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ENT OPERATIVE (SEPTOPLASTY/ETHMOIDECTOMY)

PREOPERATIVE DIAGNOSES:
1.  Nasal obstruction.
2.  Nasal septal deviation.
3.  Turbinate hypertrophy.
4.  Concha bullosa.
5.  Chronic sinusitis.

POSTOPERATIVE DIAGNOSES:
1.  Nasal obstruction.
2.  Nasal septal deviation.
3.  Turbinate hypertrophy.
4.  Concha bullosa.
5.  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 endotracheal anesthesia.

COMPLICATIONS:  None apparent.

INDICATIONS: This is a 78-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, 1%  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 needle-tip 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.

ENT – NASOLACRIMAL DUCT OBSTRUCTION/LACRIMAL PROBING

PREOPERATIVE DIAGNOSIS: Nasolacrimal duct obstruction, both eyes.

POSTOPERATIVE DIAGNOSIS: Nasolacrimal duct obstruction, both eyes.

OPERATION: Lacrimal probing, both eyes.

ANESTHESIA: General.

COMPLICATIONS: None.

PROCEDURE: The patient was brought to the operating room and was prepared for a clean procedure under suitable general anesthesia in the supine position.

The left upper punctum was dilated using a succession of punctum dilators. The #0 Bowman probe was introduced through the left upper punctum and was advanced without resistance along the superior canaliculus until bony resistance was encountered at the nasal wall of the lacrimal sac. The tip of the probe was then directed inferiorly, into and through the bony nasolacrimal duct. Membranous resistance was easily overcome. The tip of the probe was palpated using a second probe, introduced through the nostril and beneath the inferior turbinate. Both probes were removed.

The left lower punctum was then dilated using a succession of punctum dilators. The #0 Bowman probe was introduced through the left lower punctum and was advanced without resistance along the inferior canaliculus until bony resistance was encountered at the nasal wall of the lacrimal sac. The probe was removed.

The right upper punctum was then dilated using a succession of punctum dilators. The #0 Bowman probe was introduced through the right upper punctum and was advanced without resistance along the superior canaliculus until bony resistance was encountered at the nasal wall of the lacrimal sac. The tip of the probe was then directed inferiorly, into and through the bony nasolacrimal duct. Minimal resistance was easily overcome. The tip of the probe was palpated using a second probe, introduced through the nostril and beneath the inferior turbinate. Both probes were removed.

With the help of a nasal speculum, the inferior turbinate was examined under direct visualization. Because this structure did not appear to crowd the inferior meatus, infracture was deferred.

At the completion of the procedure, sulfacetamide/prednisolone solution was instilled in both eyes.

P.S. Before the probing began, nasopharyngeal cultures were taken for both aerobic and anaerobic media. 

 

ENT – ADENOTONSILLECTOMY

PREOPERATIVE DIAGNOSIS: Adenotonsillar hypertrophy.  

POSTOPERATIVE DIAGNOSIS: Adenotonsillar hypertrophy.  

OPERATION: Adenotonsillectomy.

ESTIMATED BLOOD LOSS: 10 ml. 

ANESTHESIA: General. 

COMPLICATIONS: None.

CONDITION: Stable to PACU. 

OPERATIVE FINDINGS: Three plus tonsils with adenoid bed almost completely obstructing visualization of the choana. 

INDICATIONS: This is a 9-year-old female who presented to otolaryngology clinic complaining of chronic tonsillitis and enlarged tonsils with symptoms of nasal obstruction.  After the risks and benefits of the procedure to remove the tonsils and adenoids were discussed with the patient’s family, informed consent was obtained and she was scheduled for surgery. 

Complications such as bleeding, infection, and postoperative dehydration were discussed. 

PROCEDURE: The patient was taken to the operating room and placed on the operative table in the supine position.  General anesthesia was induced via face mask and the patient was endotracheally intubated.  Once IV access was obtained, the table was turned 90 degrees and the patient was further positioned with a shoulder roll beneath the shoulder blade and the head slightly extended.  The McIvor mouth gag was inserted in atraumatic fashion and used to suspend the oral cavity from the Mayo stand.  Two red rubber catheters were introduced into each nostril and used to retract the soft palate.  The palate was palpated and no submucosal cleft was identified. 

Bilateral tonsillectomy was then performed starting on the right-hand side.  The right tonsil was grasped with an Allis clamp and retracted medially.  The tonsil was then removed in an avascular plane between the tonsil and tonsillar fossa using Bovie electrocautery in a setting of 18.  Additional electrocautery was used for any sites bleeding or obvious blood vessels.  The contralateral tonsil was handled in a typical fashion.  Indirect nasopharyngoscopy was then performed using a mirror.  The adenoid bed was found to be almost completely obstructing visualization of the choana.  The adenoid pad was then removed using suction cautery on a setting of 35.  Once adequate hemostasis was achieved, in addition to clear visualization of the choana, the red rubber catheters were removed and 0.25% Marcaine with 1:100,000 epinephrine was injected into the soft palate for postoperative analgesia.  The McIvor mouth gag was removed and the stomach was suctioned prior to extubation. 

