Case -AUDIT REPORT T9.1 OPERATIVE REPORT, ETHMOIDECTOMY AND ANTROSTOMY

Essay

Case
-AUDIT REPORT T9.1 OPERATIVE REPORT, ETHMOIDECTOMY AND ANTROSTOMY
LOCATION: Outpatient, Hospital
PATIENT: Tony Flaur
PHYSICIAN: Gregory Dawson, MD
ATTENDING PHYSICIAN: Gregory Dawson, MD
PREOPERATIVE DIAGNOSIS:
1. Chronic sinusitis.
2. Nasal polyposis.
3. Septal deviation.
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED:
1. Bilateral image-guided intranasal antrostomy.
2. Bilateral image-guided total ethmoidectomy.
3. Bilateral image-guided intranasal sphenoidotomies.
ANESTHESIA:
General endotracheal anesthesia
DESCRIPTION OF PROCEDURE: Tony is a 34-year-old woman seen in the office and diagnosed with the above condition. Decision was made in consultation with the patient to take her to the operating room to undergo the above-named procedure.
Because of her septal deviation, we had to consent for her a possible septoplasty if access was not possible. She had a CT scan of the sinus performed on an outpatient basis. The images were reconstructed in the three-dimensional display that was used during stereotactic surgery.
She was admitted through the Same Day Surgery Program and taken to the operating room where she was administered a general anesthetic via intravenous injection.
She was then intubated endotracheally. The nose was decongested with 4 ml of 4% cocaine solution on nasal pledgets. A small amount of Afrin was also used. The patient was draped in the usual fashion. The three-dimensional ray was placed on the chest and positioned.We entered our fiducial points into the computer, and good accuracy was obtained.We then removed the patties from both sides of the nose and inserted the 4-mm endoscope. The right side had excellent access. The left side was extremely narrow.We felt, however, that we would be able to do this without septoplasty, so decision was made to proceed.We started initially with the right side of the nose. The uncinate process was injected with 15 mg/kg Lidocaine with Epinephrine.
Freer elevator was used to incise the uncinate process vertically. This was removed with a Wilde forceps. Curved tracking suction was used to identify the maxillary sinus ostium. Using the tracking microdebrider, and the backbiting forceps, we removed materials to enlarge the left maxillary sinus opening. The ethmoid air cells were then penetrated with the microdebrider, and we cleaned this out on both sides.
The ground lamella was penetrated with the aid of the navigator, and we cleaned out additional cells from this area. There was a lot of polypoid material.We moved superiorly along the fovea and cleaned out both anterior and posterior ethmoid air cells.
We then entered the sphenoid sinus and enlarged this. Packing from the left was then removed, and we placed the image-guided system into the nose. The curved tracking suction was used to identify the maxillary sinus ostium. This was enlarged with the microdebrider and the backbiting forceps. The posterior ethmoid air cells were entered in a similar fashion. We cleaned this out with the microdebrider using an image-guided system.We then entered the sphenoid sinus and enlarged this ostium.
This side of the nose was then packed with the same material. The material was removed from both sides of the nose, and a FloSeal was placed on either side. A mustache dressing was placed on the nose. The patient was then allowed to recover from the general anesthetic and taken to the Post Anesthesia Care Unit in stable condition. There were no complications during this procedure.
T9.1:
SERVICE CODE(S): 31201, 31020, 31050_________________________________
ICD-10-CM DX CODE(S): J33.9_________________________________________
INCORRECT/MISSING CODE(S): ______________________________________