TONSILLECTOMY

PREOPERATIVE DIAGNOSIS: Recurrent tonsillitis with recalcitrant peritonsillar abscess.

POSTOPERATIVE DIAGNOSIS: Recurrent tonsillitis with recalcitrant peritonsillar abscess.

TITLE OF OPERATION: Quinsy tonsillectomy.

SURGEON: Michael Jones, M.D.

ASSISTANT: None.

ANESTHESIA GIVEN: General endotracheal tube anesthesia.

ESTIMATED BLOOD LOSS: Minimal.

COMPLICATIONS: None.

INDICATIONS FOR PROCEDURE: The patient is a 31-year-old white female with a peritonsillar abscess, who is unable to tolerate needle drainages, which was recalcitrant to medical therapy with worsening symptoms.

INTRAOPERATIVE FINDINGS: Left peritonsillar abscess and right acute tonsillitis.

DESCRIPTION OF OPERATIVE PROCEDURE: The patient was brought to the operating room and was placed in the supine position and placed under general endotracheal anesthesia by anesthesiology. The patient was prepped and draped in the usual sterile fashion. A Crowe-Davis mouth gag and red rubber catheter were placed.

The patient's tonsils were dissected using the electrocautery device in a capsular fashion. A large left peritonsillar abscess was encountered and drained. There was significant inflammation of the right tonsil. Hemostasis was then obtained with the suction electrocautery device where the inferior poles were fulgurated bilaterally and any of the visible vessels with minimal bleeding or irritation were also cauterized. The area was inspected. Hemostasis was inspected and was found to be adequate. The patient's stomach was suctioned. The red rubber catheter and the Crowe-Davis mouth gag were removed.

The patient was fully emerged from anesthesia and extubated and taken to the recovery room in good condition.

SEPTOPLASTY

PREOPERATIVE DIAGNOSIS: Chronic sinusitis and chronic nasal obstruction with severe nasal septal deviation and bilateral inferior turbinate hypertrophy.

POSTOPERATIVE DIAGNOSIS: Chronic sinusitis and chronic nasal obstruction with severe nasal septal deviation and bilateral inferior turbinate hypertrophy.

OPERATION PERFORMED: (1) Septoplasty. (2) Bilateral partial resection of the inferior turbinates with cauterization and outfracture. (3) Bilateral middle meatal antrostomy with debridement of maxillary sinuses. (4) Bilateral anterior-posterior ethmoidectomy with debridement of ethmoid sinuses. (5) Bilateral sphenoidotomy and culture of purulent debris of the sphenoid sinus.

SURGEON: Michael Jones, M.D.

ASSISTANT: None.

ANESTHESIA GIVEN: General endotracheal tube anesthesia.

ESTIMATED BLOOD LOSS: Minimal.

COMPLICATIONS: None.

INDICATIONS FOR PROCEDURE: The patient is a 52-year-old white male with a long history of a severe nasal obstruction recalcitrant to medical therapy with chronic sinusitis, also recalcitrant to medical therapy.

INTRAOPERATIVE FINDINGS: Severe caudal nasal septal deviation with obstructing bilateral inferior turbinate hypertrophy, bilateral polyposis of the maxillary sinuses, bilateral polyposis of the ethmoid sinuses, purulent drainage of the right sphenoid sinus.

DESCRIPTION OF OPERATIVE PROCEDURE: The patient was brought to the operating room and was placed in the supine position and was placed under general endotracheal anesthesia by anesthesiology. The patient's nose was inspected and injected with lidocaine 1% with epinephrine 1:100,000 and packed with Afrin-coated pledgets. Approximately 10 minutes was allowed to pass for maximum hemostasis to occur. The patient was prepped and draped in the usual sterile fashion. After the Afrin pledgets were removed, the inferior turbinates were infractured. The anterior 10% was sharply resected. The posterior 90% was cauterized and outfractured. Using a #15 blade, a hemitransfixion incision was made under the patient's left side and the mucosal flap was elevated. The cartilaginous septum was dissected away from the bony cartilaginous junction as well as from the nasal crest. Relaxing incisions were made vertically and a small strip of quite severely knuckled cartilaginous septum was removed. The deviated portion of the patient's perpendicular plate was also removed. This allowed for a swinging-door procedure to be performed where the septum was brought back into the midline. The patient's nasal airway was inspected and was found to be widely patent. The incision site was then closed with a chromic suture.

