Friday, July 1, 2011

Consent information for Mastoidectomy


CONSENT INFORMATION – PATIENT COPY

MASTOIDECTOMY

PLEASE READ THIS SHEET BEFORE YOU CONSENT FOR YOUR PROCEDURE

This information sheet provides general information to a person having a Mastoidectomy. 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 the “Mastoid bone”?
The mastoid bone is a bone located behind the ear (felt as a hard bump behind the ear). Inside it looks like a honeycomb, with the spaces filled with air. These air cells are connected to the middle ear through an air filled cavity called the mastoid antrum. Although the mastoid bone serves as a reserve air supply to allow normal movement of the eardrum, its connection to the middle ear may also result in the spread of middle ear infections to the mastoid bone (mastoiditis).
What is a mastoidectomy?
A mastoidectomy is a surgical procedure designed to remove infection or growths in the bone behind the ear (mastoid bone). Its purpose is to create a "safe" ear and prevent further damage to the hearing apparatus.
What are the indications for a mastoidectomy?
A mastoidectomy is indicated for mastoiditis that does not respond to antibiotics. A mastoidectomy

is also helpful in preventing further complications of mastoiditis. These include meningitis (infection in the fluid surrounding the brain), brain abscess (pocket of infection in the brain), or blood clots in the veins of the brain.
Mastoidectomy is often indicated for other diseases that spread to the mastoid bone, such as Cholesteatoma. This procedure allows complete removal of these benign yet destructive growths. Occasionally, a mastoidectomy may be used to help find and repair an injured facial nerve.
What is done in preparation for a mastoidectomy?
A complete physical examination of the ear area including the appearance of the outer ear, eardrum, and middle ear is performed. Facial nerve function is also evaluated. Hearing tests and pictures (mastoid x-ray or CT scan) are also obtained prior to surgery.
What is involved with a mastoidectomy?
A mastoidectomy is performed with the patient fully asleep (under general anesthesia). A surgical cut (incision) is made behind the ear. The mastoid bone is then exposed and opened with a surgical drill. The infection or growth is then removed. The incision is closed with stitches under the skin. A drainage tube may also be placed.
Depending on the amount of infection or cholesteatoma present, various degrees of mastoidectomies can be performed.
In a Simple Mastoidectomy, the surgeon opens the bone and removes any infection. A tube may be placed in the eardrum to drain any pus or secretions present in the middle ear. Antibiotics are then given intravenously (through a vein) or by mouth.
A Radical Mastoidectomy removes the most bone and is indicated for extensive spread of a cholesteatoma. The eardrum and middle ear structures may be completely removed. Usually the stapes (the "stirrup" shaped bone) is spared if possible to help preserve some hearing.
A Modified Radical Mastoidectomy means that some middle ear bones are left in place and the eardrum is rebuilt (tympanoplasty). Both a modified radical and a radical mastoidectomy usually result in less than normal hearing.
A hospital stay is usually required overnight for children.
Dos and don’ts: After you leave hospital to look after your ear
* Keep your ear and the wound dry. Take care when showering and washing your hair, to avoid infection.
* Place a piece of cotton wool covered in vaseline in the ear to prevent water getting into the ear. This also means you cannot go swimming until you have seen your doctor in the out-patient clinic.
* Change the cotton wool in your ear daily – always wash your hands before and after doing so. Take care not to remove the ear dressing with the pack – if it sticks to the cotton wool then cut it close to the cotton wool, but do not pull the dressing out.
* Itchiness & redness is rare, and it may mean you are allergic to the dressing. If you experience it, contact the ward on the number on the next page.
Things to avoid:
* Avoid blowing your nose violently - blow it gently from side to side. If you need to sneeze, try to do so with your mouth open.
* Try to avoid contact with family and friends who have colds for a month after your operation. There is a risk that a cold could lead to an ear infection which would destroy the graft while it is healing. If you catch a cold, you should consult your doctor.
* Avoid changes in atmospheric pressure, which causes your ear to 'pop' as this can damage the graft.
* Avoid strenuous work, sporting activities and straining until you have been seen in out-patient department.
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. Rarely, an infection may spread to adjacent structures including the brain causing meningitis or a brain abscess
(b) Facial nerve palsy. Injury to the nerve controlling the muscles of the face may result in paralysis of the face muscles. This may be temporary or may rarely be permanent
(c) Persistence or recurrence of the cholesteatoma might occur requiring further surgery
(d) Ringing in the ear (tinnitus), dizziness, or an altered sensation of taste may occur and may be temporary or permanent
(e) Partial loss of hearing or total loss of hearing may rarely occur and may be permanent
(f) Failure to improve hearing. An improvement in hearing may not be apparent despite the surgery being successful in eliminating the disease
(g) Discharging ear. Persistent pain and discharge may occur requiring 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: MASTOIDECTOMY


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- “Mastoidectomy” 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. Rarely, an infection may spread to adjacent structures including the brain causing meningitis or a brain abscess
(b) Facial nerve palsy. Injury to the nerve controlling the muscles of the face may result in paralysis of the face muscles. This may be temporary or may rarely be permanent
(c) Persistence or recurrence of the cholesteatoma might occur requiring further surgery
(d) Ringing in the ear (tinnitus), dizziness, or an altered sensation of taste may occur and may be temporary or permanent
(e) Partial loss of hearing or total loss of hearing may rarely occur and may be permanent
(f) Failure to improve hearing. An improvement in hearing may not be apparent despite the surgery being successful in eliminating the disease
(g) Discharging ear. Persistent pain and discharge may occur requiring 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……………………………………



Page 1 of 8 NDA / Physician/ Consent Mastoidectomy/ Ver.1/ Dec.2007
Patients Initials ______________

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