DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Bilateral chronic sinusitis.
2. Bilateral sinus polyps, maxillary sinus.
3. Left nasal polyposis.
4. Deviated nasal septum.
5. Nasal obstruction.
6. Turbinate hypertrophy.
7. Sinus headaches.
POSTOPERATIVE DIAGNOSES:
1. Bilateral chronic sinusitis.
2. Bilateral sinus polyps, maxillary sinus.
3. Bilateral nasal polyposis.
4. Deviated nasal septum.
5. Nasal obstruction.
6. Bilateral turbinate hypertrophy.
7. Sinus headaches.
8. Rhinitis, chronic.
OPERATION PERFORMED:
1. Bilateral anterior posterior ethmoidectomy, complex.
2. Bilateral maxillary antrostomy with biopsy, complex.
3. Bilateral frontal sinus recess exploration.
4. Bilateral nasal polypectomy.
5. Nasal septoplasty.
6. Bilateral intramural treatment, inferior turbinate (right x2 and left x1).
7. Endoscopic sinus surgery with CT assistance.
SURGEON: John Doe, MD
ANESTHESIA: General and local, 7 mL of 1% Xylocaine with 1:100,000 epinephrine and 3 mL of 1% Xylocaine 1:1 with saline.
SPECIMENS:
1. Product of left endoscopic sinus surgery and nasal polypectomy.
2. Biopsy, left maxillary sinus.
3. Left nasal polyp biopsy.
4. Product of right endoscopic sinus surgery and nasal polypectomy.
5. Biopsy, right maxillary sinus.
6. Right nasal polyp biopsy.
7. Portion of nasoseptal cartilage and bone.
ESTIMATED BLOOD LOSS: Approximately 125 mL.
COMPLICATIONS: None.
OPERATIVE FINDING: Significantly greater than expected nasal polyposis on the left and hidden nasal polyposis on the right, particularly in the middle meatal region. Lateralization of right maxillary sinus wall, maxillary sinus cyst bilaterally, significantly thickened mucosa and inflammatory changes with polyps within the ethmoid sinuses bilaterally. Deviated nasal septum, high on the right, lateralizing the middle turbinate on the right and spur formation on the left with lateral nasal wall contact. Hypertrophic inferior turbinates bilaterally. Significant thickened mucosa and changes consistent with chronic inflammation. No exophytic mass identified that would be consistent with inverting papilloma or malignancy as best can be determined grossly and intraoperatively.
DESCRIPTION OF OPERATION: After the patient was identified, she was taken to the operating room and placed on the operating table in a flat supine position. A member of the anesthesiology service was present for monitoring, as well as administration of anesthesia. The patient received IV induction and gas inhalation maintenance via an oral endotracheal tube. Once the patient was adequately anesthetized, she was placed in a semi-seated reverse Trendelenburg position and hypotensive anesthesia was requested. The anesthesiology service had to provide additional attention to the patient because of labile blood pressure issues. As a consequence of elevated blood pressure, we were particularly cautious in administration of local with vasoconstrictors, and during the course of infiltration, we did not encounter tachycardia in conjunction with elevated blood pressure. Neo-Synephrine-impregnated cottonoids were placed in the nasal cavities bilaterally. Transoral and trans greater foramen infiltration of local with epinephrine was completed bilaterally and thereby sphenopalatine block was performed bilaterally.
Local was infiltrated along the nasal septum using hydraulic dissection technique, anterior aspect of the inferior turbinates and typical lateral nasal wall infiltration for sinus surgery, in particular along the uncinate process anterior and posterior as well as the face of the middle turbinates bilaterally. This was allowed to take effect with Neo-Synephrine placed. Betadine prep was completed. VTI apparatus was applied. The patient was then sterilely prepped and draped in the routine fashion. The VTI straight suction probe was calibrated and anatomically confirmed; it was used throughout the course of the procedure and was invaluable on completing the procedure, particularly in the region of the frontal sinus recess exploration and maxillary sinus biopsies.
In addition, because of the significant amount of polyposis, the VTI apparatus also provided additional information to verify anatomical landmarks. CT assistance was used throughout the course of the procedure. A 0-degree and 70-degree endoscope with Xenon lighting was employed with camera and monitor visualization. Photo documentation was taken throughout the course of the procedure and has been charted. The left nasal cavity was approached first as routine; however, the deviated septum prohibited access to lateral nasal wall on the right and would prohibit initiation of the sinus surgery on the right side without performing the nasal septoplasty first. A Freer was employed, the middle turbinate was medialized. Biopsies of nasal polyps was taken and sent separately. The uncinate process was scored using a sickle knife along the anterior and anteroinferior aspect. The uncinectomy was performed using a straight Blakesley and sinus shaver.
Prior to the uncinectomy, the natural ostia to the maxillary sinus was identified at the junction of the superior two-third and lower one-third of the uncinate process. This was completed using a sinus probe. Before the maxillary antrostomy, however, could be performed, the bulla ethmoidalis required it to be taken down prior to acces to the lateral nasal wall for the maxillary antrostomy. A straight Blakesley was employed and the bulla ethmoidalis was taken down. Maxillary antrostomy was created on the left using a straight-biting Blakesley and straight-through cutback biter, as well as side-biting Stammberger.