The rest of the surgery was done under endoscopic guidance and further injections were made of the middle turbinates and the lateral nasal wall. Beginning on the patient's left side, the left middle turbinates, anterior-inferior portion, was sharply resected. An uncinectomy was then performed with the sickle knife. The natural ostia of the maxillary sinus was identified and the ostia was widely opened. Polyp material was found within the maxillary sinus and was debrided. The anterior and posterior ethmoid sinuses were taken down and again polyposis was noted throughout the sinuses. The base of the sphenoid was identified and taken down. No purulence was noted inside the left sphenoid sinus. Attention was then directed towards the opposite side, where the anterior-inferior portion of the middle turbinate was taken down and an uncinectomy was performed with the sickle knife. The natural ostia of the maxillary sinus was identified and widely opened. Quite a bit of polyposis was once again noted and removed. The anterior-posterior ethmoid sinuses were taken down with this polyp. The base of the sphenoid was identified and opened. Purulent material was noted within the right maxillary sinus. This was cultured and suctioned. No further disease was noted on either side.

Bacitracin antibiotic coated Kennedy packs were placed and Bacitracin-coated Merocel packs were placed in the patient's nasal airway and then expanded with Afrin nasal spray. A nasal drip pad was placed. The patient was then fully emerged from anesthesia and extubated and taken to the recovery room in good condition.

ANOTHER COMPLICATED SINUS & NASAL SURGERY SAMPLE

DATE OF SURGERY: February 10, 2005.

PREOPERATIVE DIAGNOSES: Nasal obstruction, nasal septal deviation, turbinate hypertrophy, concha bullosa, chronic sinusitis.

POSTOPERATIVE DIAGNOSES: Nasal obstruction, nasal septal deviation, turbinate hypertrophy. concha bullosa, chronic sinusitis.

OPERATION:
1. Revision reconstructive nasal septoplasty utilizing allograft implant.
2. Inferior turbinate intramural cautery with outfracture.
3. Endoscopic left total ethmoidectomy.
4. Endoscopic left maxillary antrostomy with removal of tissue for pathologic evaluation, endoscopic left sphenoidotomy with removal of tissue for pathologic evaluation.
5. On the right, endoscopic partial ethmoidectomy and endoscopic maxillary antrostomy with removal of tissue for pathology.

ANESTHESIA: General via endotracheal tube.

SURGEON: Alfred Alfred, M.D.

INDICATIONS FOR PROCEDURE:This is a 66-year-old male with a life long history of nasal obstruction. In recent years, he has had more problems, especially with mid-facial pressure pain and nasal obstruction. In the distant past, he had nasal surgery and in the mid-1980s and he believes that he had some nasal trauma after that surgery. Physical examination reveals loss of support to the nasal tip, deflection of the anterior and of the nasal septum into the right nasal vestibule and posterior deflection towards the left. The inferior turbinates are hypertrophic bilaterally. The CT scan indicates mucosal thickening and inspissated secretions in the right maxillary sinus, left sphenoid sinus, bilateral ethmoid sinuses and also there is a concha bullosa of the middle turbinate on the right side. The plan after many years of failed medical management, is to proceed with surgical intervention to relieve the symptoms of obstruction and recurrent infection.

DESCRIPTION OF THE PROCEDURE:The patient was placed in the supine position and general endotracheal tube anesthesia was obtained. Positioning was then changed to a semi-Fowler position. One percent Xylocaine with 1:100,000 parts of epinephrine was then used to infiltrate the greater palatine and incisive foramina transorally. The same solution was used to infiltrate along the nasal septum and inferior turbinates as well as the nasal columella, nasal tip, and dorsum. See the anesthesia record for the total amounts used. A planned W-shaped columellar incision was outlined before the infiltration. This incision was to extend along the leading edge of the lower lateral cartilages intranasally. The mid-face was now prepped and draped in the usual fashion for nasal and sinus surgery.

A 0-degree operating endoscope was brought into the field and the middle meatus was inspected bilaterally. The middle turbinate root, lateral wall of the nose, and the uncinate process were now infiltrated with the same Xylocaine and epinephrine solution as noted above. This was done first on the left side and then on the right while the surgeon then inspected the CT scan which was in the operating room and allowed approximately five minutes to pass before beginning the sinus surgery.

On the left side, under endoscopic guidance, the uncinate process was incised and removed using biting instruments and the suction debrider device. The ethmoid bulla was now entered and the ethmoid cells were sequentially marsupialized up to the roof of the ethmoid sinus and posteriorly through the basal lamella. The maxillary sinus natural ostium was identified and widened posteriorly and inferiorly, thus also identifying the medial and inferior wall of the orbit. This was traced back to allow anatomic orientation to the ethmoid labyrinth. After the basal lamella was entered, the posterior ethmoid cells were also marsupialized and eventually the natural ostium of the sphenoid sinus was identified and widened medially and inferiorly, avoiding lateral action of the biting instruments. Throughout this procedure, there was no evidence of cerebrospinal fluid leak and pressure over the globe did not show any signs of breech of orbital walls. Once the left side was completed in the same fashion, the right side was undertaken. On the right side, only the anterior and mid-ethmoid cells were marsupialized. The basal lamella was not passed and there was no entry into the sphenoid sinus because the CT scan did not indicate need for surgery in these areas on the right. Also, on the right side, there was a concha bullosa middle turbinate which was entered with a straight sickle knife and turbinate scissors were then used to remove the lateral lamella of that turbinate. It was passed off the field as a separate specimen. At this point, with the sinus work completed, the attention was turned to the nasal portion of the procedure.

