PREOPERATIVE DIAGNOSES
1. Nasal septal deviation with nasal obstruction.
2. Chronic maxillary ethmoid and frontal sinusitis with chronic sinus origin headaches.
3. Enlargement of inferior turbinates, bilateral.
POSTOPERATIVE DIAGNOSES
1. Nasal septal deviation with nasal obstruction.
2. Chronic maxillary ethmoid and frontal sinusitis with chronic sinus origin headaches.
3. Enlargement of inferior turbinates, bilateral
SURGICAL PROCEDURE PERFORMED
1. Nasal septoplasty.
2. Bilateral endoscopic maxillary antrostomy with tissue removal from the maxillary sinus.
3. Bilateral endoscopic total ethmoidectomy.
4. Bilateral endoscopic frontal sinusotomy.
5. Bilateral outfracture inferior turbinates.
6. Above procedures were performed using optical image guidance.
INDICATIONS FOR SURGERY
The patient is a 61-year-old besiding history of chronic headaches, facial pain and symptoms of sinusitis who underwent medical treatment and had an abnormal sinus CT scan. He has some septal deviation to the right side with nasal obstruction on the right and the CT shows near total opacification of the left maxillary sinus with some opacification within the tooth filled with some calcifications within the opacity suggesting possible impacted fungal growth. There is also mucosal thickening opacity within the ethmoid sinuses more than left from the right and obstruction of the maxillary drainage on the right. The frontal sinuses on both sides were involved with mucosal thickening in the area of the frontal recess. The sphenoid sinus was clear.
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. Bilateral greater palatine foramen injections were given for hemostasis. The nasal septum was injected with lidocaine with epinephrine and the middle turbinate on the left side was injected as well. Following the standard prep and draping the Medtronic optical image guidance system was calibrated and registered for use during the procedure. The zero-degree nasal endoscope was used to inspect both sides of the nose. The left side was more open so surgery was begun on this side 1st. The middle turbinate had a small aerated concha and underwent of the CT scan there was some opacity within the concha. Looking in the posterior part of the middle meatus there was a large accessory ostium into the maxillary sinus and some of the debried could be seen out in the maxillary sinus along with some purulent drainage. The lateral nasal wall was injected with lidocaine with epinephrine for hemostasis, injecting in the area of the uncinate. The middle turbinate was displaced medially and the antrum punch was used to incise through the lower attachment of the uncinate process and very thickened uncinate bone was reflected medially and then removed with the shaver. This was then connected with the accessory ostium allowing better exposure into the maxillary sinus with some of the more solid impacted debris could be cleaned out of the maxillary sinus. An opening was made in the ethmoidal bulla and the shaver was used to resect walls of the bulla along with both anterior and posterior ethmoid air cells and the inflamed mucosa of the nose cells. The bone was noted to be somewhat thickened. The standard landmarks of the middle turbinate medially tegmen superiorly and lateral nasal wall and the lamina laterally were identified. The skull base was identified posteriorly and then followed anterior to the area of the frontal recess. 45 degrees nasal endoscope and 60 degrees curved shaver were used along with curved frontal suction curette and with the assistance image guidance of the ethmoid air cells were opened up bleeding into the area of the frontal recess and the frontal sinus was opened. Bone fragments and mucosa were resected completely mucosal cover throughout the sinus as much as possible. The nasal septoplasty was then performed making a vertical incision on the left side of the anterior portion of the cartilage, carrying it down to the plane beneath perichondrium, and a flap was elevated of the entire left side of the septal cartilage and bone. A vertical incision was made, leaving an adequate caudal strut within the right side of the cartilage was exposed from that point posterior. Options of the septal cartilage and bone were then resected leaving and adequate caudal support and portions of the maxillary crest bone that were very thick, were also removed. There was a posterior septal spur that was resected. The septal incision was then closed with interrupted 4-0 chromic followed by a 4-0 chromic mattress suture placed through into the septum for hemostasis. The right side was then approached in the fairly thin middle turbinate was reflected medially and the lateral nasal wall was injected. The uncinate process on this side was removed in a similar fashion to what was described on the left. Although of the anatomy on this side was much more normal with no large accessory opening and no impacted debris within the sinus. The natural ostium of the maxillary was widened with the shaver. The 2nd CT scan did show involvement of the frontal sinus especially in the area of the frontal recess on the right side, so I went ahead and open into the ethmoidal bulla and removing the bony walls of the anterior and posterior ethmoid air cells. Identifying the standard landmarks and then following the skull base anteriorly. The frontal sinus was entered on the right side, as was described on the left. Into the frontal approach the 45 degrees scope was utilized. All of the small bone fragments were then removed and a prominent inferior turbinates on both sides were with outfracture of the turbinate bone with no submucosal resection. Antibiotic ointment was then placed into the ethmoid cavity on both sides followed by a Gelfoam, and covered by Gel film. A stent placed into the middle meatus and ethmoid region to keep the middle turbinate up against the septum. Telfa gauze coated and antibiotic ointment was then placed on either side of the septum for hemostasis and the throat pack was removed. He was awakened in the operating room where his extubated and transported to Recovery in stable condition.
