OPERATIVE REPORT

PATIENT NAME:

MEDICAL RECORD NO:

DATE OF BIRTH:

DATE OF SURGERY:

SURGEON:

ANESTHESIA: General laryngeal mask airway.

PREOPERATIVE DIAGNOSES:
1. Chronic rhinosinusitis.
2. Bilateral nasal polyposis.
3. Deviated nasal septum and nasal airway obstruction.
4. Bilateral inferior turbinate hypertrophy with nasal airway obstruction.

POSTOPERATIVE DIAGNOSIS: Same.

OPERATIVE PROCEDURE:
1. Endoscopic bilateral balloon sinuplasty of the frontal and sphenoid sinuses.
2. Endoscopic bilateral nasal polypectomies.
3. Endoscopic bilateral submucosal resection of inferior turbinates.
4. Endoscopically assisted submucosal resection of nasal septal cartilage and bone.
5. Endoscopic bilateral maxillary antrostomies with removal of all polyps.
6. Endoscopic bilateral anterior ethmoidectomies with removal of polyps.

ESTIMATED BLOOD LOSS: 40 mL.

SPECIMENS:
1. Nasal septal cartilage and bone.
2. Right ethmoid cells.
3. Left ethmoid cells.
4. Right nasal polyps.
5. Left nasal polyps.

COMPLICATIONS: None history.

HISTORY AND INDICATIONS: Mr. Dawes is a gentleman history of chronic and recurrent
rhinosinusitis. He has been on multiple courses of antibiotics, nasal steroids and oral
steroids without improvement in his symptoms. After reviewing CT sinuses with him, he
elected to proceed with the above-named procedures. An informed consent was obtained.
After reviewing the specific risks, benefits, alternatives, and complications of the surgeries,
all of his questions were answered, and he wished to proceed.

