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Ear, Nose and Throat

OPERATIVE PROCEDURE: Bilateral Myringotomy with Tube Insertion

The patient is brought into the operating theater and placed supine on the operating table. General anesthesia was induced via face mask, and the patient was prepped and draped in the usual fashion.

An operative microscope was brought into the field and microscopic otoscopy performed on the right ear. Using an appropriate size speculum, the ear was cleansed of excess cerumen with cerumen curette and alligator forceps. The ear canal was then irrigated with Betadine solution and suctioned clear with an angled #3 suction.

Under microscopic inspection, the tympanic membrane was retracted with an obvious thin effusion in the middle ear space. A myringotomy knife was used to create a radial incision in the anterior inferior quadrant, followed by the evacuation of the middle ear fluid with a #3 angled suction. An Armstrong beveled grommet ventilation tube was carefully and easily inserted through the myringotomy incision. Cortisporin suspension was applied and a piece of sterile cotton placed.

A similar procedure was performed in the left ear. After cleansing the ear of excess cerumen and irrigating with Betadine solution, microscopic inspection yielded a thick fluid filling the middle ear space. Radial incision was created inferior anteriorly with the myringotomy knife. Thickened glue-like fluid was evacuated with a #5 suction. An Armstrong beveled ventilation tube was carefully and easily inserted into the tympanic membrane. Cortisporin and a piece of cotton was applied.

OPERATIVE PROCEDURE:

The patient was brought into the operating theater and placed supine on the operating table. General anesthesia was induced and the patient was orotracheally intubated. The oropharynx was packed with a sympathectomy pack to avoid swallowing of any blood. Both nasal fossae were packed with half-inch Nu Gauze soaked in Neo-Synephrine 0.50%.

The gingival labial sulcus on the right was injected with 2 cc of 1% Xylocaine with 1:100,000 epinephrine. A rigid Hopkins rod video endoscopic system was brought into the field and a nasal endoscopy performed.

There was recurrent polyposis in the right ethmoid bed, which was obstructive. A large maxillary antrostomy was present with a large, bluish polyp filling the antrum completely and extruding into the nasal fossa. Upon manipulation of the polyp, was noted purulent debris and microabscesses along the mucosa. The posterior nasal fossa was unremarkable. On the left, there was also recurrent antral disease, which was not occlusive to the maxillary antrostomy.

Under 25-degree telescopic guidance, the right ethmoid was cleared of recurrent polyposis with straight and upbiting bean forceps. The lamina papyracea and the fovea ethmoidalis were identified and preserved. Additional polypoid disease over the sphenoethmoidal recess was resected. A curved suction was placed into the maxillary antrostomy and serous fluid filling some of the polyposis was suctioned clear. Due to the extreme nature of the polyposis, it was not possible to remove it all via the intranasal route.

A Caldwell-Luc on the right was next performed. A hot knife was used to create a 2.5-cm incision in the gingival labial sulcus on the right. The incision was carried down to the bone. The anterior face of the right maxilla over the canine fossa was degloved with a Freer elevator. The infraorbital nerve on the right was identified and preserved. A small 2-mm osteotome was used to gain entrance into the right maxillary fossa sinus via the canine fossa. Kerrison forceps were used to enlarge the antrostomy to approximately 2.5 to 3 cm. Copious polyposis with serous, purulent fluid and microabscesses were present throughout the maxillary sinus. Using straight and upbiting bean forceps, gross polyposis was removed. Coakley curettes were then used to completely strip the mucosa from the right antrum. Additional resection of polypoid disease about the antrostomy was performed via the antral route.

The right antrum was packed with half-inch Nu Gauze soaked in bacitracin ointment, and the packing brought out through the nose and used to pack the right nasal fossa.

A 25-degree scope was placed into the left nostril and the maxillary antrostomy identified. Obvious polypoid protrusions were resected and the antrostomy enlarged slightly to ensure good ventilation. Inspection of the ethmoid bed on the left did not reveal any significant polypoid disease.

At this point, the nasal fossa, nasopharynx, oropharynx and hypopharynx were carefully suctioned clear of any bloody secretions after removal of the throat pack.

PROCEDURE: Left Radical Neck Dissection

CT scanning revealed the left neck mass to be compressing the jugular vein, but to be free of the carotid artery.

The patient was brought to the operating room and placed supine on the operating room table, intubated with general endotracheal anesthesia, prepped and draped in the usual sterile fashion with a rolled sheet beneath the shoulders, and neck extended.

A transverse incision was made through a natural skin crease and carried transversely across the neck, curving toward the mastoid tip. A branch was then brought out toward the shoulder. This was carried down through skin, subcutaneous tissue, platysma muscle, and subplatysmal flaps were elevated above and below. The sternocleidomastoid muscle was dissected and the sternal and clavicular heads were incised. The omohyoid muscle was identified and traced anteriorly, and avulsed from the scapula. This then exposed the jugular vein, and the jugular vein was carefully dissected inferiorly and taken between clamps. Care was taken to preserve the vagus nerve and carotid artery.

Significant radiation changes with fibrosis and adhesions were evident throughout the neck. The jugular vein was taken between clamps and incised, tied above and below with 2-0 silk ties. Inferiorly, the vein was also suture ligated.

