Assessment of middle ear function in patients with cleft palate - 23

III. POST-SURGICAL FOLLOW-UP. Number of months:…….

1. Administration 1.1a Medical record number:................ 1.1b OS code:…...

1.2 Full name: ........................................................1.3 Gender: Male □ Female □

1.4 Date of birth: ........................................................1.5 Age:…………...

1.6 Address: ................................ 1.7 Date of surgery: ……/……/……

12. Potential energy: Yes│No│Unknown: 


3.1 Hearing loss



3.2 Shake your head



3.3 Rubbing ears



3.4 Feeling of fullness in the ear



3.5 Tinnitus



3.6 Dizziness



3.7 Self-resonance



3.8 Earache



3.9 Vomiting




x.1 Right ear

x.2 Left ear

12.10.x Postoperative ear discharge

Yes, over 1 week

Yes, in 1 week

Other…….

Yes, over 1 week

Yes, in 1 week

Other …….

12.11.x Tube falls out of ear





12.12.x Detection Time

Month …

Month …

12.13 Runny nose

1 month/time 3 months/time

Not affected Other ….

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Assessment of middle ear function in patients with cleft palate - 23

13. Physical examination Yes│No│Unknown: 



x.1 Right ear

x.2 Left ear

13.1 OTK Status

Still, dry Still, blocked tube Still, discharge

Fall Slip in

Other …………

Still, dry Still, blocked tube Still, discharge

Fall Slip in

Other …………

13.2 Translation status

Opaque white Slimy glue

In dilute

No Blood

Opaque white Slimy glue

In dilute

No Blood


1


13.3 Eardrum

x.1 Right ear

x.2Left ear

13.3.1 Location

Concave Swelling

Normal

Concave Swelling

Normal

13.3.2 Color

White Yellow

Green Gray shade

White Yellow

Green Gray shade

13.3.3 Air bubbles, fluid level





13.3.4 Complete atrial collapse





13.3.4.2 Flatness

1 2 3 4

1 2 3 4

13.3.5 Shrink bags





13.3.5.2 Shrinkage of bag

1 2 3 4

1 2 3 4

13.3.6 Congestion





13.3.7 Transparency

Thick opaque

Transparent

Thick opaque

Transparent

13.3.8 Light cone





13.3.9 Calcification





13.3.10 Perforation





13.3.11 Mobile





13.4.1 Dome condition

Closed Open

13.4.2 Shape of the uvula

Clear shape Indistinct shape Split

13.5.1 VA

Inflammation 

Overgrowth 

Degree: ………..

13.5.2 Tonsils

Inflammation 

Overgrowth 

Degree: ………..

13.5.3 Sinus

Inflammation 

Other: …………………………..

14. Paraclinical

14.1 Tympanogram


Tympanogram

x.1 Right ear

x.2 Left ear

14.1.1 Volume of external auditory canal (ml)



14.1.2 Flux (ml)



14.1.3 Peak pressure (daPa)



14.1.4 Tympanogram



2

14.2 Faucet opening pressure daPa



x.1 Open

x.2 Close

14.2.1. x Yang



14.2.2.x Sound



14.3 Audiogram

14.3.1 Measurement method:

Measure TL Monotone at Threshold □ Measure TL at Free Field □



Ear P

TS (Hz)

500

1000

2000

4000

8000

Condition (dB)






DX (dB)







Ear T

TS (Hz)

500

1000

2000

4000

8000

Condition (dB)






DX (dB)







15. Diagnosis: …………………………………………………………………..


…………………………………………………………………………………….


…………………………………………………………………………………….


Hanoi, date … month … year ……

Medical Recorder


Khieu Huu Thanh


3

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