DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Chronic rhinosinusitis.
2. Deviated nasal septum.
3. Turbinate hypertrophy.
4. Bilateral concha bullosa.
POSTOPERATIVE DIAGNOSES:
1. Chronic rhinosinusitis.
2. Deviated nasal septum.
3. Turbinate hypertrophy.
4. Bilateral concha bullosa.
OPERATION PERFORMED:
1. Bilateral anterior-posterior ethmoidectomy, complex, right side.
2. Bilateral maxillary antrostomy.
3. Bilateral endoscopic sinus surgery.
4. Nasal septoplasty, complex.
5. Columellar reconstruction.
6. Submucosal resection, bilateral anterior turbinates.
7. Fractured bilateral anterior turbinates.
8. Partial bilateral middle turbinectomy and turbinopexy.
SURGEON: John Doe, MD
SEDATION: General and local, 8 mL 1% Xylocaine with 1:100,000 epinephrine.
ESTIMATED BLOOD LOSS: Approximately 150 mL.
COMPLICATIONS: None.
DESCRIPTION OF OPERATION: After the patient was identified, he was taken to the operating room and placed on the operating room table in flat, supine position. The patient received IV induction and gas inhalation maintenance via an oral endotracheal tube. The patient was placed in a semi-seated reverse Trendelenburg position in a Richards headrest and gently turned to the right. Neo-Synephrine-impregnated cottonoids were placed in the nasal cavity. A transoral sphenopalatine block was completed to the greater palatine foramen with instillation of 1.5 mL of local. Additionally, the septum was infiltrated using a hydraulic dissection technique bilaterally, as well as routine lateral nasal wall and sphenopalatine foramen infiltration on the lateral nasal wall bilaterally. Betadine prep was completed. VTI head apparatus was applied.
The patient was sterilely prepped and draped in the routine fashion. The VTI CT-assistance equipment was calibrated and anatomically confirmed and used throughout the case on an as-needed basis, but particularly to address the posterior ethmoid cells and towards the recess of the frontal sinuses bilaterally. Then, 0-degree and 70-degree endoscopes with Xenon lighting was employed with a routine microdebrider/shaver as well as endoscopic sinus equipment, both upbiting and straight as well as backbiters and side-biting Stammberger instrumentation and through-cut instruments. Irrigator to the endoscopic equipment with camera head was also employed. We were able to access the left nasal passage beyond the deviated septum. The middle turbinate was medialized.
Uncinectomy was performed using a sickle knife, backbiter and shaver after the natural ostia was identified in the lower one-third of the hiatus semilunaris. The maxillary antrostomy was widened until examination did not reveal any acute process or masses. Following this, an anteroposterior ethmoidectomy was completed, first with dissection through the bulla ethmoidalis and inferior aspect of the anterior ethmoid cells into the posterior ethmoid cells superiorly to the base of the skull and then anteriorly. We did not create a CSF leak or encroach the intracranial space. The medial orbital wall was identified. There was no dehiscence noted. The wall was left intact and there was no encroachment of the orbital space. Positive bulbar pressure was employed and no herniation was identified. A shaver was used to remove any additional debris. Dissection towards the frontal sinus recess was completed and the opening towards the frontal sinus recess was noted to be patent.
The left middle turbinectomy was completed using a sinus shaver, as well as backbiting and through-cut instrumentation. In this fashion, the concha bullosa was taken down. This did leave the middle turbinate slightly more floppy but still had some integrity anteriorly. Neo-Synephrine-impregnated cottonoids were placed into the surgerized field as we addressed the right side. The septum on the right was deviated in the region of the middle turbinate, likely due to the larger concha bullosa on the left. We were able to flatten the middle turbinate on the right. Access to the lateral nasal wall ethmoid sinuses was difficult, but we persisted, despite the deflected septum. Uncinectomy was performed on the right as it was on the left. It was flattened and lateralized making it more difficult.
