PREOPERATIVE DIAGNOSIS
1. Nasal septal deviation with nasal obstruction.
2. Bilateral chronic and recurring maxillary sinusitis.
3. Hypertrophy of inferior turbinates.
POSTOPERATIVE DIAGNOSIS
1. Nasal septal deviation with nasal obstruction.
2. Bilateral chronic and recurring maxillary sinusitis.
3. Hypertrophy of inferior turbinates
SURGICAL PROCEDURE PERFORMED
1. Nasal septoplasty.
2. Bilateral endoscopic maxillary antrostomy with tissue removal from the maxillary sinuses.
3. Left submucous resection inferior turbinate.
4. Right outfracture inferior turbinate.
INDICATIONS FOR SURGERY
The patient is a 29-year-old with a history of chronic nasal obstruction, blocking the right side of the nose with intermittent flare-ups of facial pain and sinusitis and abnormal sinus CT showing narrowing and blockage of the drainage of the maxillary sinuses on both sides. She has prominent septal deviation to the right side and very large left inferior turbinate with thick intra turbinate bone.
DESCRIPTION OF OPERATION
The patient was taken to the main operating room under general endotracheal anesthesia. The nose was packed with cotton pledgets soaked in Afrin solution and a throat pack was placed. Lidocaine with epinephrine was injected in the nasal septum on both sides for hemostasis. The following a standard prep and draping and the zero-degree nasal endoscope was used in the left side was approached 1st. There was a concha of the middle turbinate on the left side and then had a fairly small air pocket, so I did not remove the lateral wall of the turbinate. The middle turbinate was displaced medially to gain access to the area of the middle meatus where the lateral nasal wall in the area of the uncinate process was injected. Access to the middle meatus was somewhat difficult because of the large size of the inferior turbinate, which on CT scan had very thick bone within the inside of the turbinate. Before completion of the maxillary surgery on this side I went ahead performed the nasal septoplasty in order to get better exposure to the middle meatus on the left. A vertical incision was made on the left side of the septal cartilage anteriorly and could down to the plane beneath the perichondrium. A submucosal flap was then elevated off the left side of the septal cartilage and bone extending posteriorly. A vertical incision was made through the septal cartilage, leaving an adequate caudal strute anteriorly for support. Mucosa on the right side of the vertical cartilage cut was then elevated back and abnormal portions of the septal cartilage with deviated way over the right side of the nose were then resected. Inferiorly the mucosa was elevated off of the cartilage and bone portion of the septal ledge projecting to the right portions of the maxillary crest bone were resected. Thickened posterior and superior septal cartilage and bone were removed as well as some thickening in the area of the mid portion of the septum representing a septal spur was removed. The small tear was created on the mucosa of the septum on the right side but no involvement on the left. Some flat segments of the septal cartilage and bone were placed back between the mucosal flaps for additional support and then the septal incision was closed with interrupted 4-0 chromic suture followed by a 4-0 chromic mattress suture placed through into the septum for hemostasis. This allowed for marked improvement in exposure on the right side with more thin middle turbinate was reflected medially and the lateral nasal wall on the right was injected with local anesthetic. The maxillary surgery was then performed starting on the right side. The antrum punch was used to incise through the lower attachment of the uncinate process and the mid and upper portion was reflected medially with a blunt probe. The shaver was used to remove the uncinate and expose the area of the natural ostium of the maxillary sinus. There was some edema of the mucosa in the area of the natural ostium of a little bit of thickened secretion minimally cloudy but no purulent drainage noted. Maxillary opening was widened with the shaver allowing good exposure out of the maxillary sinus. The left side was then approached and the uncinate process was removed on this side as well, exposing the natural ostium and enlarging it in a similar manner to what was described on the right. Both inferior turbinates were injected with local anesthetic in the left turbinate was approached 1st. There was a large amount of compensatory enlargement of the turbinate due to the degree of the septal deviation and a good portion of the enlargement was bony thickening. A vertical incision was made on the anterior aspect of the turbinate, dissected down to the turbinate bone and resected to the mucosa of the medial and lateral surface of the turbinate bone. The bone was so thick that had to use a chisel to fracture along the superior portion of the turbinate attachment and then of very thick piece of turbinate bone was removed. The removing the turbinate bone, little bit of the mucosa of the mid portion of the turbinate stated apparent to the bone in created there in the middle portion of the surface mucosa. This created some roughened edges of the mucosa but it was able to smooth down with the shaver removing segments of the mid portion of the turbinate mucosa preserving the anterior portion. On the right side of the extreme anterior part of the turbinate was not very prominent and there was some prominence of the posterior portion of the structure, so I used Freer elevator and outfractured the mid and posterior portion of the turbinate without making any incisions on the through that mucosa. Antibiotic ointment was then placed in the middle meatus on both sides. Followed by a stent of Gelfoam covered with gel film that was placed between the middle turbinate and lateral nasal wall to adhesions. Telfa gauze coated, antibiotic ointment was then placed on either side of the septum for hemostasis. The throat pack was removed. She was awakened in the operating room where she was extubated and transported to Recovery in stable condition.