The columellar incision outlined earlier was now incised down to the medial crura of the lower lateral cartilages. The rim incision was continued along the cephalic rim of the lower lateral cartilages up into the nose. Iris scissors and then Joseph scissors were used to elevate the soft tissues off the nasal tip cartilages and up onto the nasal dorsum, connecting all of these tunnels, thus degloving the nasal tip and dorsum. An Aufricht elevator was used to hold up the soft tissues while inspecting the lower lateral cartilages. The assistant grasped opposite the surgeon at the medial crura of the lower lateral cartilages just inferior to the domes and the soft tissue between these cartilages was dissected with sharp and blunt dissection, eventually identifying the deflected leading edge of the nasal septum. An incision was made on the left side of the nasal septum through this tunnel and the mucosa was elevated and extended posteriorly into the nose, encountering a marked amount of scarring and voids in the nasal septal cartilages. Both sides of the remainder of the perpendicular plate of ethmoid and vomer were identified and elevated from this tunnel and deflected portions were resected. Also, a wide maxillary crest was identified inferiorly and it was resected using a V-chisel. At this point, only a small amount of cartilage which was thin was noted to have been left at the anterior end of the nasal septum. He had had an apparent submucous resection previously. There was an inadequate amount of remaining bone to be able to perform an autograft to support it, therefore, allograft material was brought into the field. I utilized Gore-Tex SAM material sheeting 3-mm thick and an appropriate piece of this material was cut to size and soaked in Bacitracin and Polymyxin antibiotic solution for 15 minutes and then tailored to fit at the anterior end of the nasal septum. The mucosal flaps were returned to their anatomic position and 4-0 PDS suture was used to sew in a basting fashion through-and-through anchoring the implant material into this tunnel, thus supporting the anterior end of the nasal septum and once again supporting the tip and returning the septum to the midline. This material was also sutured to the periosteum at the remainder of the maxillary crest anteriorly. At this point, the deflected portions of the nasal septum were noted to be relieved. It now returned to its normal anatomic midline position. Attention was then turned to the inferior turbinates.

Both inferior turbinates were infractured using a Goldman elevator. The needletip bipolar turbinate cautery device was now used to cauterize intramurally in several positions, both inferiorly and then medially, after the turbinates were once again outfractured. This was done bilaterally observing blanching of the mucosa and shrinkage of the mucosa. Once this was completed, the attention was turned back to the nasal soft tissues, where the tip soft tissues were returned to their anatomic position and the columellar incision was closed in layers using 4-0 chromic in the subcutaneous and dermal planes in an interrupted fashion followed by 5-0 Prolene in the skin at the points of the W-incision and 4-0 chromic on the intranasal portions of the rim incisions in an interrupted fashion bilaterally. Note that hemostasis had been obtained along the way by the use of the Bovie electrocautery device and the wound had been irrigated with sterile normal saline solution.

Telfa packs were now cut to size, coated with a K-Y jelly Bacitracin Polymyxin antibiotic solution combination and slid along the nasal septum medial to the inferior turbinates bilaterally. Then 2-0 silk sutures were attached to the anterior end of these Telfa packs and tied over the nasal columella. The same K-Y jelly and Bacitracin Polymyxin antibiotic solution mixture was then applied to the columellar incision. The nasal tip and dorsum were now cleaned of any blood and debris. A skin protected barrier pad was used to treat the skin of the tip of the nose and 3-M Steri-Strips were now placed in a tip supporting taping fashion. Following the tapes, Mastisol was applied to the paper tapes and finally, an aluminum nasal splint was applied in the usual fashion. A gauze drip pad holder was attached to the ears, holding a drip pad to the nasal base, as the patient was turned over to anesthesia for emergence.

OPERATIVE FINDINGS:
1. Marked scarring and cartilaginous and bony voids in the nasal septum, with deviation to the left posteriorly and to the right anteriorly, repaired via open approach with Gore-Tex SAM implant material placed anteriorly in submucosal tunnel to add support to the nasal tip and septum.

2. Polypoid mucosa throughout the ethmoid and maxillary sinuses, both sides, as well as polypoid mucosa in the left sphenoid sinus.

3. Right middle turbinate concha bullosa lateral lamella resected.

4. Inferior turbinate parenchymal hypertrophy treated with intramural cautery and outfracture, bilateral.

5. No evidence of cerebrospinal fluid leak.

6. No evidence of breech of orbital wall.

7. No purulent material.

8. Estimated blood loss less than 50 cc.

9. No complications.