The dissection was then carried superiorly with the tumor evident encompassing the jugular vein, but having to be peeled off the carotid artery as well. It was peeled from the common carotid artery up superiorly to the branching of the artery. Posteriorly, the posterior fat pad was dissected free and the transverse cervical vessels were identified and preserved. The posterior fat pad was preserved and dissection was then carried up superiorly along the anterior border of the trapezius. Superiorly, the sternocleidomastoid muscle was incised at the mastoid. Careful sharp and blunt dissection was undertaken to identify the jugular vein superiorly.

This having all been freed up, the mass could then be worked superiorly, laterally and inferiorly, so that it could be dissected off the carotid artery completely. The mass was then removed. The submandibular gland was left in place as it was totally fibrosed and scarred to near negligible size. There was very minimal bleeding.

The wound was irrigated with warm saline. No clots or debris were identified. A Penrose drain was placed. The platysma muscle and subcutaneous tissues were reapproximated with 2-0 chromic subcutaneous sutures and the skin was closed with skin staples. Penrose drain was sewn in place with silk suture ligature.

OPERATIVE PROCEDURE: Tonsillectomy and Adenoidectomy

The patient was brought into the operating theater and placed supine on the operating table. General anesthesia was induced and the patient was orotracheally intubated. The patient was then prepped and draped in the usual sterile fashion.

The neck was placed into extension. A Crowe-Davis mouth gag with an appropriate tongue blade was carefully and easily inserted into the mouth, taking care not to damage the lips, tongue or teeth in any fashion. The mouth gag was opened and suspended from a Mayo stand.

The tonsils were inspected and found to be grossly hypertrophic and obstructive in appearance without exudate. The soft palate was palpated for any signs of a submucosal cleft, but none were found. Size #8 French red rubber catheters were placed through each naris, and brought out through the mouth respectively, then clamped above the mouth gag with a tonsil clamp. This provided excellent soft palate exposure and elevation and access to the nasopharynx. The nasopharyngeal bed was palpated and noted to be completely filled with hypertrophic adenoids.

Using adenoid curettes of various sizes and with several passes, the nasopharynx was completely cleared of hypertrophic adenoidal tissue. Indirect inspection with the laryngeal mirror revealed additional prolapsed adenoidal tissue into the posterior nares. These were resected with biting forceps. The nasopharynx was then packed with cotton balls soaked in cool saline.

The left tonsil was grasped with a curved Allis clamp and retracted medially. A #12 blade was used to create a mucosal incision in the medial aspect of the anterior tonsillar pillar. Using sharp and blunt dissection, the capsule of the left tonsil was identified. Suction Bovie technique was then used to clean and dissect the left tonsil from the left tonsillar fossa. The left tonsillary fossa was packed with tonsillar packing soaked in cool saline.

The right tonsil was then grasped with a curved Allis clamp and retracted medially. The mucosal incision was made in the medial aspect of the anterior tonsillar pillar, followed by isolation of the tonsillar capsule by sharp and blunt dissection. A suction cautery technique was used to completely dissect the right tonsil from the right tonsillar fossa. The right tonsillar fossa was packed with tonsillar packing.

After approximately 7 minutes, all packing was removed and final hemostasis achieved with suction electrocautery. The nasal fossa and the oropharynx were irrigated with cool saline and suctioned clear. A catheter was passed down into the stomach and all stomach contents evacuated. The mouth gag was let down from extension and carefully withdrawn from the mouth, taking care not to damage the lips, tongue or teeth in any fashion.

OPERATIVE PROCEDURE: Tracheostomy - No. 8 Nonfenestrated Cuffed Shiley Tracheostomy Tube

The patient was brought into the operating theater and placed supine on the operating table. General anesthesia was induced, and the neck was prepped and draped in the usual sterile fashion.

The old tracheostomy site was palpated for signs of a tracheal defect; none was noted. The old tracheostomy scar was approximately 3 mm below what was palpated to be the cricoid cartilage. The tracheostomy site was injected with local anesthesia consisting of 1% Xylocaine with 1:100,000 epinephrine.

A 2.5-cm vertical incision was made through the old scar. The incision was deepened through several layers of scar tissue, until the trachea was reached. A small amount of lateral dissection was performed to completely isolate the trachea from surrounding structures. There were significant calcifications of the tracheal rings, making identification of the individual rings virtually impossible.

A location was chosen that should correspond with approximately the 2nd tracheal ring. A #11 blade was used to create a vertical incision through the anterior aspect of the trachea in the midline. Scar tissue over the previous tracheostoma was excised until the endotracheal tube was well visualized. The trachea was suctioned of all secretions.

The cuff of the endotracheal tube was let down, and the endotracheal tube was advanced superiorly, clearing the tracheostoma for insertion of the tracheostomy tube. A #8 nonfenestrated cuffed Shiley tracheostomy tube was easily inserted into the tracheostomy. Bilateral breath sounds were assured as well as adequate CO2 return through the anesthesia circuit. The tracheostoma was packed with quarter-inch Nu Gauze soaked in Betadine. The tracheostomy ties were securely fashioned around the neck and a drain sponge placed below the flange.

Postoperatively in recovery, a chest x-ray revealed the tube to be in good position without evidence of pneumothorax.