A widely patent maxillary antrostomy was created without injury to nasal lacrimal duct apparatus. Visualization within the maxillary sinus was completed. Using a 70-degree scope, polyp was identified. Biopsy of this was taken. The polyp was ruptured as would be expected of what turned out to be a cystic structure. Smaller polyps were identified and appeared to be benign in nature. The maxillary antrostomy was made difficult due to the inflammation and the parameter of the ostia. The prominent uncinate process showed encroachment by the anterior ethmoid air cells. In addition, there is mild concavity of the lateral nasal wall. Following this, anterior/posterior ethmoidectomy was completed using straight-biting Blakesley as well as biting Blakesley with dissection inferiorly being carried out until the anterior face of the sphenoid sinus was reached and then superiorly to the base of the skull and followed anteriorly. The medial wall of the orbit was left intact. There was no encroachment into the intracranial space and there was no creation of CSF leak as identifiable with the endoscope intraoperatively.
Sinus shaver was used to take down any fragments of bone and tissue left. There was significant amount of thickened tissue and areas of hardened bone through the ethmoid sinuses and also significant polypoid changes within the ethmoid air cells made the ethmoidectomy more complex. A 70-degree endoscope was employed. Dissection in the frontal sinus recess was completed. Frontal sinus probe was employed and soft tissue was taken down, visualization of the frontal sinus recess and patency was verified. Small polyps near the anterior attachment of middle turbinate were also taken down until all nasal polyps were removed. Sinus shaver was employed to remove residual polyps within the nasal cavity and operative sinus field. It should be noted that the middle turbinate appeared to be quite voluminous with the presence of an air pocket. The middle turbinate was compressed as part of this medialization and what appeared to be a concha bullosa was therefore reduced. There was no egress of purulent debris as a consequence of the flattening of the middle turbinate. Neo-Synephrine-impregnated cottonoids were placed into the surgical field. We were not able to approach the right endoscopic sinus surgery and, therefore, the nasal septoplasty was then undertaken.
A modified Killian incision was made on the left with 15 blade scalpel. The mucoperichondrial and periosteum were elevated using a Freer elevator, Freer knife, as well as a caudal elevator. A swing-door technique was employed, and the contralateral mucoperichondrial and periosteum were elevated. The spurious formation on the left side was identified, it was the adjoining cartilage, and the deviated portion of septum was taken down. A vertical incision was employed to further medialize the deviated septum to the right. An adequate dorsal as well as caudal strut was left in place. The mucoperichondrium and periosteum was allowed to redrape. This verified medialization of nasal septum and reduction of the deviation, lateral nasal wall contact on the left, and allowed for access to lateral nasal wall on the right. The modified Killian incision was closed using chromic sutures in single interrupted fashion, and a running horizontal plain gut suture was employed to reapproximate the mucoperichondrium and periosteum along the length of the dissection. At the conclusion, the septum took on a more midline position, and as noted above, reduction of the deviated septum bilaterally was improved along for access on the right and taking down the portion of septum with lateral nasal wall contact on the left. The Neo-Synephrine-impregnated cottonoid was removed from the surgical field on the left; although, septoplasty was being performed and new cottonoid was placed once the septoplasty was completed.
The right endoscopic sinus surgery was then completed similarly as was completed on the left; however, the lateral nasal wall was even more concave on the right than the left. A pocket was also delineated in the right middle turbinate. However, compression revealed an egress of purulent debris that was aspirated. The right endoscopic sinus surgery was otherwise similarly completed with similar findings and without complications such as encroachment into the orbital space, a creation of CSF leak, or injury to the nasal lacrimal duct apparatus. We had similar complexity in completing the anterior-posterior ethmoidectomy on the right as on the left and even more difficulty with the maxillary antrostomy on the right due the concavity of the lateral nasal wall, and biopsy was also performed of a polyploid structure on the right. There were smaller polypoid changes on the right maxillary sinus as well, all of which appeared to be benign. The largest polyp was biopsied. We found a similar degree of polyps within the anterior and posterior ethmoids on the right as we did on the left.
Neo-Synephrine-impregnated cottonoids placed on the right and left to take effect. Local was infiltrated in the inferior turbinates bilaterally in preparation for coblation treatment of the inferior turbinates.
Kennedy splints impregnated with Bactroban re-placed in the middle meatal regions bilaterally. Neiman splints impregnated with Bactroban were placed bilaterally. The Kennedy splints were affixed to the Neiman splints, and the Neiman splints were affixed to each other using a transseptal 4-0 nylon suture. A coblation treatment of left inferior turbinate was completed in a single pass. Using a coblation setting of 6 in the typical fashion and along the medial inferior aspects of the fleshy portion of the inferior turbinate, the right inferior turbinate was treated twice, one more posteriorly than the other. All treatments were carried out with approximately 12 seconds, treatment with a setting of 6.
During the course of the procedure, positive bulbar pressure did not reveal any herniation or periorbital fat bilaterally. An NG tube was passed transorally. The stomach and esophagus was suctioned. All blood clots and debris was also removed from the nasopharynx, oropharynx, and hypopharynx. The table was flattened. The patient was awakened and extubated and then taken to recovery room in stable condition. Specimens were sent to pathology for routine evaluation. Instrumentation for the endoscopic sinus surgery included straight and up-biting Blakesley, backbiters, side-biting Stammberger, straight through cut, up-biting through cut, and sinus shaver.