Maxillary antrostomy was created more widely on the right than on the left due to presence of a Haller cell and lateral displacement of the lateral nasal wall due to the aforementioned deformity. Anterior-posterior ethmoidectomy was completed, but we were somewhat restrained towards the frontal sinus and the superior aspect of the posterior as well as anterior ethmoid cells. Our first attempt at completing the right endoscopic sinus surgery was foiled by the deviated septum, and therefore, we paused prior to completion to undertake the nasal septoplasty. Otherwise, the right endoscopic sinus surgery was essentially completed as it was on the left side with similar instrumentation. The septum was then addressed using a hemitransfixion incision.
The mucoperichondrium and periosteum were carefully elevated bilaterally without any tears or rents. There was some difficulty in elevating the tissue due to the complexity of the deformity, septal crest dislocation, columellar dislocation and the curvature of the septum. We separated the caudal portion of the septum from the maxillary septal crest. The redundant cartilage was taken down sharply and then the bony component was taken down with the Takahashi as well. A caudal Freer elevator and Freer knife were used for the elevation of the mucoperichondrium and periosteum. The Freer knife and Freer elevator were used in addition to the Takahashi, Gorney scissors to take down the deviated portion of the nasal septum. Once the redundant portion of the septum was removed on the left, this did reduce the lateral nasal wall contact and allowed us to swing the septum more into the midline position within the columella. This did remove some of the support more posteriorly, but the anteriormost aspect remained on the septal crest once the septum was able to be repositioned and was fashioned in a way to avoid the redundancy.
A Takahashi Freer knife and Freer elevator were used to take down additional portion of the nasal septal cartilage and bone, particularly in the region of the right middle turbinate and inferiorly on the left, leaving an adequate dorsal as well as caudal strut. The portion of the nasal septal cartilage and bone were removed and the mucoperichondrium and periosteum were allowed to redrape. There remained some deflection of the septum anteriorly. A 6-0 Prolene suture was used to fix the septum to the anterior septal spine. An additional suture was placed on the columella region to fix the caudal portion of the septum in a more midline position.
The mucoperichondrium and periosteum were allowed to redrape then. This revealed a significant improvement in nasal passage bilaterally and particularly for the completion of right ethmoid sinus surgery and reduction of the deflection of the septum and nasal obstruction. The hemitransfixion incision was closed using chromic suture. A running horizontal mattress plain gut suture was used to reapproximate the mucoperichondrium and periosteum along the length of the dissection. Outfracture of the anterior turbinates was completed bilaterally. The right anterior-superior and posterior-superior ethmoidectomy was completed as it was on the left, once the middle turbinate was able to be lateralized sufficiently to allow for safe dissection. The middle turbinate on the right was particularly floppy in nature. There was concern of lateralization.
The medial aspect of the middle turbinate on the right as well as on the left was abraded with the sinus shaver as well as the adjacent septal mucosa without any perforation. A transseptal stitch was applied and a middle turbinopexy was thereby completed bilaterally. This proved to be difficult, in order to pass a Keith needle through both turbinates and the septum under endoscopic methods. This was ultimately completed with protection of the lateral nasal wall bilaterally.
Photodocumentation was taken. A splint impregnated with Bactroban was applied in the middle meatal region bilaterally and fixed the Neiman splints, also impregnated with Bactroban, and fixed using a transseptal nylon suture x1. Infiltration of the anterior aspect of the inferior turbinates was completed. Through-cut instrumentation was used to submucosally resect the turbinates bilaterally with gentle cauterization, avoiding the anterior turbinate bone bilaterally. Single stitch was placed on the right side. The degree of dissection on the left was not as cumbersome, and therefore, a stitch was not applied. NG tube was passed transorally.
The oropharynx, hypopharynx and nasopharynx were suctioned. All blood clots and debris were removed. The table was flattened, the patient was awakened, extubated and then taken to the recovery room in stable condition. There were no complications including CSF leak, injury to the nasolacrimal duct or encroachment in the orbital space.
