DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Severe epistaxis.
POSTOPERATIVE DIAGNOSES:
1. Epistaxis.
2. Intraoperative anterior ethmoid CSF leak.
OPERATIONS PERFORMED:
1. Endoscopic anterior ethmoid artery ligation.
2. Repair of anterior ethmoid CSF leak endoscopically.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal anesthesia.
ESTIMATED BLOOD LOSS: Approximately 50 mL.
SPECIMENS: None.
OPERATIVE FINDINGS: The patient had bleeding from the anterior ethmoids consistent with bleeding from the anterior ethmoid artery.
DESCRIPTION OF OPERATION: The patient came to the operating room and was placed in the supine position on the operating table. General face mask anesthesia was given until a deep plane of anesthesia was obtained. At that point, endotracheal tube was placed per the anesthesiology service without difficulty. The patient’s packing was removed, and Afrin-soaked nasal pledgets were placed into the nares bilaterally for decongestion. At that point, approximately 6 mL of 1% lidocaine with 1:100,000 epinephrine was injected between the lamina papyracea and the orbit and superficial skin for anesthesia and decongestion prior to an external approach to the right anterior ethmoidal artery and possible left anterior ethmoidal artery.
A 15 blade was used through a Lynch incision down to the nasal bone. Caudal elevator was then used to elevate the periorbit away from the lamina papyracea. This was carried posteriorly to the goal of finding the anterior ethmoid artery. There were a couple of rents made within the periorbita, and periorbital fat was blocking the view of the anterior ethmoid arteries, so the decision was made to go endoscopically to locate the right anterior ethmoidal artery.
A 4 mm endoscope was used to visualize the middle turbinate and ethmoid bulla. The middle turbinate was medialized at the lower third to prevent cracks in the cribriform plate. An ethmoid bulla was then resected. A large maxillary antrostomy was performed. The lamina papyracea was identified up towards the skull base. The nasal frontal recess was identified, and the anterior ethmoidal artery was identified. The lamina papyracea was dissected away from the anterior ethmoid artery with caudal elevator. Suction was used to gently lateralize the periorbita to gain access to the entry of the anterior ethmoid artery into the skull base roof. Two hemoclips were then placed onto the anterior ethmoid artery, and there was immediate decrease in the patient’s epistaxis.
Suction Bovie cautery was then used to cauterize the distal portion of the anterior ethmoid artery. At that point, a defect in the cribriform plate tore secondary to use of the suction Bovie cautery. The defect was not identified prior to the release of CSF fluid. The defect measured approximately 4 to 5 mm in total length. At that point, caudal elevator was then used to identify the bone surrounding the bony defect. The dura was completely intact in the rest of the bony defect. After removal of surrounding mucosa around the bony defect, a piece of thin AlloDerm was placed over the defect. DuraSeal was then placed over the AlloDerm to provide a sealant of the AlloDerm to the underlying tissues. Surgicel was then placed over the DuraSeal, and Gelfoam was placed for a gentle packing over the entire CSF leak repair. There was no further evidence of CSF leak.
The entire nasopharynx and nasal cavities were suctioned free of old blood. There was no new epistaxis. At that point, the surgery was completed. The patient was awoken from general anesthesia, extubated, and sent to the postanesthesia care unit in stable condition. Prior to leaving the operating room, the patient’s orbits were palpated bilaterally and were soft. There was no evidence of retro-orbital hematoma. The surgery was completed.