Dr. XX was present throughout the entire procedure and the patient tolerated the procedure well without complications. 

ENT – TOTAL LARYNGECTOMY

PREOPERATIVE DIAGNOSIS: Left vocal cord squamous cell carcinoma. 

POSTOPERATIVE DIAGNOSIS: Left vocal cord squamous cell carcinoma.

OPERATION: Total laryngectomy.

ANESTHESIA: General endotracheal.

ESTIMATED BLOOD LOSS: 50.

COMPLICATIONS: None.

INDICATIONS: 

PROCEDURE: The patient was brought to the operating room and placed supine on operating table. After adequate sedation was achieved, the patient was endotracheally intubated.

The table was turned and a shoulder roll and head donut was placed and the left neck was prepped and draped in a standard fashion.

A 2-cm curvilinear incision 2 fingerbreadths below the cricoid was made in the skin with a 15 blade followed by removal of excess subcutaneous fat with electrocautery. Dissection continued on to the strap muscles which were divided in the midline. The thyroid isthmus was divided with electrocautery carefully and the fascia was cleared off of the tracheal wall and the trachea was divided with Metzenbaum scissors and an anode tube was placed and secured near the clavicle with a Prolene suture.

After this was done, incision was made over the STM and then into a natural skin crease above the tracheostomy incision and crossing the midline. The incision was made with a 15 blade through subcutaneous tissue and then electrocautery down through subcutaneous fat and onto the platysma. Subplatysmal flaps were raised, and the fascia over the STM was divided. The spinal accessory nerve was identified, and entering the spinal accessory nerve dissection continued anterior to the STM collecting fibrofatty and lymphatic tissue from zones 2, 3, and 4. The omohyoid was identified and divided as were the cervical rootlets which were preserved. Dissection continued onto the internal jugular vein and sharply on the vein carefully preserving the internal jugular vein and suture ligating tributaries to the vein. Dissection was carried out with a 15 blade.

The hypoglossal nerve was identified as was the posterior belly of the digastric. The zones 2, 3, and 4 were passed off as specimen. Next, the strap muscles were divided inferiorly off the thyroid cartilage and the fascia was divided off the thyroid cartilage and cricoid. The cricothyroid membrane was carefully divided and inspected. It was evident that there was a posterior portion of subglottic involvement off the left vocal cord. Several frozen sections were taken from the portion from the cricoid cartilage as well as the inferior portion of the subglottic space on the left side and posteriorly near the arytenoid on the left side. Several of these margins were positive.

A decision was made to perform a total laryngectomy and then abandoning any further effort to completing a supracricoid laryngectomy. The lateral aspect of the thyroid cartilage was identified bilaterally and the inferior constrictors were divided off of the thyroid cartilage. Mucosa of the piriformis sinus was peeled off of the thyroid cartilage, carefully preserving this mucosa. The trachea was divided and posteriorly beveled and dissection plane was created between the esophagus and the posterior tracheal wall, cleanly, releasing the larynx of the subglottis which was passed off as specimen.

Next, a stoma plasty was performed with 2-0 chromic suture securing the trachea to the subcutaneous tissue, a 7 mm on the right and a 10 mm on the left. Jackson-Pratt drains were placed through separate stab incisions. The nasopharynx was created with a vertical closure with a 3-0 Vicryl suture and then this was reinforced closing the additional tissue of the pharynx over the original closure. This was proved to be watertight with insufflation of water into the hypopharynx.

An NG tube was placed and secured through the septum with a 2-0 Prolene. The wound was copiously irrigated and the platysma was then closed with a chromic suture and the skin with staples. A 10 laryngectomy tube was placed and a pressure dressing was applied.

The patient tolerated the procedure well and Dr. XXX was scrubbed and present for the entire case.

THYROIDECTOMY

PREOPERATIVE DIAGNOSIS: Papillary thyroid cancer. 

POSTOPERATIVE DIAGNOSIS: Papillary thyroid cancer.

OPERATION: Total thyroidectomy.

ANESTHESIA: General endotracheal.

INDICATIONS: The patient is a 57-year-old white male with palpable thyroid masses. Needle aspiration biopsies were consistent with papillary cancer. The patient was brought to the operating room for thyroidectomy.

INTRAOPERATIVE FINDINGS: Bilateral solid masses in each lobe suggestive grossly of papillary cancer. Large tumor nodule on the right lobe going to the posterior capsule into trachea with the right recurrent nerve densely adherent to the tumor as it penetrated into the larynx. A large nodule adjacent to that suggestive of tumor metastases to lymph node. The right parathyroid gland was not visualized. The right recurrent laryngeal nerve lay medial and posterior to the main inferior thyroid artery but was densely adherent to the posterior capsule where tumor penetrates through.

