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Endoscopic Maxillary Antrostomy / Ethmoidectomy / Frontal Sinusotomy / Sphenoidotomy ENT Medical Transcription Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Chronic sinusitis, nasal polyposis.

POSTOPERATIVE DIAGNOSIS: Chronic sinusitis, nasal polyposis.

OPERATIONS PERFORMED:  Bilateral endoscopic maxillary antrostomies, bilateral endoscopic complete ethmoidectomies, bilateral endoscopic frontal sinusotomy, bilateral endoscopic sphenoidotomies and fluoroscopy.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal anesthesia.

ESTIMATED BLOOD LOSS:  Approximately 40 mL.

FLUIDS:  Crystalloid.

COMPLICATIONS:  None.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and placed on the operating room table in the supine position. General endotracheal anesthesia was then induced. The 4% cocaine-soaked cottonoid pledgets were then placed in the patient's nasal cavity for decongestion. The patient was then draped. After 5 minutes, the cottonoid pledgets were removed. The left nasal cavity was addressed first. A 0 degree nasal endoscope was used to visualize the left nasal cavity as well as the sinuses. Xylocaine 1% with epinephrine was infiltrated into the base of the middle turbinate anteriorly and posteriorly for further decongestion as well as hemostasis. A Freer elevator was used to medialize the middle turbinate. A Freer elevator was then used to take down the uncinate process. The uncinate process was then excised using Blakesley forceps. The maxillary sinus ostia were visualized and it was enlarged using the microdebrider. There was polypoid tissue in the maxillary antrum and this was removed using the microdebrider. The ostia were opened widely. The bulla ethmoidalis was then taken down using the microdebrider. Anterior and posterior ethmoid air cells were then opened completely using the microdebrider. The patient had polypoid changes in the ethmoid mucosa.

The area of the frontal recess was then cleaned out using the microdebrider. The frontal recess was then visualized with 0 degree nasal endoscope and the frontal sinus catheter guide was placed in the area of the frontal recess. A wire guide was then threaded up into the frontal sinus and the position of the wire guide was confirmed using fluoroscopy. A 7 mm balloon was then passed over the wire guide up into the frontal recess and frontal sinus ostia. This was inflated to 8 atmospheres. The position of the balloon was confirmed using fluoroscopy. The balloon was then deflated and the wire guide, the catheter guide, as well as the balloon were removed. Next, the sphenoid recess was visualized using the 0 degree nasal endoscope. The sphenoid ostia were identified and this was enlarged further using microdebrider. The sphenoid sinus ostia were widely opened. There was purulent material in the sphenoid sinus, which was released. The nasal endoscope was then removed from the left nasal cavity.

Next, the right nasal cavity and sinuses were addressed. Again, the right sinuses and nasal cavity were visualized using a 0 degree nasal endoscope. Xylocaine 1% with epinephrine was infiltrated into the base of the middle turbinate anteriorly and posteriorly for hemostasis as well as decongestion. A Freer elevator was used to medialize the middle turbinate. There was a large polyp obstructing the maxillary ostia on the right side and this was taken down using the microdebrider. An uncinectomy was then performed using the Freer elevator. The uncinate process was then removed using Blakesley forceps. The maxillary sinus ostia were opened widely using the microdebrider. There was thick mucoid material in the maxillary sinuses, which was suctioned out. The bulla ethmoidalis was then taken down using the microdebrider. The anterior and posterior ethmoid air cells were then opened widely using the microdebrider. There were polypoid changes to the ethmoid sinus mucosa. This was taken down using the microdebrider.

The frontal recess was then visualized using a 0 degree nasal endoscope and cleansed using the microdebrider. A sinus catheter guide was then placed up into the frontal recess. A wire guide was then threaded through the sinus catheter guide up into the frontal sinus. The position of the wire guide was confirmed using fluoroscopy. A 7 mm balloon was then guided over wire guide up into the frontal sinus ostia. The balloon was then inflated to 8 atmospheres. The position of the balloon was confirmed using fluoroscopy. The balloon was then deflated. The balloon, the wire guide, as well as the sinus catheter guides were then removed. The sphenoid ostia were then visualized using a 0 degree endoscope. A sinus catheter guide was then placed in the area of the sphenoid ostia. A wire guide was then threaded into the sphenoid sinus and the position was confirmed using fluoroscopy. A 7 mm balloon was then guided over the wire guide and into the sphenoid ostia. The balloon was then inflated to 8 atmospheres. The position of the balloon was confirmed using fluoroscopy. The balloon was then deflated. The wire guide, the sinus catheter guide, as well as the balloon were then all removed. Stammberger sinus gel was then placed in the middle meatus bilaterally for postoperative hemostasis. The patient was then awakened from anesthesia and taken to the recovery room in stable condition.