DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Chronic sinusitis.
POSTOPERATIVE DIAGNOSIS: Chronic sinusitis.
OPERATIONS PERFORMED:
1. Bilateral endoscopic ethmoidectomy.
2. Bilateral endoscopic maxillary antrostomy with removal of maxillary sinus contents, right.
3. Right endoscopic frontal sinusotomy.
4. Right endoscopic sphenoidotomy.
SURGEON: John Doe, MD
ANESTHESIA: General.
ANESTHESIOLOGIST: Jane Doe, MD
ESTIMATED BLOOD LOSS: 200 mL.
IV FLUIDS: 900 mL of crystalloid.
INDICATIONS FOR OPERATION: The patient is a pleasant (XX)-year-old female with history of chronic sinusitis. She has had persistent disease despite antibiotics, steroids and topical decongestants. A CT scan was obtained recently and found to be significant for complete opacification of the right maxillary ethmoid and frontal sinuses with mucosal thickening in the right sphenoid sinus. Although the left sinuses appeared clear, the patient has had an upper respiratory tract infection for the past week and asked to have the left sinuses addressed and cleared out if necessary.
OPERATIVE FINDINGS:
1. Greenish-blackish pasty material within the right maxillary sinus with copious purulent drainage.
2. Purulent drainage involving the right ethmoid and frontal sinuses as well. The sphenoid sinus had mucosal thickening. All sinuses had evidence of chronic inflammatory disease. In regards to the left sinus cavity, the anterior ethmoid sinus had evidence of acute mucosal thickening with obstruction of the ostiomeatal complex.
DESCRIPTION OF OPERATION: The patient was orally intubated and placed under general anesthesia. Clindamycin 600 mg and Decadron 10 mg were given intravenously. The nasal and septal mucosa injected with 1% lidocaine with 1:100,000 epinephrine and cottonoids soaked in it were inserted into the nasal cavities bilaterally. The patient was then prepped and draped using sterile technique. The right side was addressed first. The caudal elevator was used to medialize the right middle turbinate. The uncinate bone and mucosa were then incised using the caudal elevator. The uncinate bones and mucosa were removed using the handheld microdebrider. The right maxillary sinus was emanating purulent drainage after removal of the uncinate process. The handheld microdebrider was used to remove the mucosal disease from the ostiomeatal complex. The maxillary sinus was then cleared using the curved suction tip and maxillary sinus forceps. As stated above, there was a large amount of greenish-blackish pasty material within the maxillary sinus and copious purulent drainage. A culture was taken and sent for cultures and sensitivities, including anaerobic, aerobic and fungal cultures.
The ethmoid sinus was addressed next. The handheld microdebrider was used to remove the diseased tissues from the ethmoid sinus. There was a small area of dehiscence of the right lamina papyracea, measuring approximately 2 to 3 mm. On reinspection of the preoperative scan, this dehiscence was also noted. Care was taken to avoid any injury to the orbital fat and there was none. The right sinus cavities were then packed with cottonoids soaked in 1:100,000 epinephrine and the left side was addressed.
The caudal elevator was used again to medialize the middle turbinate. The uncinate process bone and mucosa were then removed using the handheld microdebrider. As stated previously, due to her recent upper respiratory tract infection, there was obstruction of the ostiomeatal complex on the left. The ethmoidectomy was performed using a handheld microdebrider. There was no evidence of bone dehiscence of the lamina papyracea on the left side. An anterior ethmoidectomy was only required on the left. The frontal recess appeared fairly patent; this was left untouched as well on the left hand side. The left maxillary sinus was then cannulated using the curved suction tip. A small amount of purulent drainage was suctioned clear from the left maxillary sinus. The maxillary sinus cavities on the left were then irrigated with copious normal saline mixed with Betadine and hydrogen peroxide.
The right frontal sinus was addressed next. The frontal sinus seeker was used to identify the area of the frontal recess as this was completely blocked with polyps. The polyps were removed using the giraffe and frontal sinus forceps. Upon entry into the right frontal sinus, there was a large amount of purulent drainage also noted. The frontal sinusotomy was enlarged using the frontal sinus punch. The right frontal sinus was then irrigated with the Betadine, saline and peroxide solution. The right sphenoid sinus was addressed lastly. The inferior aspect of the superior turbinate was resected using the handheld microdebrider. The sphenoid sinus was then entered using the Frazier suction tip. The sphenoidotomy was enlarged using the handheld microdebrider. The sinus cavities were reirrigated with Betadine, saline and peroxide mixture. Stammberger foam mixed with Kenalog was then injected into the sinus cavities bilaterally. Merocel sponges were then cut to size and placed as middle turbinate spacers to prevent synechia and lateralization in the early postoperative period. The patient was then suctioned free of blood and secretions prior to extubation. The patient was successfully extubated and transferred to the recovery room in stable condition.
