ties divided?

Dividing your baby's tongue-tie does not require a general anesthetic, providing they are less than 8 months of age. It only takes a minute or so, though it may well seem longer. A trained health professional will simply wrap your baby up with a towel, divide the tongue-tie with sterile scissors and bring him back to you quickly so that you can feed him.

Does it hurt?

Logically, dividing a tongue tie ought to hurt. However, a significant number of small babies (about 1 in 6) are asleep when their tongue tie is divided and remain asleep during the procedure!

Older babies do not like being wrapped up so they usually cry out, and it can sometimes be quite difficult to know whether dividing their tongue-tie is actually painful, as they are already complaining at being wrapped up.

Following division, the baby is promptly unwrapped and returned for feeding. Although some babies will cry for up to 60 seconds, the average is just 15 seconds (and some just stay asleep).

So, for some babies division does not hurt and for the rest it does not hurt very much at all.

What about the wound?

A few drops of blood are normal, but this always stops quickly and is never a problem. The inside of the mouth heals much faster than most of the rest of the body because the lining of the mouth is being worn away and renewed all the time. This happens even quicker in babies, so there is no need for any form of wound management, the baby just needs to be fed. Often there is a white patch under the tongue which takes 24 - 48 hours to heal. This does not seem to cause the baby any discomfort.

The Future

If the baby is breastfeeding or bottle feeding well, then the tongue-tie does not need to be divided. Most tongue-ties in newborn babies are thin, but those remaining in 3-year-olds are mostly thick. So, the thin ones must either have been divided by the lower teeth as they come through, or they are accidentally torn by a parent putting a teaspoon of food under, rather than over, the tongue, or the infant thrusts a toy into their own mouth, which they will all do.

Although some babies can breast- or bottle feed well, they may have problems coping with lumpy food. They may not be able to transfer food from the front to the back of the mouth or chew properly. These infants will be helped by tongue-tie division, at any age.

A few tongue-ties do persist and may cause speech or other problems, but this will not be really apparent until the child is at least 3 years old. If there is a problem, the tongue-tie can be divided under a very short General Anesthetic. Most children with a tongue-tie and a speech problem improve following division.

General Risks of having the procedure:

These have been mentioned in the “Anesthesia Consent Form.” Please discuss this with your Anesthetist before signing the Anesthesia Consent Form.

What are the risks of the procedure?

While majority of patients have an uneventful procedure and recovery, few cases may be associated with complications. These are seen infrequently and not all the ones listed below are applicable to one individual. However it is important that you are aware of the complications/risks that may arise out of this procedure which are as below:

There are some risks/ complications, which include:
(a) Bleeding. This may occur either at the time of surgery or in the first 2 weeks after surgery. Delayed bleeding may require readmission to hospital and may require another operation to stop the bleeding. A blood transfusion may be necessary depending on the amount of blood lost.
This complication is extremely rare.
(b) Infection. Persistent bad breath, worsening mouth discomfort or delayed bleeding may indicate an infection. This is usually treated with antibiotics. Delayed bleeding is treated as outlined above
(c) Pain. Mild mouth pain is common during the first few days after surgery, requiring regular pain killers.
(d) Damage to sublingual gland, which sits beneath the tongue. This may cause a cyst to form. This may need further surgery.
(e) Injury to the teeth, lips, gums or tongue.
(f) Burns from the equipment used to seal of bleeding areas during the operation.
(g) Rarely, tongue tie may come back due to growth of scar tissue. This may need further surgery.

