Endoscopic Maxillary Antrostomy Sample Report
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right maxillary sinus B-cell lymphoma.
POSTOPERATIVE DIAGNOSIS: Right maxillary sinus B-cell lymphoma.
OPERATION PERFORMED: Right maxillary antrostomy, endoscopic, with removal of tissue from the maxillary sinus.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal anesthesia.
ESTIMATED BLOOD LOSS: 50 mL.
SPECIMEN: Right maxillary sinus contents.
OPERATIVE FINDINGS: The patient had a large soft mass filling the right maxillary sinus.
COMPLICATIONS: None.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old gentleman with a history of right maxillary sinus mass. Biopsies in the office revealed a B-cell lymphoma. Plan today was to perform a maxillary antrostomy with removal of sinus mass prior to radiation therapy. The patient agreed to go ahead with the procedure. The risks and benefits were explained to the patient.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and was placed in a supine position on the operating room table. General face mask anesthesia was given until a deep plane of anesthesia was obtained. At that point, endotracheal tube was placed by the anesthesiology service without difficulty. Afrin-soaked nasal pledgets were placed in the nares bilaterally for anesthesia and decongestion. After allowing time for decongestion, approximately 3 mL of 1% lidocaine with 1:100,000 epinephrine was injected into the middle turbinate and uncinate in the right nasal cavity. The patient was then draped in routine fashion.
A 0-degree nasal endoscope was used to visualize the right nasal cavity. There was a bulge of tumor from the right maxillary sinus below and above the inferior turbinate on the right. The left nasal cavity had no lesions or masses noted. Surgery began with medialization of the inferior third of the middle turbinate in the right nasal cavity under endoscopic assistance with the 0-degree nasal endoscope. This allowed visualization of the uncinate.
An uncinectomy was performed in routine fashion with backbiting forceps and the microdebrider. This allowed visualization of the right maxillary sinus tumor. Biting forceps were then used to remove tissue specimen from the right maxillary sinus for permanent specimen. A straight microdebrider was then used to remove the medial portion of the mass from the maxillary sinus.
A 45-degree nasal endoscope was then used with a curved microdebrider to remove the more lateral and inferior aspects of the maxillary sinus mass. A curved curette and 45-degree upbiting forceps were then used to dissect tumor from the posterior and superior and lateral walls of the maxillary sinus. This tissue was removed and sent for permanent pathology.
The very inferior extent of the tumor could not be reached with the sinus instruments. Due to the fact the patient had tumor bulging into the oral cavity, we did not want to remove this portion of the tumor to prevent an oroantral fistula. The patient will receive postoperative radiation therapy for his lymphoma, and it should treat the remaining tumor.
Gelfoam pledgets were then placed in the right maxillary sinus for hemostasis. The wound was thoroughly irrigated with approximately 200 mL of normal saline. There was good hemostasis at the end of the procedure. The nasopharynx was then suctioned of blood. The procedure was then terminated. The patient was awoken from general anesthesia, extubated, and sent to postanesthesia care unit in stable condition.