OPERATIVE NOTE: Patient was correctly identified in the preoperative holding area and
escorted to the operating room. The patient was placed in the supine position on operating
room table. After successful induction of general anesthesia and laryngeal mask airway was
secured, he was prepped and draped in routine manner. Afrin-soaked pledgets were placed
in the bilateral nasal passages. After 5 minutes they were removed and 1% lidocaine with
1:100,000 epinephrine was then injected into the submucosal planes of the nasal septum,
the bilateral inferior turbinates, the superior attachments of the bilateral middle turbinates
and lateral nasal walls as well as polypoid tissues in the bilateral middle meatuses. 30 mL
were used. The pledgets were then replaced. After 10 minutes the pledgets were removed
and then under endoscopic guidance, an incision was made along the anterior portion of the
right nasal septal mucosa. Underlying cartilage was identified and a Cottle elevator was
then used to raise the mucosa off the underlying cartilage and bone. Once this was done, a
15 blade was used to make an incision to the caudal aspect of the septum, taking care to
maintain a sturdy dorsal and caudal strut. Once this was done, a Cottle elevator was then
used to raise the mucosa on the contralateral side. After it was raised, a Stevens scissors
and swivel knife were used to resect the deviated portion of the cartilaginous septum
anteriorly. A Cottle elevator was used to raise a bony spur on both the right and left sides
off the maxillary crest. This was passed off as specimen. The mucosal flaps were then
reapproximated and then a 4-0 plain stitch on a Keith needle were utilized to make a
mattress suture going from anterior to posterior, superior to inferior and incision was then
closed with the same suture material. Attention was then turned to the right middle meatus
where large polypoid tissue was noted occluding the meatus. A small biter was used to take
specimen to pass off for pathology and then an Olympus 4.0 mm shaver was then used to
slowly debride the polyps around the middle turbinates extending along the middle meatus
into the area of the frontal ethmoid recess. The middle turbinate was then lateralized and
more polypoid tissue was noted in the sphenoethmoid recess. This was also debrided until
the sphenoid sinus opening was identified. The middle turbinate was then medialized again
and a shaver was used to identify the uncinate process and small portion of the inferior
uncinate was resected utilizing the shaver, allowing the maxillary os to be further widened
and opened. The shaver was then removed and a Cottle was used to open the ethmoid
bulla on the right side. The bone was noted to be sclerotic and thickened. Polypoid mucosa
was noted behind it. The Cottle was then used to gently open the cells posterior to this and
a small biter was used to remove these portions of tissue and these were passed off as
specimen. Polypoid tissue was noted in the ethmoid areas. Next, attention was turned to
the left nasal passage where again the middle turbinate was medialized and the middle
meatus was seen to be occluded by polypoid tissue. The Olympus 4.0 mm shaver was then
used to debride and excise these polypoid tissues proceeding along the surfaces of middle
turbinate until the ethmoid bulla was identified and proceeding to the area of the middle
meatus. Once these polyps were removed, the frontal ethmoid recess was also seen and
had polypoid disease. This was also removed utilizing the shaver. The uncinate process
was identified and the Olympus 4.0 mm shaver was used to resect the inferior portion.
Therefore, allowing the maxillary sinus os and further widened and open. A Cottle was then
used to open the ethmoid bulla on left side, again noting sclerotic bone with thickened
polypoid mucosa within it. The Cottle was then used to sequentially open the remainder of
the anterior ethmoid cells until the basal lamella was identified. A small biter was then used
to pass these tissues off as specimen. Once this was done, attention was turned to the
right frontal ethmoid recess, noted to be narrowed and occluded by mucosal thickening.
The Acclarent frontal sinus balloon catheter was introduced in the field. The light catheter
was passed into the frontal sinus. Once it was confirmed by transillumination, the balloon
catheter was placed into the sinus itself. The balloon was then inflated and left in position
for 10 seconds, deflated, pulled down 1 cm and then reinflated again to further widen the
frontal ethmoid recess. The balloon catheter was then deflated and removed and the right
frontal ethmoid recess was seen to be clear. The endoscope was passed posteriorly along
the septum into the right sphenoid face was identified. Thickened polypoid mucosa was
noted. The shaver was used to further debride this, allowing the right sphenoid os to be
further opened. Attention was then turned to the left nasal passage where again the left
frontal ethmoid recess was seen to be narrowed by polypoid tissue. The shaver was used to
resect some more this polypoid tissue, allowing further access to the left frontal ethmoid
recess. The Acclarent frontal sinus balloon catheter was introduced into the field
endoscopically on the left side. The light catheter was passed into the frontal sinus on the
left. It was noted to be in good position by transillumination and the balloon catheter was
passed over the light until it was in the sinus. The balloon was then inflated and left in
position for 10 seconds before being deflated and then pulled down 1 cm and reinflated
again. Once it was dilated, it was then deflated and removed. The left frontal ethmoid
recess was seen to be clear. The endoscope was then guided along the left posterior
septum until the left sphenoid os was identified, noted to be occluded by thickened polypoid
mucosa. This was also debrided with a shaver and then allowing the balloon catheter to be
passed into the sphenoid os to be dilated to further widen it. Attention was turned back to
the right side where again moving posteriorly along the septum the sphenoid os was seen to
be narrowed. Balloon catheter was passed into it, dilated, deflated and then removed
showing a widened right sphenoid ethmoid os. Attention was then turned to the right. The
balloon catheter system was then removed attention was turned to the right inferior
turbinate, noted to be hypertrophic. Stab incision was made at the anterior face 1 cm
beyond the head with a 15 blade. Cottle elevator was then used to raise hypertrophic
mucosa off underlying bone and an Olympus 2.0 mm shaver was introduced through the
incision and 2 passes were made from anterior to posterior to resect underlying
hypertrophic mucosa. The incision site was then closed with the coag feature. The
turbinate was then infractured with a Freer and then outfractured with a long nasal
speculum, greatly improving the inferior nasal airway. Attention was then turned to the left
inferior turbinate noted to be hypertrophic and obstructing the anterior and posterior
airways. Stab incision made was made 1 cm beyond the actual head of the turbinate with a
15 blade and then a Cottle elevator was used to raise hypertrophic mucosa off the
underlying bone. The shaver was then introduced through the incision and 2 passes were
made from posterior to anterior to resect underlying hypertrophic mucosa. The incision was
then closed with the coag feature. A Freer was used to infracture the turbinate. Long nasal
speculum used to outfracture it, greatly improving the inferior nasal airway. The nasal
passages and open sinus passages were then thoroughly irrigated and suctioned clean. No
excessive bleeding was noted Sinu-Foam was placed in the area of the open ethmoid cells in
the middle meatus and then Doyle septal airway splints were coated in bacitracin and
secured across the bilateral septum with a 3-0 silk suture. The patient was then reversed
from anesthesia, extubated in the operating room without difficulty and escorted to
recovery room in stable condition. There were no complications.

THIS IS A PRELIMINARY REPORT

Doctor Test, MD

DT/sp/6340591
DD: 3/4/2022 08:54 A.M.
DT: 3/4/2022 12:07 P.M.