Month Date, Year
John Doe, MD
(Address)
Dear John Doe:
I recently saw your patient. As you know, she is a (XX)-year-old who is status post tonsil-adenoid removal back in 2010 by another surgeon and states that she has continued to have obstructive sleep apnea, is currently on CPAP. The patient is presently being treated with palate expanders by Dr. Jane Doe who noted on her evaluation a deviation of her nasal septum. The patient denies any significant nasal airway symptoms, including obstruction, rhinorrhea or significant sinus infection.
On examination, both ear canals and drums are completely normal. She has got a palate expander present. Tonsils are absent from previous surgery. The posterior pharyngeal airway looks open. Nasal endoscopy demonstrates a very slight deviated septum towards the right side. The airways, however, are patent. Adenoids are absent from previous surgery. We did not see any other sinus pathology, nasal polyps or signs of infection. No cervical nodes or masses are present in the neck.
We had a lengthy discussion with her mom. At this point, we do not think her septum is likely contributing to her snoring and/or sleep apnea situation and correction of this is unlikely to result in any improvement. In addition, at the age of (XX), we would be reluctant to disturb any facial growth centers with elective nasal surgery. We advised them to continue using the CPAP and to follow up with Dr. Jane Doe for further noninvasive treatments. We do not think any ENT intervention is warranted at this point. Thank you again for the consultation.
Sincerely,
ENT Letter Sample Report #2
Month Date, Year
John Doe, MD
(Address)
Dear John Doe:
The patient recently returned to the clinic after an absence. As you recall, she has had multiple sinus surgeries for nasal polyps. Lately, she has been having increased nasal congestion, postnasal drip, anosmia and exacerbation of her asthma.
On examination, she was found to have regrowth of polyps on both sides causing obstruction of the sinuses as well as the nasal cavities.
At this point, we think she is ready for a revision surgery. We are planning this for later next month. We will be utilizing Propel steroid-eluting implants, which usually help reduce the recurrence rate of these polyps as well as postoperative steroid irrigation. Obviously, she will continue to do her immunotherapy with Dr. Jane Doe. We are asking her to see you preoperatively for preop clearance given her history of asthma and hypertension, and we will keep you informed of her progress.
Sincerely,
ENT Letter Sample Report #3
Month Date, Year
John Doe, MD
(Address)
Dear John Doe:
The patient was recently seen for one-week history of acute onset of dizziness. He is feeling much better now but still gets some momentary lapses of dizziness whenever he moves quickly, but he is overall remaining active and doing his full range of activities. He does have occasional ringing in the ears but no definite hearing loss in either ear or any other otologic symptoms.
On examination, both ear canals and drums are completely normal. There is no evidence of infection or fluid. Cranial nerve testing is intact. There is no nystagmus. His head impulse testing as well as his head shake testing demonstrated no provokable nystagmus, which indicates that if this was a viral labyrinthitis, it is mostly compensated by now. The remainder of his exam was unremarkable.
Audiometric testing was also normal.
At this point, it could be that the patient suffered a viral labyrinthitis, which is already getting better. We have advised him to remain active, drink plenty of fluids, and if he is not completely better in the next two weeks, to give us a call back where we would consider further testing. We expect he will do well from here on in.
Sincerely,
