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Sphenoidotomy, Ethmoidectomy, Polypectomy ENT Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Chronic sinusitis.
2.  Bilateral nasal polyposis.

POSTOPERATIVE DIAGNOSES:
1.  Bilateral nasal polyposis.
2.  Chronic sinusitis.
3.  Sphenoid sinus mucocele.

OPERATIONS PERFORMED:
1.  Bilateral sphenoidotomy with removal of tissue.
2.  Bilateral frontal sinus exploration.
3.  Bilateral total ethmoidectomies.
4.  Polypectomy.
5.  Bilateral maxillary antrostomy with removal of tissue.
6.  Stereotactic computer-assisted surgery.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA: General endotracheal anesthesia.

ESTIMATED BLOOD LOSS: 200 mL.

COMPLICATIONS:  None.

INDICATIONS:  The patient is a (XX)-year-old male who woke up 4 weeks ago with headache and double vision. CT scan revealed pansinusitis with expansion of the sphenoid sinus and erosion of the lateral wall of the sphenoid sinus. The patient also had severe nasal polyposis bilaterally.

DESCRIPTION OF OPERATION:  The patient was taken to the operating room and was placed in the supine position on the operating room table. General facemask anesthesia was given until adequate anesthesia was achieved. At that point, an endotracheal tube was placed by the anesthesiology service without difficulty. The table was then turned 180 degrees. Approximately, 8 mL of 1% lidocaine with 1:100,000 epinephrine was injected into the uncinates, middle turbinate, septum and sphenoid bilaterally. Cocaine-soaked nasal pledgets 5% were placed in the nares bilaterally. At that point, the patient's images were loaded onto the LandmarX image guidance system. The head device was then placed. Point-to-point registration was then obtained with an accuracy of 1.8 mm.

The patient was then prepped and draped in the routine fashion. Cocaine-soaked nasal pledgets were removed. Surgery began on the right nasal cavity using a 0-degree nasal endoscope. The 0-degree Straightshot microdebrider was then used to remove polyps between the middle turbinate and septum. This was taken all the way back to the anterior face of the sphenoid. Superiorly, the dissection was carried up to the cribriform plate. After removal of these polyps, attention was turned towards the middle meatus. The middle turbinate was then partially resected and medialized. Polyps were removed from the anterior ethmoid cells including the ethmoid bulla. The uncinate was identified and outfractured with backbiting forceps. Straightshot microdebrider was used to remove the rest of the uncinate. A large maxillary antrostomy was then performed with a curved microdebrider. A large antrostomy was performed to remover the polypoid tissue from the maxillary sinus. Purulent material was also seen draining from the maxillary sinus. Straightshot microdebrider was then used to create a window through the basal lamella of the middle turbinate into the posterior ethmoids. Polypoid tissue again was removed from the posterior ethmoids.

Attention was then turned towards the sphenoid sinus on the right. Natural ostium was identified and enlarged in medial and inferior direction with Straightshot microdebrider. Concretions and purulent drainage were seen from the right sphenoid sinus. The sphenoidotomy was then enlarged laterally and superiorly with Straightshot microdebrider. Inflamed mucosa and mucocele was identified and ruptured, removed with Takahashi forceps. Attention was then turned towards the left nasal cavity. A 0 endoscope was used to identify structures in the left nasal cavity. The Straightshot microdebrider was then used to remove polyps between the middle turbinate and septum. This was carried posteriorly back to the anterior face of the sphenoid and superiorly to the cribriform plate. Attention was then turned towards the middle meatus. Again, a large amount of nasal polyps were in the anterior ethmoids and removed with Straightshot microdebrider.

A partial middle turbinectomy was then performed for access. A large antrostomy was then performed after removal of the uncinates with backbiting forceps. Antrostomy was widened with curved microdebrider. Polypoid tissue from the left maxillary sinus was then removed with the curved microdebrider. A small window was made in the basal lamella of the middle turbinate to gain access into the posterior ethmoids. Again, polypoid tissue was removed. A large sphenoidotomy was then performed on the left side, first in the medial and inferior direction. Polypoid tissue was removed from the sphenoid sinus with microdebrider and Takahashi forceps. The inner sinus septum and the posterior septum were then taken down with through-cutting instrumentation and rongeurs. This allowed communication between the right and left sphenoid sinuses. Curved suction was then used to remove concretions from the base of the sphenoid sinus.

The sphenoid sinus was then thoroughly irrigated. After entry into the sphenoid sinus, purulent drainage was seen. Access to the sphenoid sinus on both sides was confirmed with image guidance to avoid injury to the skull base. Image guidance was also used to identify the carotid artery and the optic nerves bilaterally. This aided in complete removal of the disease within the sphenoid sinus. Approximately 10 mL of Surgiflo was then placed in the sphenoid sinus, anterior-posterior ethmoids and maxillary sinuses for hemostatic control. After application of Surgiflo for 5 minutes, the nasopharynx was inspected and there was no further evidence of bleeding. At that point, the procedure was terminated. The patient was then awoken from general anesthesia, extubated and sent to the postanesthesia care unit in stable condition.

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