Consent Acknowledgement:

* The doctor has explained my medical condition and the proposed surgical procedure.
* I understand the risks of the procedure, including the risks that are specific to me, and the likely outcomes. The doctor has explained other relevant treatment options and their associated risks, the prognosis and the risks of not having the procedure.
* I have been given an Anesthesia Informed Consent Form.
* I have been given a Patient Information Sheet about the Condition, the Procedure, and associated risks.
* I was able to ask questions and raise concerns with the doctor about my condition, the procedure and its risks, and my treatment options.
* My questions and concerns have been discussed and answered to my satisfaction.
* I understand that the procedure may include a blood / blood product transfusion.
* I understand that if organs or tissues are removed during the surgery, that these may be retained for tests for a period of time and then disposed of sensitively by the hospital.
* The doctor has explained to me that if immediate life-threatening events happen during the procedure, they will be treated as appropriate.
* It has been explained to me, that during the course of or subsequent to the Operation/Procedure, unforeseen conditions may be revealed or encountered which may necessitate urgent surgical or other procedures in addition to or different from those contemplated. In such exigency, I further request and authorize the above named Physician / Surgeon or his designee to perform such additional surgical or other procedures as he or they consider necessary or desirable.

On the basis of the above statements,

I REQUEST TO HAVE THE PROCEDURE.

Name of Patient/Substitute Decision Maker…………………………………………….
Relationship …………………………………….
Signature………………………………………
Date………………………………………………
Name of the Witness…………………………
Relationship/Designation………………………
Signature………………………………………..
Date…………………



INFORMED CONSENT: DIVISION OF TONGUE TIE


Patient Identification Label to be affixed here






A. INTERPRETER
An interpreter service is required.Yes______________No_______________
If Yes, is a qualified interpreter present.Yes_____________No___________

B. CONDITION AND PROCEDURE
The doctor has explained that I have the following condition:
(Doctor to document in patient’s own words)
_______________________________________________and I have been advised to undergo the following treatment/procedure____________________________________________________________________________________________________________________________________________________________
See patient information sheet- "Division of tongue tie” for more

C.ANAESTHETIC

Please see your “Anesthesia Consent Form”. This gives you information of the General Risks of Surgery. If you have any concern, talk these over with your anesthetist.

D.RISKS OF THIS PROCEDURE

While majority of patients have an uneventful surgery/procedure and recovery, few cases may be associated with complications. These are seen infrequently and not all the ones listed below are applicable to one individual. However it is important that you are aware of the complications/risks that may arise out of this procedure which are as below:

There are some risks/ complications, which include:
(a) Bleeding. This may occur either at the time of surgery or in the first 2 weeks after surgery. Delayed bleeding may require readmission to hospital and may require another operation to stop the bleeding. A blood transfusion may be necessary depending on the amount of blood lost.
This complication is extremely rare.
(b) Infection. Persistent bad breath, worsening mouth discomfort or delayed bleeding may indicate an infection. This is usually treated with antibiotics. Delayed bleeding is treated as outlined above
(c) Pain. Mild mouth pain is common during the first few days after surgery, requiring regular pain killers.
(d) Damage to sublingual gland, which sits beneath the tongue. This may cause a cyst to form. This may need further surgery.
(e) Injury to the teeth, lips, gums or tongue.
(f) Burns from the equipment used to seal of bleeding areas during the operation.
(g) Rarely, tongue tie may come back due to growth of scar tissue. This may need further surgery.

SIGNIFICANT RISKS AND RELEVANT TREATMENT OPTIONS:F. SIGNIFICANT RISKS AND

The doctor has explained any significant risks and problems specific to me, and the likely outcomes if complications occur.
The doctor has also explained relevant treatment options as well as the risks of not having the procedure.
(Doctor to document in Medical Record if necessary. Cross out if not applicable. )

PATIENT CONSENT: CONSENT

I acknowledge that:
* The doctor has explained my medical condition and the proposed procedure. I understand the risks of the procedure, including the risks that are specific to me, and the likely outcomes.
* The doctor has explained other relevant treatment options and their associated risks. The doctor has explained my prognosis and the risks of not having the procedure.
* I have been given a Patient Information Sheet on Anesthesia.
* I have been given the patient information sheet regarding the condition, procedure, risks and other associated information.
* I was able to ask questions and raise concerns with the doctor about my condition, the procedure and its risks, and my treatment options. My questions and concerns have been discussed and answered to my satisfaction.
* I understand that the procedure may include a blood transfusion.
* I understand that if organs or tissues are removed during the surgery, that these may be retained for tests for a period of time and then disposed of sensitively by the hospital.
* The doctor has explained to me that if immediate life-threatening events happen during the procedure, they will be treated accordingly.
* I understand that photographs or video footage maybe taken during my operation. These may then be used for teaching health professionals. (You will not be identified in any photo or video).
* I understand that no guarantee has been made that the procedure will improve the condition, and that the procedure may make my condition worse.

