EXAMPLE
Donald W. Burt, Jr., M.D.
OPERATIVE REPORT
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PREOPERATIVE DIAGNOSES:
1. Chronic ethmoid sinusitis.
2. Chronic maxillary sinusitis.
3. Deviated nasal septum.
4. Hypertrophic inferior turbinates.
5. Nasal airway obstruction.
POSTOPERATIVE DIAGNOSES:
1. Chronic ethmoid sinusitis.
2. Chronic maxillary sinusitis.
3. Deviated nasal septum.
4. Hypertrophic inferior turbinates.
5. Nasal airway obstruction.
PROCEDURE PERFORMED:
Using the Landmark stereotactic surgical system:
1. Right ethmoid sinus endoscopy.
2. Left ethmoid sinus endoscopy.
3. Maxillary sinus endoscopy.
4. Left maxillary sinus endoscopy.
Without the Landmark system:
1. Nasal septoplasty.
2. Submucous resection of the right inferior turbinate.
3. Submucous resection of the left inferior turbinate.
SURGEON: Donald W. Burt Jr., M.D.
ASSISTANT: None.
ANESTHESIOLOGIST: Kuldeep Jagpal, 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 50-year-old male was referred by Dr. Barbara
in February 2006 for a history of constant cold-like symptoms for
the last five months. He had been treated with multiple
antibiotics, antihistamines, decongestants, and nasal steroid
sprays. He had a chest x-ray performed, which was unremarkable.
Examination in the office showed an irregularly deviated nasal
septum with bilateral spurring, 3/4+ inferior turbinates, and 90%
overall nasal airway obstruction. A sinus CT scan was performed,
which showed extensive sinus disease with obstruction of both
osteomeatal units. There was near-complete opacification of the
frontal sinus with soft tissue extending into the frontal ethmoid
recess. There was near-complete opacification of the ethmoid air
cells also seen with near-complete opacification of the right
half of the sphenoid sinus. There was extensive circumferential
mucosal thickening in the maxillary sinuses measuring out to 1
cm. No air-fluid levels were seen. With this in mind, the
findings, the diagnoses, and treatment options, to include doing
nothing to medical or surgical management, as well as the
attendant risks, benefits, and complications of performing or not
performing any of these modalities were discussed with him. He
indicated his acceptance and understanding, and desired to
proceed with surgery at this time.
FINDINGS: There was an irregular deviated nasal septum with
bilateral spurring, 3/4+ inferior turbinates, and 90% overall
nasal airway obstruction. Also noted was hypertrophic mucosa of
the osteomeatal complex areas obstructing the osteomeatal outflow
tracts with hypertrophy of the mucosa of the ethmoid cells and
maxillary sinuses.
PROCEDURE: The patient was brought in the operating room, placed
on the operating table in 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 using the anesthetic mix as noted above. Bilateral
intranasal pledgets using a total of 80 mg of cocaine were
placed. At this time, the Landmark forehead piece was placed on
the patient, and the various instruments to be used in the
procedure were registered.
After an adequate amount of time, the patient was prepped and
draped in the usual manner. The packs were taken from the nasal
cavities. Findings were as noted above. A left Killian incision
was then made and the mucoperiosteum and perichondrium elevated
off the left side of the nasal septum. At the bony cartilaginous
juncture, an incision was made, and the mucoperiosteum was
elevated to the right side of the nasal septum. Care was taken
around the areas of the spurring. The spurs were then carefully
and sequentially removed using the Takahashi forceps. Some
spurring along the midline maxillary crest was exposed elevating
the mucosa with Joseph elevator and the spurs fractured using the
elevator and then removed using Takahashi forceps. All rough
edges were carefully smoothed down. The remaining portions of
the bony septum were then fractured back to the midline. The
cartilaginous septum was centered into a midline position and the
mucosa carefully redraped and the incision closed and the mucosa
held into position using a running circular mattress suture of 40 plain suture.
