DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right chronic sphenoid sinusitis.
POSTOPERATIVE DIAGNOSIS: Right chronic sphenoid sinusitis.
OPERATION PERFORMED: Revision, right sphenoidotomy.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal anesthesia.
ESTIMATED BLOOD LOSS: Less than 20 mL.
SPECIMENS: None.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old female with a history of chronic vertex headaches. She had a CT scan performed, which showed a right chronic sphenoid sinusitis. She had a right sphenoidotomy performed by an outside physician; however, she continued to complain of headaches. A repeat CT showed persistent blockage of the right sphenoid sinus. The decision was made to take the patient back to the operating room for revision right sphenoidotomy. The risks and benefits of the procedure were explained to the patient, and she agreed to proceed.
OPERATIVE FINDINGS: The patient had a small sphenoid ostium with a minor amount of debris in the floor of the right sphenoid sinus.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and 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, an endotracheal tube was placed by the anesthesiology service without difficulty. Then the table was turned. Afrin-soaked nasal pledgets were placed in the nose for decongestion. The Afrin-soaked pledgets were then removed, and approximately 5 mL of 1% lidocaine with 1:100,000 epinephrine was injected bilaterally into the middle turbinates, the septum and the posterior, the anterior sphenoid face. The Afrin-soaked nasal pledgets were placed back into the nasal cavities bilaterally.
At that point, the patient was prepped and draped in a routine fashion. The Afrin-soaked pledgets were removed from the right nasal cavity. A 0-degree nasal endoscope was used to visualize the right nasal cavity. There was no evidence of purulent drainage in the right nasal cavity. A Cottle elevator was used to lateralize the middle turbinate. The superior turbinate was visualized and lateralized with the Cottle elevator. A small pseudo-ostium was identified in the anterior-inferior medial aspect of the sphenoid face. At that point, a 4 mm Straight Shot microdebrider was used to enlarge the opening of the sphenoid ostium in the medial and inferior direction.
At that point, a Kerrison punch rongeur was used to further enlarge the sphenoid ostium superiorly to the planum sphenoidale laterally to visualize the opticocarotid recess and inferiorly to the floor of the sphenoid sinus. Bleeding from the posterior nasal artery was controlled with suction Bovie cautery. Visualization of the sphenoid sinus included the sella, the carotid artery, and the optic nerve and the opticocarotid recess, the sellar, the planum sphenoidale, and the floor of the sphenoid. Small amount of debris was irrigated from the sphenoid sinus.
At that point, a 45-degree endoscope was used to evaluate the entire extent of the right sphenoid sinus. There was no overt evidence of debris or mucopurulence. Again, the sphenoid sinus was irrigated out with normal saline. Approximately 3 mL of FloSeal was placed at the opening of the right sphenoid sinus and the posterior ethmoids for hemostasis and healing. A small synechia was noticed between the inferior turbinate and the septum, and this was transected with a Cottle elevator. A small piece of Merocel was placed between the inferior turbinate and the septum to prevent further synechia. The nasopharynx was then suctioned of blood products. The surgery was then completed. There were no complications during the procedure.