On the basis of the above statements,

I hereby authorize Dr……………………………………………………………………and those he may designate as associates or assistants to perform upon me the following medical treatment, surgical operation and / or diagnostic / therapeutic procedure…………………………………………………………..

I REQUEST TO HAVE THE PROCEDURE

Name of Patient/Substitute Decision Maker…………………………………………….
Relationship …………………………………………………………………………………….
Signature……………………………………………Date……………………………………….

Name of the Witness…………………………………………………………………………
Relationship/Designation………………………………………………………………………
Signature……………………………………………Date………………………………………
FERENCES
INTERPRETER’S STATEMENT:
I have given a translation in……………………………………………………………………
Name of interpreter…………………………………………………………………………….
Signature……………………………………………Date………………………………………

DOCTOR’S STATEMENTS
I have explained
* The patient ‘s condition
* Need for treatment
* The procedure and the risks
* Relevant treatment options and their risks
* Likely consequences if those risks occur
* The significant risks and problems specific to this patient

I have given the Patient/ Guardian an opportunity to:
* Ask questions about any of the above matters
* Raise any other concerns, which I have answered as fully as possible.

I am of the opinion that the Patient/ Substitute Decision Maker understood the above information.

Name of doctor…………………………………………………………………………..
Designation………………………………………………………………………………
Signature………………………………………Date……………………………………



Patients Initials ______________

Standard Consent form for Tympanoplasty

CONSENT INFORMATION – PATIENT COPY

TYMPANOPLASTY

PLEASE READ THIS SHEET BEFORE YOU CONSENT FOR YOUR PROCEDURE

This information sheet provides general information to a person having a Tympanoplasty. It does not provide advice to the individual. It is important that the content is discussed between the patient and the concerned doctors who understand the level of fitness and medical condition.

What is “Tympanoplasty”? 

A tympanoplasty is a surgical procedure that repairs or reconstructs the eardrum (tympanic membrane) to help restore normal hearing. This procedure may also involve repair or reconstruction of the small bones behind the tympanic membrane (ossiculoplasty) if needed. Both the eardrum and middle ear bones (ossicles) need to function well together for normal hearing to occur.

What are the indications for a tympanoplasty? 

This procedure is usually not performed (or needed) in children under four years of age. A tympanoplasty is recommended when the eardrum is torn (perforated), sunken in (atelectatic), or otherwise abnormal and associated with hearing loss. Abnormalities of the ear drum and middle ear bones can occur through injury, otitis media, congenital (at birth) deformities, or chronic ear conditions such as a cholesteatoma.


What are the signs & symptoms of a ruptured eardrum? 

A ruptured eardrum can be painful, particularly at first. Signs and symptoms may include:
* Sharp, sudden ear pain or discomfort
* Clear, pus-filled or bloody drainage from your ear
* Sudden decrease in ear pain followed by drainage from that ear
* Hearing loss
* Ringing in your ear (tinnitus)

How successful is tympanoplasty in restoring normal hearing? 

Return to a normal range of hearing after tympanoplasty is dependent upon the extent of the abnormality. Surgeries that involve repair of the eardrum only usually have a success rate of 85-90%. A second operation may be necessary in some cases if the hearing is not restored to an acceptable level.

Are there any other options aside from tympanoplasty?

Tympanoplasty in most cases is an elective procedure, meaning that it can be scheduled whenever the patient is ready to have it done. Another option instead of this procedure includes the use of a hearing aid. When the tympanic membrane has a hole (perforation) in it, earplugs are usually recommended to protect the middle ear from infection. In a few cases, such as a significant infection or a cholesteatoma, this procedure may prevent more significant damage to the ear and the surgery may need to be performed more urgently.

What is done in preparation for a tympanoplasty? 