At this time, the right nasal cavity was entered, and using the
Landmark stereotactic registered instruments, the accuracy of the
registration was tested and was felt adequate. Using the sinus
endoscope, which was passed in the right nasal cavity, and using
the registered sinus probe, the middle turbinate was medialized
and immediately visible was hypertrophic mucosa obstructing the
osteomeatal units. The probe was used to enter the ethmoid
sinuses and the anterior aspects exposed. At this time, the
correct position of the uncinate process was checked and was
accurate on the Landmark video. The maxillary sinus ostia were
identified, and, again, was accurate on the video, and the mucosa
over this area was scored using the probe. The probe was then
removed.
At this time, the registered sinus shaver, which was a 4-mm, 12degree, Medtronic shaver, was placed into the nasal cavity, and
dissection of the ethmoid sinuses was begun in an inferior
posterior aspect and carried anterior superiorly while constantly
observing its position on the Landmark video. All disease was
completely exenterated. At the end of this portion of the
procedure, the uncinate process was taken down removing
hypertrophic mucosa in this area, which was obstructing the
outflow tract.
At this time, the tip of the shaver was rotated laterally, and
the hypertrophic mucosa over the ostia of the maxillary sinus was
taken down. Finally, the ostia itself was entered and enlarged.
There was hypertrophic mucosa noted throughout the sinus, and,
again, positioning appeared accurate on the Landmark video. The
rough edges of the ostia were then smoothed down, and this
portion of the procedure terminated.
The left nasal cavity was then entered, again using the
registered sinus probe and the endoscope. Positioning of the
probe was checked and felt to be adequate. The probe was passed
into the nasal cavity. The middle turbinate was medialized, and
immediately there was hypertrophic mucosa obstructing the
osteomeatal units. The anterior aspect of the ethmoid sinuses
was then entered and left open using the sinus probe. The
maxillary sinus ostia were identified, and the mucosa over this
area was scored using the sinus probe. The sinus probe was then
removed.
At this time, the registered sinus shaver was then brought into
the nasal cavity, and dissection of the ethmoid itself was begun
in an inferior posterior aspect and carried anterior superiorly
while monitoring it on the Landmark system. All disease was
carefully exenterated. The uncinate process was then taken down
using the shaver as well, as it was obstructive in nature.
At this time, the tip of the shaver was rotated laterally, and
the mucosa over the maxillary sinus ostia was taken down.
Finally, the sinus was entered using the shaver and its position
noted on the Landmark system and was felt to be accurate. The
ostia were opened and all rough edges carefully smoothed down.
Some hypertrophic mucosa within the sinus was removed.
shaver and endoscope were then removed.
The
At this time, the right nasal cavity was exposed using the nasal
speculum and thoroughly suctioned, and an incision was made at
the anterior inferior aspect of the inferior turbinate and a
submucosal tunnel fashioned using the turbinate shaver blade. A
submucosal resection was then performed using the shaver with
good result. At this time, the nasal cavity was thoroughly
suctioned and MeroGel placed into the nasal cavity.
The left nasal cavity was then exposed using the nasal speculum
and thoroughly suctioned, and an incision was made in the
anterior inferior aspect of the inferior turbinate and a
submucosal tunnel fashioned using the turbinate shaver blade. A
submucosal resection was then performed with the shaver blade
with good results. The nasal cavity was then thoroughly
suctioned and the nasal cavity packed with MeroGel. The nose was
then thoroughly cleansed and dried and nasal dressing applied.
The oral cavity was thoroughly suctioned, and the procedure was
terminated at this point. The patient tolerated the procedure
well and was taken to the postanesthesia care unit in
satisfactory condition.
CLOSURE: 4-0 plain suture.
ESTIMATED BLOOD LOSS: Less than 100 mL.
COMPLICATIONS: None.
DRAINS AND PACKS: Bilateral MeroGel and nasal gel.
NEEDLE AND SPONGE COUNT: Correct at the end of the procedure.