DIAGNOSIS: Chronic maxillary sinusitis based pain
PROCEDURES PERFORMED:
1. Right endoscopic maxillary antrostomy
2. Right endoscopic partial ethmoidectomy
ANESTHESIA: General endotracheal
FLUIDS: 1000mL crystalloid
ESTIMATED BLOOD LOSS: 5mL
COMPLICATIONS: None
DRAINS: None
PACKING: None
INDICATIONS FOR PROCEDURE: John is 40 and has been struggling with atypical infectious problems in his face and neck. This most recently appears to have settled into his right maxilla as evidenced by his symptoms and by imaging. We come in to recify this by surgical drainage, culture, and biopsy of his right maxillary tissues.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed supine on the table. General anesthesia was induced and oral endotracheal tube was placed. When sufficient anesthesia was accomplished, the face was prepared and draped in the usual sterile fashion and local anesthetic was infiltrated into the sidewall structures. Nasal endoscopy ensued and a partial ethmoidectomy was performed by removal of the uncinate process of the ethmoid and tissues behind it, which were obstructive off maxillary outflow. These were sent for pathology. The natural ostia and the maxillary sinuses were identified and opened widely into the posterior fontanelle and a Haller cell formation was removed, which was obstructive of the maxillary outflow. Thickened mucous was then collected out of the maxillary flow and sent for a culture, aerobic, anaerobic, and fungal and tissues withing the maxillary sinus were sent for pathology. Mucosal structures were left in place and intact as much as possible and then the patient was suctioned and awakened from anesthesia, extubated, and brought to the recovery room in satisfactory condition.
Electronically Signed
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