Left recurrent laryngeal nerve was deep within the tracheoesophageal groove. Left upper and lower parathyroid glands were identified and preserved.

PROCEDURE: The patient was brought to the operating room and placed in a supine position. Adequate general endotracheal anesthesia was obtained without difficulty. A shoulder roll was placed and the head hyperextended, and the patient placed in a semi-sitting position. Neck was prepped with Betadine and draped in a sterile fashion.

A curvilinear neck incision was made through a lower skin crease, sharply, and dissection was carried down through the subcutaneous tissue with electrocautery. Subplatysmal flaps were raised from the tip of the thyroid cartilage down the sternal notch using electrocautery.

Strap muscles were separated in the midline using electrocautery from the tip of the thyroid cartilage down the sternal notch and strap muscles were reflected off each thyroid lobe towards the carotid sheath. Left strap muscles were reflected off the thyroid towards the carotid sheath and retracted laterally. Lateral thyrocervical fascia was opened with electrocautery.

The middle thyroid vein was controlled with clamps and 2-0 silk ties. The fascia alongside the thyroid gland was opened with electrocautery. Inferior thyroid veins were now controlled off the trachea with clamps and microhemoclips. Dissection was maintained along the lower pole of the thyroid gland where the lower pole parathyroid was separated and its blood supply controlled with electrocautery. The fascia overlying the tracheoesophageal groove was opened and the inferior thyroid artery was identified. Medial and posterior to this, a recurrent nerve was visualized.

Individual branches of the left inferior thyroid artery to the lateral capsule was controlled with microhemoclips.

Attention was then turned to the isthmus of the thyroid which was separated away from the tip of the thyroid cartilage with electrocautery. The space between cricothyroideus and left lobe was opened with electrocautery and superior pole vessels were controlled with clamps and 2-0 silk ties. Downward and medial retraction on the upper pole allowed division of the upper thyroid fascial bands. 

The upper parathyroid was separated away from the thyroid and its blood supply controlled with electrocautery. This parathyroid was just anterior to the recurrent nerve. It had penetrated into the larynx.

The thyroid gland was now suspended on Berry’s ligament and thyroid tissue was divided at that level with electrocautery. Remaining left lobe and isthmus were now reflected off the trachea towards the right using electrocautery.

Attention was then turned to the right thyroid lobe where the strap muscles were similarly separated off the thyroid capsule towards the carotid sheath and retracted laterally.

Inferior thyroid veins were controlled using microhemoclips or clamps and 3-0 silk ties. The lower pole of the right lobe was separated up off the trachea with electrocautery. Parathyroid gland was not visualized at this level.

A large nodular mass was seen in the posterior aspect of the thyroid gland. Due to this large lesion over the right recurrent laryngeal nerve, it could not be visualized as it entered up out of the anterior mediastinum.

Attention was then turned to the right upper lobe where crossing supply to the cricothyroideus was controlled with clamps and 2-0 silk ties and microhemoclips.

Individual superior pole vessels now could be dissected free and were controlled with clamps and 2-0 silk ties. Downward and medial retraction of the thyroid gland allowed division of the upper thyroid fascial bands. A large tumor nodule consistent with metastatic node was seen posterior and adjacent to the right lobe.

The fascia overlying this was opened with electrocautery.

Large and right inferior thyroid artery was seen coursing over the enlarged metastatic node and a tumor mass. This was controlled with clamps and 2-0 silk ties. With this, a nodular tumor and node could be lifted anteriorly and medially and the recurrent nerve now could be seen on the posterior capsule of thyroid and tumor.

Dissection was maintained now through Berry’s ligament and multiple small vessels were controlled with electrocautery. Right upper parathyroid was not visualized.

Thyroid tissue was now separated at Berry’s ligament with electrocautery. Remaining branches of the right inferior thyroid artery of the posterior capsule were controlled with clamps and 3-0 silk ties. Inferior branch of the inferior thyroid artery going to the lower pole required electrocautery for final hemostasis.

Thyroid was removed. On palpation, however, a tumor nodule was seen adherent to the trachea, medial and posterior to the nerve as it entered into the larynx.

This tumor nodule was then grasped and was dissected from the medial capsule of the nerve with a combination of sharp dissection and electrocautery. The tumor nodule was freed from the surface of the nerve and from the larynx. It was now dissected off the trachea with electrocautery and removed.

Hemostasis for fine bleeding points on the trachea was obtained with electrocautery. A sheet of Surgicel was placed within the thyroid bed.

The strap muscles were reapproximated with interrupted simple sutures of 4-0 PDS. The platysma was closed with a running suture of 5-0 PDS. The skin was closed with a running subcuticular suture of 4-0 Prolene.

Mastisol, Steri-Strips, and a sterile dressing were applied to the wound.

At this point the procedure was terminated, the patient having tolerated the procedure well. The patient was reversed from general anesthesia, extubated in the operating room, and transported to recovery room in stable condition.