Mastoidectomy #2

               SWEDISH MEDICAL CENTER
                             501 EAST HAMPDEN AVENUE
                             ENGLEWOOD CO  80113

PATIENT NAME:    ZOUBEK,JOHN ROBERT  

REPORT#:0601-0177
REPORT STATUS: Signed

ATTENDING PHY:  Pazurek,Anna Maria  MD

                                   OPERATIVE REPORT

CC:   ROCKY MOUNTAIN EAR CENTER

   Christopher M Courtney, MD

   Edward J Hepworth, MD

Patient Name:  ZOUBEK, JOHN ROBERT

Date of Surgery:  06/01/2023

SURGEON:  James Eric Lupo, MD

REFERRING PHYSICIAN:
Anna M Pazurek, MD

PREOPERATIVE DIAGNOSIS:
Left chronic mastoiditis.

POSTOPERATIVE DIAGNOSIS:
Left chronic mastoiditis.

PROCEDURES PERFORMED:
1. Left revision mastoidectomy.
2. Use of operating microscope for microdissection.
3. Needle EMG cranial nerve supplied muscle.
4. Neurophysiology monitoring in the operating room, 1-on-1 monitoring
    requiring personal attendance.

INDICATIONS FOR PROCEDURE:
The patient is a 43-year-old male.  He has a history of left mastoiditis.  He
had undergone a mastoidectomy a year ago and had done well in terms of
postoperative recovery.  Over the last few weeks; however, he has began having
left-sided pain.  The pain is on his ear and behind his ear as well as
extending onto the left side of the face along the jaw across the midline.  He
had presented to an Emergency Department in April 2023 and a CT scan was
obtained at that point showing fluid in the left mastoid process.  He then had
an MRI in the middle of May, which demonstrated continued fluid in the
inferior portion of the mastoid.  He has been on chronic antibiotics and most
recently has been on Rocephin.  Despite treatment with antibiotics by PICC
line, he has continued to have significant discomfort, sensitivity and pain on

the left around the ear and extending on to the lower face. He was informed of
the risks, benefits, and alternatives of the above- mentioned procedure and
freely consented to undergoing the above- mentioned procedure.

ANESTHESIOLOGIST:
Dr. Kenneth Swank.

ANESTHESIA:
General anesthesia.

ESTIMATED BLOOD LOSS:
5 cc.

DESCRIPTION OF OPERATION:
After the patient was met and greeted in the preoperative holding area, the
history and consent were carefully reviewed.  The patient was marked on the
left-hand side, was brought back to the operating room and then the operating
table in the supine position.  The anesthesia team attached monitors and
induced general anesthesia without any difficulty.  Once a sufficient plane of
anesthesia was obtained, the table was turned 180 degrees.  The head was
turned to the right-hand side and facial nerve electrodes were placed on the
left side of the face by the recording neurophysiologist, Eleanor Wang.
Operation of the facial nerve monitor was verified with the tap test.  The
patient was prepped and draped in usual sterile manner for left-sided otologic
surgery.  The postauricular sulcus was injected with 1% lidocaine with
1:100,000 epinephrine.  A total of 10 cc was injected.

Procedure commenced by bringing the microscope on the field using microscope
for the duration of procedure.  The postauricular area was visualized.  An
incision was made through the prior incision site.  Hemostasis was achieved
with Bovie as necessary.  Anterior and posterior flaps were elevated.  Then, a
reverse 7 incision was made on the periosteum with the Bovie.  Periosteal
elevator was used to develop an anterior flap.  The mastoid was entered and
the Perkins retractor was placed for exposed mastoid.

Attention was turned to the mastoid tip.  Soft tissue was elevated off the
mastoid process.  Attention was then turned towards the revision
mastoidectomy.

Under microscopic visualization, using the 6 and 4 cutting burs as well as the
4 diamond bur, revision mastoidectomy was performed.  Air cells that were
still present as indicated by the CT were the mastoid tip as well as the
tegmen medially near the ossicular chain.  The mastoid tip was addressed
first.  Using the 6 cutting bur, the bone was exonerated.  The mastoid air
cells were filled with mucoid fluid and edematous mucosa.  The exenteration
products were collected and sent as antibiotic specimen.  These were sent for
aerobic, anaerobic, Gram stain, fungal, and AFB.  The mastoid tip was removed
in its entirety.  Attention was then turned to the rest of the mastoid.  The
sinodural angle was investigated.  Small air cells were exonerated.  Small
mastoid air cells present on the posterior face of the mastoid.  These were
exonerated as well.  Attention was turned medially and superiorly and the
small air cells that were identified on CT scan were exonerated.  A small
portion of the tegmen was removed revealing dura.  There was no CSF leak.  The
prior surgery involved opening up the facial recess and this was found to be

patent.  There were numerous fibrotic webs in the mastoid, which were lysed
sharply during this portion of the procedure.

The ossicular chain was palpated and found to be mobile.  There was good
communication from the mastoid to the middle ear and through the facial
recess.  The area was thoroughly irrigated.  Hemostasis was ensured with the
diamond burs as necessary.  The procedure at this point turned towards
closure.  The anterior based periosteal flap was closed with interrupted 3-0
Vicryl.  The skin was approximated in deep dermal fashion with 3-0 Vicryl,
followed by Mastisol and Steri-Strips.  A mastoid pressure dressing was then
placed in the usual sterile manner.  The patient was then awoken and appeared
to have tolerated the procedure well.

SPECIMENS:
Left mastoid contents.

COUNTS:
Counts were correct at the end of the procedure.

CONDITION:
The patient was awoken in fair and stable condition with good facial nerve
function.

DISPOSITION:
The patient was woken, taken to recovery room, where he would begin his
recovery before being sent back to the floor for continued antibiotic
treatment and pain relieve.