10.25.2023 Operative Note

OPERATIVE NOTE
REPORT#:1025-0286 REPORT STATUS: Signed
DATE OF SURGERY: 10/25/2023

SURGEON: Edward Hepworth, MD

PREOPERATIVE DIAGNOSES: Chronic maxillary sinusitis, chronic ethmoid sinusitis, chronic frontal sinusitis, chronic sialadenitis and
sialodocholithiasis.

POSTOPERATIVE DIAGNOSES: Chronic maxillary sinusitis, chronic ethmoid sinusitis, chronic frontal sinusitis, chronic sialadenitis and
sialodocholithiasis.

PROCEDURES:

1. Left endoscopic total ethmoidectomy.
2. Right endoscopic total ethmoidectomy.
3. Left endoscopic frontal sinusotomy with tissue removal.
4. Right endoscopic frontal sinusotomy with tissue removal.
5. Left endoscopic maxillary sinusotomy with tissue removal.
6. Right endoscopic maxillary sinusotomy.
7. Four-duct sialendoscopy, left Stensen’s, right Stensen’s, left Warthin’s, right Warthin’s.

ANESTHESIA: General endotracheal.

FLUIDS: 1000 mL of crystalloid.

ESTIMATED BLOOD LOSS: 25 mL.

FINDINGS: Abscess in the left frontal region. Complete obstruction of left Wharton’s and Stensen’s and right Wharton’s and Stensen’s duct puncta with a small amount of purulent sludging in the 4 ducts, otherwise without evidence of damage to the acini of the glands.

INDICATIONS FOR PROCEDURE: Mr. Zoubek is 43 and has been struggling mildly with face pain, mouth pain, mouth dryness, sinus infection, and inclusion cyst throughout his mucosa and cystic structures within his external facial tissues. Previously, this has been thought to be actinomycosis, but has failed to respond in any kind of definitive manner to multiple types and courses of antibiotics. Imaging and office examinations are demonstrative of sinusitis
and purulent drainage from the salivary ducts. We are coming to attempt remedy of this more definitively surgically today.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed supine on the table. General anesthesia was induced, and an oral endotracheal tube was placed. After sufficient anesthesia was accomplished, the face was prepared and draped semi-sterilely. Local anesthetic was infiltrated into the nasal sidewall structures. The ethmoid cavities on both sides were obscured and obstructed by scar tissue spanning between the medial turbinate lateral aspect and the medial orbital wall. This was divided and cleared until the ethmoid roof could be seen, and the medial orbital wall visualized. This required removal of several septations constituting total ethmoidectomy back to the anterior wall of the sphenoid. At the anterior ethmoid roof anterior aspect, the frontal sinus recess was identified and cleared of septations and scar tissue. Both frontal sinuses were obstructed in this manner. The left frontal sinus was filled with thickened mucopus, much like is seen with allergic fungal sinusitis. This was collected in its entirety and sent for culture. The left maxillary sinus outflow was obstructed
by scar tissue, which was divided and polypoid matter within the maxillary sinus cleared so that the normal mucosal surfaces were restored. This constituted tissue removal. A small scar tissue band also obstructed the right maxillary outflow, which was viewed with a 70-degree endoscope and removed, and the maxillary sinus lavaged clear of mucopus.

Attention was then directed to the oral cavity. Each of the Stensen’s and Wharton’s duct puncta were dilated with lacrimal dilators until a 1.5 mm sialendoscope could be passed through them, and then the ducts were lavaged and photographed. After reaching acini of the submandibular and parotid glands, there seemed to be no intrinsic ductal obstruction, but the dilation of the puncta was extremely difficult owing to scar tissue obstruction. After this, saliva seemed to be clearly flowing through each of the 4 ducts. The patient
was then suctioned, awakened from anesthesia, extubated, and brought to the recovery room in satisfactory condition.