1. Nasal septal deviation with nasal obstruction.
2. Chronic maxillary ethmoid and frontal sinusitis with chronic sinus origin headaches.
3. Enlargement of inferior turbinates, bilateral.
POSTOPERATIVE DIAGNOSES
1. Nasal septal deviation with nasal obstruction.
2. Chronic maxillary ethmoid and frontal sinusitis with chronic sinus origin headaches.
3. Enlargement of inferior turbinates, bilateral
SURGICAL PROCEDURE PERFORMED
1. Nasal septoplasty.
2. Bilateral endoscopic maxillary antrostomy with tissue removal from the maxillary sinus.
3. Bilateral endoscopic total ethmoidectomy.
4. Bilateral endoscopic frontal sinusotomy.
5. Bilateral outfracture inferior turbinates.
6. Above procedures were performed using optical image guidance.
INDICATIONS FOR SURGERY
The patient is a 61-year-old besiding history of chronic headaches, facial pain and symptoms of sinusitis who underwent medical treatment and had an abnormal sinus CT scan. He has some septal deviation to the right side with nasal obstruction on the right and the CT shows near total opacification of the left maxillary sinus with some opacification within the tooth filled with some calcifications within the opacity suggesting possible impacted fungal growth. There is also mucosal thickening opacity within the ethmoid sinuses more than left from the right and obstruction of the maxillary drainage on the right. The frontal sinuses on both sides were involved with mucosal thickening in the area of the frontal recess. The sphenoid sinus was clear.
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. Bilateral greater palatine foramen injections were given for hemostasis. The nasal septum was injected with lidocaine with epinephrine and the middle turbinate on the left side was injected as well. Following the standard prep and draping the Medtronic optical image guidance system was calibrated and registered for use during the procedure. The zero-degree nasal endoscope was used to inspect both sides of the nose. The left side was more open so surgery was begun on this side 1st. The middle turbinate had a small aerated concha and underwent of the CT scan there was some opacity within the concha. Looking in the posterior part of the middle meatus there was a large accessory ostium into the maxillary sinus and some of the debried could be seen out in the maxillary sinus along with some purulent drainage. The lateral nasal wall was injected with lidocaine with epinephrine for hemostasis, injecting in the area of the uncinate. The middle turbinate was displaced medially and the antrum punch was used to incise through the lower attachment of the uncinate process and very thickened uncinate bone was reflected medially and then removed with the shaver. This was then connected with the accessory ostium allowing better exposure into the maxillary sinus with some of the more solid impacted debris could be cleaned out of the maxillary sinus. An opening was made in the ethmoidal bulla and the shaver was used to resect walls of the bulla along with both anterior and posterior ethmoid air cells and the inflamed mucosa of the nose cells. The bone was noted to be somewhat thickened. The standard landmarks of the middle turbinate medially tegmen superiorly and lateral nasal wall and the lamina laterally were identified. The skull base was identified posteriorly and then followed anterior to the area of the frontal recess. 45 degrees nasal endoscope and 60 degrees curved shaver were used along with curved frontal suction curette and with the assistance image guidance of the ethmoid air cells were opened up bleeding into the area of the frontal recess and the frontal sinus was opened. Bone fragments and mucosa were resected completely mucosal cover throughout the sinus as much as possible. The nasal septoplasty was then performed making a vertical incision on the left side of the anterior portion of the cartilage, carrying it down to the plane beneath perichondrium, and a flap was elevated of the entire left side of the septal cartilage and bone. A vertical incision was made, leaving an adequate caudal strut within the right side of the cartilage was exposed from that point posterior. Options of the septal cartilage and bone were then resected leaving and adequate caudal support and portions of the maxillary crest bone that were very thick, were also removed. There was a posterior septal spur that was resected. The septal incision was then closed with interrupted 4-0 chromic followed by a 4-0 chromic mattress suture placed through into the septum for hemostasis. The right side was then approached in the fairly thin middle turbinate was reflected medially and the lateral nasal wall was injected. The uncinate process on this side was removed in a similar fashion to what was described on the left. Although of the anatomy on this side was much more normal with no large accessory opening and no impacted debris within the sinus. The natural ostium of the maxillary was widened with the shaver. The 2nd CT scan did show involvement of the frontal sinus especially in the area of the frontal recess on the right side, so I went ahead and open into the ethmoidal bulla and removing the bony walls of the anterior and posterior ethmoid air cells. Identifying the standard landmarks and then following the skull base anteriorly. The frontal sinus was entered on the right side, as was described on the left. Into the frontal approach the 45 degrees scope was utilized. All of the small bone fragments were then removed and a prominent inferior turbinates on both sides were with outfracture of the turbinate bone with no submucosal resection. Antibiotic ointment was then placed into the ethmoid cavity on both sides followed by a Gelfoam, and covered by Gel film. A stent placed into the middle meatus and ethmoid region to keep the middle turbinate up against the septum. Telfa gauze coated and antibiotic ointment was then placed on either side of the septum for hemostasis and the throat pack was removed. He was awakened in the operating room where his extubated and transported to Recovery in stable condition.
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