DEPARTMENT OF E.N.T. AND HEAD AND NECK SURGERY, K.E.

M HOSPITAL

 DISCHARGE CARD

HEAD OF UNIT:- DR NILAM U.SATHE

NAME: ADITYA DEEPAK DUBEY

AGE: 9 YRS SEX: MALE

RES: R. NO 23/3, A.M JAIN ESTATE , VILLAGE RD, OPP, BHATIYA HOSP., BHANDUP(W), MUMBAI,
Maharashtra

IPD NO: 23/59770 PH NO:- 8828039731 OPD NO: G/25154

Date of admission: 04/12/2023 Date of surgery: 05/12/2023 Date of discharge: 19/12/2023

Diagnosis : Spontaneous Cerebrospinal Fluid Leak Under Evaluation

Surgery: Left Endonasal endoscopic CSF Leak Repair under general anaesthesia d/b Dr Nilam Sathe a/b
Dr Anjali Dr Andalib Dr Ankit on 07/12/2023.
HISTORY – C/o Clear watery discharge from nose since 6 months from both nostrils, unable to sniff
back , aggravated after rhinitis
-H/o Fever associated with chills , Moderate grade
-H/o Frontal Headache present
-H/o Vomiting present
-No H/o Recurrent rhinitis/sneezing
-No H/o Watering from eyes
-No h/o Facial pain/paraesthesia
-No h/o DOV/Diplopia
-No h/o fever with vomiting/blurring of vision/irritability/ behavioural abnormality
-No h/o nasal surgery/road traffic accident
-No H/o nasal bleed
-No h/o any other ENT complaints
-No H/o DM/HTN/TB/TBC

Clinical Examination:
GENERAL: GC- Fair, conscious, oriented
SpO2- 98% Kernig’s and Brudzinski’s sign negative
EAR: Right Left. TFT Right Left
PRE AURICULAR 256hz
PINNA 512hz
POST AURICULAR 1024hz
EAC Weber
TM
NOSE :No External deformity,, Air blast equal, No sinus tenderness, mucosa -normal no active leak at
present

THROAT : Posterior pharyngeal wall – within normal limits

Vn:
EOM:

PLR:

INVESTIGATIONS:
MRI Brain: leptomeningeal enhancement , herniation of brain parenchyma and meninges through
defect in anterior ethmoid region suggestive of fronto-ethmoid encephalomeningocele
CT PNS: small defect in roof of left ethmoid sinus with herniation of left frontal lobe tissue

OT NOTES: Left Endonasal endoscopic CSF Leak Repair under general anaesthesia d/b Dr Nilam Sathe a/b Dr Anjali Dr
Andalib Dr Ankit on 07/12/2023
1)Patient taken under general anaesthesia
2)Parts, painted and draped under aseptic precautions
3)Nasal decongestion done
4)Local infiltration given
5) Diagnostic nasal endoscopy done – suggestive of Deviated Nasal Septum to left seen, posteriorly septum
abutting over middle turbinate
6)Left middle turbinatectomy done to get better visualization
7)Uncinectomy done
8)Anterior and posterior ethmoidectomy done
9)Meningocele seen coming out at the junction of lateral and medial lamella
10) Meningocele cauterized with bipolar cautery
11) Cerebrospinal Fluid leak confirmed by giving valsalva
12)Tensor fascia graft harvested and fat harvested from right anterolateral aspect of thigh
13) cerebrospinal fluid leak site sealed with using tensor fascia Lata graft by overlay technique
14)Tissue glue applied over it
15)Gelfoam placed
16)Valsalva given , no leak seen
17)Suturing done, net cell placed
18)Anterior nasal dressing given
19)Post op uneventful
COURSE IN THE WARD: Inj Xone 500g IV BD x 14 days
Inj Amikacin 375mg IV OD x 14 days

ADVICE ON DISCHARGE:
TREATMENT:
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FOLLOW UP IN E.N.T. OPD 107 – MON/WED/FRI AT FOR SR / DRESSING/ FOLLOW UP

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