Usually other ear, nose, and throat conditions are treated before a tympanoplasty is considered. For example, if an adenoidectomy is indicated, this surgery is usually completed before tympanoplasty.
Otitis Media of any type should not be present at the time of surgery, as infections in the ear make the operation much more difficult and may ruin the reconstruction. If your surgeon has suggested certain medications prior to surgery, these should be done without exception to ensure a successful outcome. A hearing test is performed to document any hearing deficiency. The more significant the hearing loss, the sooner the procedure should be performed. The eardrum will also be examined before surgery using a special operating microscope.

What to expect in hospital? 

Before surgery you will talk to your surgeon about the operation and you will be asked to sign a Consent Form either for yourself, or on behalf of your child. This confirms that you understand the risks, benefits and possible alternatives to the procedure and have given your permission for it to go ahead.
Fasting instructions must be followed before a general anesthetic. Typically, you must not eat or drink for about six hours. However, some anesthetists allow occasional sips of water until two hours beforehand.

How is Tympanoplasty performed? 

A tympanoplasty is performed with the patient fully asleep (under general anesthesia). A surgical cut (incision) is usually made behind the ear, the ear is moved forward, and the eardrum is then carefully exposed. The eardrum is then lifted up (tympanotomy) so that the inside of the ear (middle ear) can be examined. If there is a hole in the eardrum, it is cleaned (debrided) and the abnormal area can be cut away. A piece of fascia (tissue under the skin) from the temporalis muscle (behind the ear) is then cut and placed under the hole in the ear drum to create a new intact ear drum. This tissue is called a graft. The graft allows your child's normal eardrum skin to grow across the hole.
If needed, reconstruction of the middle ear bones (ossiculoplasty) or Cholesteatoma removal may also be performed at this time.

Post operative care: 

Some soreness in the jaw is common after a Tympanoplasty.  To ease the pain and quicken the healing process, your doctor can advise that you keep the ear dry and avoid air travel and contact with people who have colds.  Water in the ear can often cause problems so doctors recommend that you don’t take showers, or even walk in the rain for the first 5-6 days.  The graft should seal the hole within two weeks.

Length of Tympanoplasty: 

This surgery usually requires an overnight hospital stay. The patient usually has a dressing (large bandage) over the surgical site. This is removed the next morning and the patient is discharged home. Occasionally, in older children, or those undergoing a less involved procedure, same-day surgery is possible. Eardrops may be prescribed after discharge.

The most important part of this surgery for the parent is your part in restricting activity as outlined by your surgeon

General Risks of having the procedure: 

These have been mentioned in the “Anesthesia Consent Form.” Please discuss this with your Anesthetist before signing the Anesthesia Consent Form.

What are the risks of the procedure? 

While majority of patients have an uneventful procedure and recovery, few cases may be associated with complications. These are seen infrequently and not all the ones listed below are applicable to one individual. However it is important that you are aware of the complications/risks that may arise out of this procedure which are as below:

There are some risks/ complications, which include:
(a) Bleeding or infection in the ear or in the wound
(b) Ringing in the ear (tinnitus) or dizziness may occur and may be temporary/ permanent
(c) Partial loss of hearing or total loss hearing due to inner ear injury may rarely occur and may be permanent
(d) Facial nerve palsy. Temporary or permanent paralysis of the muscles of the face may rarely occur
(e) Failure to improve hearing. An improvement in hearing may not be apparent despite the surgery being successful in repairing the hole reconstructing the chain of bones
(f) Failure of the repair. There may be persistence of the tympanic membrane perforation or ossicular chain damage which may require further surgery
(g) Intracranial complications are rare.
(h) Altered sensation of taste may occasionally occur
(i) Temporary loss of sensation to ear (pinna).
(j) Abnormal scar tissue formation. This may result in a thickened, wide red scar which may require further surgery
10. Consent Acknowledgement:

