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Endoscopic Sphenoidotomies Partial Ethmoidectomy Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Bilateral sphenoid and posterior ethmoid sinusitis, acute.
2.  Meningitis.

POSTOPERATIVE DIAGNOSES:
1.  Bilateral sphenoid and posterior ethmoid sinusitis, acute.
2.  Meningitis.

OPERATION PERFORMED:
Image-guided bilateral endoscopic sphenoidotomies with right partial posterior ethmoidectomy.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal anesthesia.

ESTIMATED BLOOD LOSS:  Less than 25 mL.

DESCRIPTION OF PROCEDURE:  The patient was brought into the operating room and placed on the OR table in the supine position. After demonstration of adequate endotracheal anesthesia, the table was turned 90 degrees. The nose was prepped with 3 Afrin-soaked pledgets bilaterally. Two mL of 1% lidocaine with 1:100,000 epinephrine was infiltrated in both the right and left greater palatine foramen to assist with hemostasis. Next, the patient was prepped and draped sterilely. Registration and calibration processes were performed followed by verification of the Stealth image-guided system. This was utilized for preoperative planning and intraoperative navigation. We began on the left side. The middle turbinate was placed in the lateral position using Freer. The posterior wall was then infiltrated locally with 0.5 mL of 1% lidocaine with 1:100,000 epinephrine. This was then repeated on the right. The superior turbinate was lateralized. Natural ostium in the left sphenoid sinuses was instrumented with the Freer and widened with 1 and 2 mm Kerrison rongeurs. The sphenoethmoid recess was fairly tight prior to this exploration. Mucoid material was evacuated from the left sphenoid sinus. There was polypoid edema of the walls. Kerrison was used to widely open the sinus to allow observation of the superior, medial and lateral walls. No obvious bony dehiscence was evident. Next, attention was turned to the right side. A portion of the superior turbinate was removed and opening was made into the posterior ethmoid area. Evacuation of thick yellow mucoid material was performed as well as culture with a swab. Lukens trap was placed on suction, which was attached in the image-guided system as the sphenoethmoidal recess was explored. The natural ostium was then opened. A 2 mm Kerrison rongeur was then utilized to open the ostia further inferiorly and medially. Careful opening was performed laterally into a posterior ethmoid air cell. All the purulent material was evacuated. There was some thick particulate yellow material, which was sent separately to cytology, obtained from the right sphenoid sinus. Again, the sphenoid walls were without obvious bony defect. Both right and left side was sequentially observed during Valsalva procedure per Anesthesia. No evidence of spinal fluid leak was identified. The sphenoid sinuses were then copiously irrigated. Liquid MeroGel was then inserted into the right and left sphenoid bony recess to assist with healing. The patient was turned over to the care of the anesthesia team for extubation and returned to the recovery room, having tolerated the procedure well.