EXAMPLE
Donald W. Burt, Jr., M.D.
OPERATIVE REPORT
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PREOPERATIVE DIAGNOSES:
1. Chronic ethmoid sinusitis refractory to medical management.
2. Chronic maxillary sinusitis refractory to medical management.
3. Persistent left tympanic membrane perforation status post
tympanoplasty with chronic otitis media and externa.
POSTOPERATIVE DIAGNOSES:
1. Chronic ethmoid sinusitis refractory to medical management.
2. Chronic maxillary sinusitis refractory to medical management.
3. Persistent left tympanic membrane perforation status post
tympanoplasty with chronic otitis media and externum.
PROCEDURE PERFORMED:
1. Right ethmoid sinus endoscopy with removal of mucosa.
2. Left ethmoid sinus endoscopy with removal of mucosa.
3. Right maxillary sinus endoscopy with removal of mucosa.
4. Left maxillary sinus endoscopy with removal of mucosa.
5. Left exploratory tympanotomy with placement of EpiDisc patch
over tympanic membrane perforation.
SURGEON: Donald W. Burt, Jr. M.D.
ASSISTANT: None.
ANESTHESIOLOGIST: Amitabh Mathur, M.D.
ANESTHESIA TYPE: General via endotracheal tube. Local, 4 mL of a
1:1 mix of 2% lidocaine with 1:100,000 epinephrine and 0.5%
Marcaine injected intranasally and topical, 80 mg of cocaine via
intranasal pledgets.
BRIEF HISTORY: This 13-year-old male was first referred into my
office in October 2005 with a chronic draining left ear, with
traces of blood off and on. Significant in his history is that
he had a left tympanoplasty in 2003, but had had persistent ear
infections since that time and a persistent perforation as well.
He also has a history of recurrent sinusitis. Examination of the
ears at that time showed a large amount of purulent material in
the external auditory canal with inflamed canal skin and tympanic
membrane. Perforation could not be identified at that time;
however, after treatment with Ciprodex and Omnicef, the ear has
cleared and the anterior central perforation is noted at about 2
x 4-mm in size. At this time, the ear infection appears well
controlled. He also had a CT scan of the ear, which showed some
thickening of the left tympanic membrane, but otherwise was
unremarkable. Sinus CT scan showed a near complete opacification
of the left maxillary sinus with obstruction of osteomeatal unit.
There is complete opacification of the right frontal sinus with
obstruction of the frontal ethmoid recess. There was left
posterior ethmoid sinus disease and mucosal thickening of the
right maxillary sinus. He has had a fairly persistent sinusitis
over the years, which may have complicated his ear problems. His
septum was noted to be midline, turbinates were 2/4+ and airways
were adequate. He had been treated with multiple antibody
regimens without much relief. In the 2 months since I have been
seeing him, he has been treated twice for sinus infections. He
is currently clear of any overt disease. With this mind, the
findings and diagnosis and treatment options, to include doing
nothing to medical or surgical management, as well as the
attendant risks, benefits, complications of performing or not
performing any of these modalities were discussed with him and
his parents and they indicated their acceptance and understanding
and desired to proceed with surgery at this time.
FINDINGS: Bilaterally polyploid middle turbinates with actual
polyps attached to them with large concha bullosa of the middle
turbinates as well. These almost completely obstructed this
portion of the nasal airway and the osteomeatal complex outflow
tracts. There is hypertrophic mucosa of the maxillary and
ethmoid sinuses and the osteomeatal complex with almost complete
obstruction bilaterally, including the nasal airways. There was
a 2 x 4-mm central perforation with some granulation tissue of
the edges of the left tympanic membrane. The middle ear mucosa
appeared normal throughout and the ossicles appeared intact. The
external auditory canal was clear.
PROCEDURE: The patient was brought into the operating room,
placed on the operating table in the dorsal supine position and
general anesthesia via endotracheal tube was begun. Once an
adequate level of anesthesia had been achieved the patient’s nose
was injected with the anesthetic mix as noted above and bilateral
pledgets using a total of 80 mg of cocaine were placed. After an
adequate amount of time, the packs were removed and the patient
was prepped and draped in the usual manner. Findings were as
noted above. Using the sinus scope, the right nasal cavity was
entered and using the sinus probe the middle turbinate was
medialized, but was noted to be quite polypoid in nature with
polyps growing from multiple aspects of the middle turbinate,
which also had a large contained concha bullosa. The shaver was
then brought into use and the polyps removed from the middle
turbinate and the concha bullosa removed as well. There was a
stub of the middle turbinate left at the end of this procedure.
The ethmoid sinus cells were then identified and opened using the
sinus probe and using the shaver, dissection was begun from an
inferior posterior position and carried anteriorly superiorly
until all the mucosal disease was removed. The concha bullosa
was taken down as well due to its large obstructive nature.
At this time, using the sinus probe the maxillary sinus ostia was
identified and the mucosa over this area scored. Using the
shaver, the mucosa was taken down and the ostia opened and
widened. All rough edges were carefully smoothed down.
Examination of the sinus showed hypertrophic mucosa of the sinus,
but no cyst or polyps.
At this time, the left nasal cavity was entered and using the
sinus scope and the sinus probe the left middle turbinate was
medialized and it was also noted to be quite polyploid in nature
with polyps protruding from it. It also had a large contained
concha bullosa and a shaver was brought into use and the polyps
removed and concha bullosa excised. The ethmoid sinus cells were
also then entered using the sinus probe and then using the
shaver, dissection was begun in the inferior posterior aspect and
carried anteriorly superiorly until mucosal disease was removed.
Using a sinus probe, the maxillary sinus ostia were identified
and then mucosa over this area scored. A large uncinate process
was taken down using the shaver and the mucosa over the maxillary
sinus ostia thinned out. The maxillary sinus ostia were entered,
opened, all rough edges smoothed down. Examination of the sinus
showed no cysts or polyps. The mucosa was hypertrophic. Both
nasal cavities were then thoroughly suctioned and MeroGel placed
into the osteomeatal complex areas bilaterally. A nasal dressing
was applied and the oral cavity thoroughly suctioned.
At this time, the patient’s head was gently rotated to the right.
Using the microscope an ear speculum was placed and cerumen
removed from the external auditory canal. A 2 x 4-mm central
anterior perforation was identified with some granulation tissue
at the edges. The edges of the perforation were then teased
using a fine House forceps and denuded of epithelium. The middle
ear mucosa appeared normal throughout and the ossicles appeared
intact. An EpiDisc patch was then placed over the perforation
and it was well adherent with some mild blood from the
perforation edges. This was tamped down using a right angle
pick. A second EpiDisc was then placed over this one and again
tamped down using EpiDisc pick. The perforation was well
covered. The ear speculum was then removed and this portion of
the procedure terminated.
The procedure was terminated overall at this time, the patient
allowed to awaken and taken to the postanesthesia care unit in
satisfactory condition.
CLOSURE: None.
ESTIMATED BLOOD LOSS: Less than 50 mL.
COMPLICATIONS: None.
DRAINS AND PACKS: Bilateral MeroGel of the nasal cavity.
NEEDLE AND SPONGE COUNT: Correct at the end of the procedure.