ASSISTANT:
ANESTHESIOLOGIST:
CHRISTINE DOYLE, M.D.
PROCEDURE: Open reduction of nasal pharynx, open reduction
of nasal septum, fracture reduction inferior
turbinectomies.
PREOPERATIVE DIAGNOSES: Fractured nose, fractured nasal
septum, large inferior turbinates causing obstructive
bleeding.
POSTOPERATIVE DIAGNOSES: Fractured nose, fractured nasal
septum, large inferior turbinates causing obstructive
bleeding.
ANESTHESIA:
General by Dr. Doyle.
OPERATIVE FINDINGS: A patient with a fractured nose,
fractured nasal septum, and large inferior turbinates.
OPERATIVE PROCEDURE: After adequate endotracheal
anesthesia was accomplished, 4% cocaine cotton pledgets
were placed in the nose. The face was prepped and draped
in the usual manner for nasal surgery. The vibrissae were
trimmed, cotton pledgets were removed, 1% Xylocaine with
1:200,000 of epinephrine was used for local infiltration of
the nasal septum, of the inferior turbinates, of the
intercartilaginous area of the nasal vestibule, and the
dorsum of the nose.
A left Killian incision was made in the nasal septum and a
Cottle elevator was used to elevate the mucoperichondrium
and periosteum off the left side of the nasal septum. The
quadrangular cartilage was dissected off the posterior
pillar of the ethmoid and the mucoperiosteum was elevated
off the right side of the bony septum. Jansen-Middleton
bone-biting forceps were used to remove the bony defect
from the fractured nasal septum. This allowed the
quadrangular cartilage to come to the midline and remain in
the midline. An incision was made in the right mucosal
flap for drainage purposes. The Killian incision was
sutured together with 4-0 chromic and the mucosal flap was
sutured together through and through, back and forth, with
4-0 plain catgut.
Then using a Coblator turbinate wand, it was inserted into
the left inferior turbinate and advanced through mucosa to
the pterygoid where Coblation was accomplished for 10
seconds at 6 power. Then for the midportion of the left
inferior turbinate, Coblation was accomplished for 10
seconds into the anterior caudal end of the left inferior
turbinate where Coblation was accomplished for 10 seconds.
The wand was withdrawn and placed into the mucosa of the
right inferior turbinate, advanced through mucosa to the
pterygoid where Coblation was accomplished for 10 seconds,
and to the midportion of the right inferior turbinate where
Coblation was accomplished for 10 seconds, and then to the
anterior caudal end of the right inferior turbinate where
Coblation was accomplished for 10 seconds. The wand was
removed. A Gillies elevator was used to outfracture the
inferior turbinate.
Then an intercartilaginous incision was made on the nasal
vestibule and Metzenbaum scissors were used to elevate the
dorsal skin off the nasal bone. A Joseph elevator was used
to elevate the procerus muscle and the periosteum off the
dorsum of the nasal bone. The upper lateral cartilages
were released from the dorsum of the cartilaginous septum.
Using a guarded osteotome, the small hump was removed from
the dorsum of the nose, and this was removed with straight
hemostats. A straight osteotome was used to make medial
osteotomies bilaterally. Then the cartilaginous septum and
the upper lateral cartilages were trimmed appropriately.
An incision was made in the left inferior aspect of the
nasal vestibule and a Joseph elevator was used to elevate
the periosteum off the nasal floor of the maxillary bone.
A straight osteotome was used to make lateral osteotomies
and the lateral and medial osteotomies were connected by
manipulation of the osteotome and infracture was
accomplished. The procedure was repeated on the right side
with again an incision being made in the inferior aspect of
the nasal vestibule on the right side. A Joseph elevator
was used to elevate the periosteum off the nasal floor of
the maxillary bone and a straight osteotome was used to
make lateral osteotomies and the lateral and medial
osteotomies were connected with manipulation of the
osteotome and infractures were accomplished. This released
the nasal bones and these were brought to the midline and
remained in the midline.
All the incisions were sutured with 4-0 chromic. The nose
and pharynx were well aspirated. The dorsum of the nose
was protected with paper tape and a Therma Splint was used
to hold the nasal bones in place.
The patient tolerated the procedures well.