1. Nasal septal deviation with nasal obstruction.
2. Bilateral chronic and recurring maxillary sinusitis.
3. Hypertrophy of inferior turbinates.
POSTOPERATIVE DIAGNOSIS
1. Nasal septal deviation with nasal obstruction.
2. Bilateral chronic and recurring maxillary sinusitis.
3. Hypertrophy of inferior turbinates
SURGICAL PROCEDURE PERFORMED
1. Nasal septoplasty.
2. Bilateral endoscopic maxillary antrostomy with tissue removal from the maxillary sinuses.
3. Left submucous resection inferior turbinate.
4. Right outfracture inferior turbinate.
INDICATIONS FOR SURGERY
The patient is a 29-year-old with a history of chronic nasal obstruction, blocking the right side of the nose with intermittent flare-ups of facial pain and sinusitis and abnormal sinus CT showing narrowing and blockage of the drainage of the maxillary sinuses on both sides. She has prominent septal deviation to the right side and very large left inferior turbinate with thick intra turbinate bone.
DESCRIPTION OF OPERATION
The patient was taken to the main operating room under general endotracheal anesthesia. The nose was packed with cotton pledgets soaked in Afrin solution and a throat pack was placed. Lidocaine with epinephrine was injected in the nasal septum on both sides for hemostasis. The following a standard prep and draping and the zero-degree nasal endoscope was used in the left side was approached 1st. There was a concha of the middle turbinate on the left side and then had a fairly small air pocket, so I did not remove the lateral wall of the turbinate. The middle turbinate was displaced medially to gain access to the area of the middle meatus where the lateral nasal wall in the area of the uncinate process was injected. Access to the middle meatus was somewhat difficult because of the large size of the inferior turbinate, which on CT scan had very thick bone within the inside of the turbinate. Before completion of the maxillary surgery on this side I went ahead performed the nasal septoplasty in order to get better exposure to the middle meatus on the left. A vertical incision was made on the left side of the septal cartilage anteriorly and could down to the plane beneath the perichondrium. A submucosal flap was then elevated off the left side of the septal cartilage and bone extending posteriorly. A vertical incision was made through the septal cartilage, leaving an adequate caudal strute anteriorly for support. Mucosa on the right side of the vertical cartilage cut was then elevated back and abnormal portions of the septal cartilage with deviated way over the right side of the nose were then resected. Inferiorly the mucosa was elevated off of the cartilage and bone portion of the septal ledge projecting to the right portions of the maxillary crest bone were resected. Thickened posterior and superior septal cartilage and bone were removed as well as some thickening in the area of the mid portion of the septum representing a septal spur was removed. The small tear was created on the mucosa of the septum on the right side but no involvement on the left. Some flat segments of the septal cartilage and bone were placed back between the mucosal flaps for additional support and then the septal incision was closed with interrupted 4-0 chromic suture followed by a 4-0 chromic mattress suture placed through into the septum for hemostasis. This allowed for marked improvement in exposure on the right side with more thin middle turbinate was reflected medially and the lateral nasal wall on the right was injected with local anesthetic. The maxillary surgery was then performed starting on the right side. The antrum punch was used to incise through the lower attachment of the uncinate process and the mid and upper portion was reflected medially with a blunt probe. The shaver was used to remove the uncinate and expose the area of the natural ostium of the maxillary sinus. There was some edema of the mucosa in the area of the natural ostium of a little bit of thickened secretion minimally cloudy but no purulent drainage noted. Maxillary opening was widened with the shaver allowing good exposure out of the maxillary sinus. The left side was then approached and the uncinate process was removed on this side as well, exposing the natural ostium and enlarging it in a similar manner to what was described on the right. Both inferior turbinates were injected with local anesthetic in the left turbinate was approached 1st. There was a large amount of compensatory enlargement of the turbinate due to the degree of the septal deviation and a good portion of the enlargement was bony thickening. A vertical incision was made on the anterior aspect of the turbinate, dissected down to the turbinate bone and resected to the mucosa of the medial and lateral surface of the turbinate bone. The bone was so thick that had to use a chisel to fracture along the superior portion of the turbinate attachment and then of very thick piece of turbinate bone was removed. The removing the turbinate bone, little bit of the mucosa of the mid portion of the turbinate stated apparent to the bone in created there in the middle portion of the surface mucosa. This created some roughened edges of the mucosa but it was able to smooth down with the shaver removing segments of the mid portion of the turbinate mucosa preserving the anterior portion. On the right side of the extreme anterior part of the turbinate was not very prominent and there was some prominence of the posterior portion of the structure, so I used Freer elevator and outfractured the mid and posterior portion of the turbinate without making any incisions on the through that mucosa. Antibiotic ointment was then placed in the middle meatus on both sides. Followed by a stent of Gelfoam covered with gel film that was placed between the middle turbinate and lateral nasal wall to adhesions. Telfa gauze coated, antibiotic ointment was then placed on either side of the septum for hemostasis. The throat pack was removed. She was awakened in the operating room where she was extubated and transported to Recovery in stable condition.
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