DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left subperiosteal abscess of the left eye.
POSTOPERATIVE DIAGNOSES:
1. Acute maxillary, ethmoid, and sphenoid sinusitis.
2. Fungal sinusitis.
3. Subperiosteal abscess.
OPERATIONS PERFORMED:
1. Left sphenoidotomy.
2. Left anterior-posterior total ethmoidectomy.
3. Left maxillary antrostomy.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal anesthesia.
ESTIMATED BLOOD LOSS: 25 mL.
SPECIMEN: Left nasal cavity contents, including ethmoid sinus tissue, sphenoid sinus tissue, and maxillary sinus tissue.
OPERATIVE FINDINGS: The patient had black necrotic mucosa within the left nasal cavity consistent with a mucormycosis. Frozen section diagnosis was consistent with fungus but no definitive organisms could be identified on H and E staining. Defer to permanent staining.
DESCRIPTION OF OPERATION: The patient came to the operating room and was placed in the supine position on the operating room table. General face mask anesthesia was given until a deep plane of anesthesia was obtained. At that point, an endotracheal tube was placed by the anesthesiology service without difficulty. The table was turned. Approximately 8 mL of 1% lidocaine with 1:100,000 epinephrine was injected into the left nasal cavity. Then, 5% cocaine-soaked nasal pledgets were placed in the left nasal cavity. The patient was then prepped and draped in routine fashion. The cocaine-soaked nasal pledgets were removed.
The procedure began with a 0-degree 4 mm nasal endoscope. Evaluation of the nasal cavity revealed necrotic, dead inferior turbinate and middle turbinate with crusting up to the skull base. The patient also had dead nasal mucosa back to the pterygopalatine fossa. The procedure began by making an inferior meatal window. This was performed with straight suction due to the necrotic nature of the lateral nasal cavity wall.
A Straight Shot microdebrider was used to resect the entire inferior turbinate back to the pterygopalatine fossa. Again, there was necrotic debris over the pterygopalatine fossa back to the pterygoid plates. The lateral wall of the nasal cavity was then removed, creating a large maxillary antrostomy. Purulent debris from the maxillary sinus was suctioned into a specimen container and sent for microbiology. Large pieces of tissue were sent for frozen and permanent pathology. As noted above, the frozen pathology came back as necrotic debris with fungal elements, no particular fungus identified.
At that point, the ethmoid bulla was taken down. The entire middle turbinate was removed due to its necrotic nature. A large posterior ethmoidectomy was performed as well as a sphenoidotomy with the Straight Shot microdebrider. Purulent drainage was suctioned free from the sphenoid sinus. The lamina papyracea overlying the periorbita was then removed due to the patient’s subperiosteal abscess. No discrete abscess was identified; however, there was some clear fluid that was liberated with removal of the lamina papyracea.
The anterior and posterior ethmoid arteries were identified and preserved. The skull base was identified and preserved. Of note, the skull base showed black necrotic tissue and bone at the olfactory cleft and ethmoid sinus roof. The wound was then thoroughly irrigated with normal saline. Surgiflo was placed within the wound for hemostasis though there was very little bleeding throughout the entire procedure secondary to the vasculitis that was present.
Of note, the patient also had necrotic debris up to the nasal valve and nasal ala. The decision was made at that point to complete the surgery. There were no complications during the procedure. The patient was then awakened from general anesthesia, extubated, and sent to the postanesthesia care unit in stable condition.