* The doctor has explained my medical condition and the proposed surgical procedure.
* I understand the risks of the procedure, including the risks that are specific to me, and the likely outcomes. The doctor has explained other relevant treatment options and their associated risks, the prognosis and the risks of not having the procedure.
* I have been given an Anesthesia Informed Consent Form.
* I have been given a Patient Information Sheet about the Condition, the Procedure, and associated risks.
* I was able to ask questions and raise concerns with the doctor about my condition, the procedure and its risks, and my treatment options.
* My questions and concerns have been discussed and answered to my satisfaction.
* I understand that the procedure may include a blood / blood product transfusion.
* I understand that if organs or tissues are removed during the surgery, that these may be retained for tests for a period of time and then disposed of sensitively by the hospital.
* The doctor has explained to me that if immediate life-threatening events happen during the procedure, they will be treated as appropriate.
* It has been explained to me, that during the course of or subsequent to the Operation/Procedure, unforeseen conditions may be revealed or encountered which may necessitate urgent surgical or other procedures in addition to or different from those contemplated. In such exigency, I further request and authorize the above named Physician / Surgeon or his designee to perform such additional surgical or other procedures as he or they consider necessary or desirable.
On the basis of the above statements,

I REQUEST TO HAVE THE PROCEDURE.
Name of Patient/Substitute Decision Maker…………………………………………….
Relationship …………………………………….
Signature………………………………………
Date………………………………………………
Name of the Witness…………………………
Relationship/Designation………………………
Signature………………………………………..
Date……………………………



INFORMED CONSENT: TYMPANOPLASTY


Patient Identification Label to be affixed here


A. INTERPRETER 

An interpreter service is required.Yes______________No_______________
If Yes, is a qualified interpreter present.Yes_____________No___________

B. CONDITION AND PROCEDURE 

The doctor has explained that I have the following condition:
(Doctor to document in patient’s own words)
_______________________________________________and I have been advised to undergo the following treatment/procedure____________________________________________________________________________________________________________________________________________________________
See patient information sheet- "Tympanoplasty” for more

C.ANAESTHETIC 

Please see your “Anesthesia Consent Form”. This gives you information of the General Risks of Surgery. If you have any concern, talk these over with your anesthetist.

D.RISKS OF THIS PROCEDURE 

While majority of patients have an uneventful surgery/procedure and recovery, few cases may be associated with complications. These are seen infrequently and not all the ones listed below are applicable to one individual. However it is important that you are aware of the complications/risks that may arise out of this procedure which are as below:

There are some risks/ complications, which include:
(a) Bleeding or infection in the ear or in the wound
(b) Ringing in the ear (tinnitus) or dizziness may occur and may be temporary/ permanent
(c) Partial loss of hearing or total loss hearing due to inner ear injury may rarely occur and may be permanent
(d) Facial nerve palsy. Temporary or permanent paralysis of the muscles of the face may rarely occur
(e) Failure to improve hearing. An improvement in hearing may not be apparent despite the surgery being successful in repairing the hole reconstructing the chain of bones
(f) Failure of the repair. There may be persistence of the tympanic membrane perforation or ossicular chain damage which may require further surgery
(g) Intracranial complications are rare.
(h) Altered sensation of taste may occasionally occur
(i) Temporary loss of sensation to ear (pinna).
(j) Abnormal scar tissue formation. This may result in a thickened, wide red scar which may require further surgery

SIGNIFICANT RISKS AND RELEVANT TREATMENT OPTIONS:F. SIGNIFICANT RISKS AND
The doctor has explained any significant risks and problems specific to me, and the likely outcomes if complications occur.
The doctor has also explained relevant treatment options as well as the risks of not having the procedure.
(Doctor to document in Medical Record if necessary. Cross out if not applicable. )

PATIENT CONSENT: CONSENT 

I acknowledge that:
* The doctor has explained my medical condition and the proposed procedure. I understand the risks of the procedure, including the risks that are specific to me, and the likely outcomes.
* The doctor has explained other relevant treatment options and their associated risks. The doctor has explained my prognosis and the risks of not having the procedure.
* I have been given a Patient Information Sheet on Anesthesia.
* I have been given the patient information sheet regarding the condition, procedure, risks and other associated information.
* I was able to ask questions and raise concerns with the doctor about my condition, the procedure and its risks, and my treatment options. My questions and concerns have been discussed and answered to my satisfaction.
* I understand that the procedure may include a blood transfusion.
* I understand that if organs or tissues are removed during the surgery, that these may be retained for tests for a period of time and then disposed of sensitively by the hospital.
* The doctor has explained to me that if immediate life-threatening events happen during the procedure, they will be treated accordingly.
* I understand that photographs or video footage maybe taken during my operation. These may then be used for teaching health professionals. (You will not be identified in any photo or video).
* I understand that no guarantee has been made that the procedure will improve the condition, and that the procedure may make my condition worse.

On the basis of the above statements,

I hereby authorize Dr……………………………………………………………………and those he may designate as associates or assistants to perform upon me the following medical treatment, surgical operation and / or diagnostic / therapeutic procedure…………………………………………………………..

I REQUEST TO HAVE THE PROCEDURE

Name of Patient/Substitute Decision Maker…………………………………………….
Relationship …………………………………………………………………………………….
Signature……………………………………………Date……………………………………….

Name of the Witness…………………………………………………………………………
Relationship/Designation………………………………………………………………………
Signature……………………………………………Date………………………………………

PREFERENCES

INTERPRETER’S STATEMENT:

I have given a translation in……………………………………………………………………
Name of interpreter…………………………………………………………………………….
Signature……………………………………………Date………………………………………

DOCTOR’S STATEMENTS

I have explained
* The patient ‘s condition
* Need for treatment
* The procedure and the risks
* Relevant treatment options and their risks
* Likely consequences if those risks occur
* The significant risks and problems specific to this patient

I have given the Patient/ Guardian an opportunity to:

* Ask questions about any of the above matters
* Raise any other concerns, which I have answered as fully as possible.

I am of the opinion that the Patient/ Substitute Decision Maker understood the above information.

Name of doctor…………………………………………………………………………..
Designation………………………………………………………………………………
Signature………………………………………Date……………………………………

New ENT Clinic

Dear Reader,

I have started a new ENT Clinic at A-131, Sai Chowk, Madhu Vihar. Timings would be 6-8 PM Mon to sat.


with Best Regards,

Dr. Ajay Jain

Wegener's Granulomatosis

Wegener`s graulomatosis is a potentially lethal systemic disease that affects the upper(nasal mucosa) and lower respiratory tract and the kidneys. It is characterized histologically by necrotizing granulomatous vasculitis. The cytoplasmic staining antineutrophil cytoplasmic antibody(c-ANCA) test, has high specificity and sensitivity, but tissue diagnosis is necessary to confirm diagnosis. Biopsy specimens taken from the edge of the involvement give better yield, but obtaining a positive biopsy may be difficult and several biopsies may be required.It usually affects young or middle aged adults.Although it is uncommon in children it can affect people at any age. The cause of wegener`s granulomatosis is not known.

Risks of ear surgery

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To: drajayjain@hotmail.com
Subject: risks of ear surgery
Date: Wed, 27 Feb 2008 12:32:32 -0500
From: n1k1979@aol.com

Hello Sir,

Is there a risk of "dead ear" wtih cutting the tenosr tympani and stapedial tendons/muscles?

Thanks You

Mr Patel

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Dear Mr. Patel,

There is no risk of dead ear by cutting tensor tympani and stapedial tendon/muscle but this may lead to nullification of natural protective response from loud sounds and may cause noise induced hearing loss.

Dr. Ajay Jain

Median Rhomboid Glossitis

 

The embryonic tongue is formed by two lateral processes (lingual tubercles) meeting in the midline and fusing above a central structure from the first and second branchial arches, the tuberculum impar. The posterior dorsal point of fusion is occasionally defective, leaving a rhomboid-shaped, smooth erythematous mucosa lacking in papillae or taste buds. This median rhomboid glossitis (central papillary atrophy, posterior lingual papillary atrophy) is a focal area of susceptibility to recurring or chronic atrophic candidiasis, prompting a recent movement toward the use of posterior midline atrophic candidiasis as a more appropriate diagnostic term.

For more information click here