Can someone please help me with this surgery?
1. Frontal sinus trephine procedure with irrigation of sinus as well as
placement of titanium mesh plating for closure.
2. Forehead rotation advancement flap of approximately 10 square
centimeters to close sinocutaneous fistula.
history of chronic rhinosinusitis that resulted in some
rather severe forehead sinus infection that ultimately ruptured through herforehead leaving her with a sinocutaneous fistula as well as a bony defect.She was treated aggressively with oral medications as well as topical medications and appears to have seen rather remarkable improvement in thes inus outflow tracts from the frontal sinus. As such, the decision was made to attempt closure of the sinocutaneous fistula without performing endoscopic sinus surgery. The risks and benefits of the procedure were explained to the patient as well as informed consent obtained. She was then taken to the operating room, placed supine on the OR table and regular endotracheal anesthesia instituted. The patient was then prepped and draped in the standard fashion using Betadine paint. The area around the fistula was injected with 1% lidocaine with 1:100,000 epinephrine. We then sharply incised the edges of the fistula and carried this dissection down to the level of the bone using a 15 blade. The fistulous tract was then
elevated away from the bone using a Cottle elevator all the way into the frontal sinus while taking care to avoid any sort of injury to the
posterior table. This tissue itself was sent to Pathology to rule out
tumor. In addition, there was some dried debris and other secretions in the frontal sinus which were suctioned free and sent to Microbiology for culture. We then proceeded to irrigate the sinus copiously and to inspect it and make sure there was no other evidence of obstruction or any sort of swollen tissue. There did not appear to be any. Overall, the mucosa inside the sinus appeared healthy. It was left undisturbed. In addition,we felt that we had completely excised the fistulous tract and that there was no danger of remaining elements in this area. The wound was further irrigated and then titanium mesh was cut from the Synthes midface set to appropriately cover the bony defect which appeared to be about 1.5 cm in greatest diameter. This was placed in position over the bone in the subperiosteal plane and secured at the edges using 4 mm screws with good results. With this in good position we then proceeded to develop bilateral subgaleal flaps on each side of the patient's forehead. These were then rotated into position over the titanium mesh plating. Of note, Ciprodex drops were placed through the titanium mesh into the frontal sinus prior to closure. We then proceeded to close the galea in a layer using interrupted
3-0 Vicryl sutures followed by the dermal layer being closed with similar sutures. The skin itself was closed with a 5-0 fast-absorbing gut suture with good results. Ointment was applied to the area. Overall, there appeared excellent improvement of the patient's forehead as well as excellent closure and good reconstruction of the forehead. It remains to be seen if the frontal sinus will effectively re-establish outflow drainage, but we are hopeful given the finding seen on the CT scan prior to surgery. At this point the procedure was terminated and the patient's bed was returned to its original position. She was awakened, extubated and taken to the recovery room in stable condition with plans for further outpatient care.
1. Frontal sinus trephine procedure with irrigation of sinus as well as
placement of titanium mesh plating for closure.
2. Forehead rotation advancement flap of approximately 10 square
centimeters to close sinocutaneous fistula.
history of chronic rhinosinusitis that resulted in some
rather severe forehead sinus infection that ultimately ruptured through herforehead leaving her with a sinocutaneous fistula as well as a bony defect.She was treated aggressively with oral medications as well as topical medications and appears to have seen rather remarkable improvement in thes inus outflow tracts from the frontal sinus. As such, the decision was made to attempt closure of the sinocutaneous fistula without performing endoscopic sinus surgery. The risks and benefits of the procedure were explained to the patient as well as informed consent obtained. She was then taken to the operating room, placed supine on the OR table and regular endotracheal anesthesia instituted. The patient was then prepped and draped in the standard fashion using Betadine paint. The area around the fistula was injected with 1% lidocaine with 1:100,000 epinephrine. We then sharply incised the edges of the fistula and carried this dissection down to the level of the bone using a 15 blade. The fistulous tract was then
elevated away from the bone using a Cottle elevator all the way into the frontal sinus while taking care to avoid any sort of injury to the
posterior table. This tissue itself was sent to Pathology to rule out
tumor. In addition, there was some dried debris and other secretions in the frontal sinus which were suctioned free and sent to Microbiology for culture. We then proceeded to irrigate the sinus copiously and to inspect it and make sure there was no other evidence of obstruction or any sort of swollen tissue. There did not appear to be any. Overall, the mucosa inside the sinus appeared healthy. It was left undisturbed. In addition,we felt that we had completely excised the fistulous tract and that there was no danger of remaining elements in this area. The wound was further irrigated and then titanium mesh was cut from the Synthes midface set to appropriately cover the bony defect which appeared to be about 1.5 cm in greatest diameter. This was placed in position over the bone in the subperiosteal plane and secured at the edges using 4 mm screws with good results. With this in good position we then proceeded to develop bilateral subgaleal flaps on each side of the patient's forehead. These were then rotated into position over the titanium mesh plating. Of note, Ciprodex drops were placed through the titanium mesh into the frontal sinus prior to closure. We then proceeded to close the galea in a layer using interrupted
3-0 Vicryl sutures followed by the dermal layer being closed with similar sutures. The skin itself was closed with a 5-0 fast-absorbing gut suture with good results. Ointment was applied to the area. Overall, there appeared excellent improvement of the patient's forehead as well as excellent closure and good reconstruction of the forehead. It remains to be seen if the frontal sinus will effectively re-establish outflow drainage, but we are hopeful given the finding seen on the CT scan prior to surgery. At this point the procedure was terminated and the patient's bed was returned to its original position. She was awakened, extubated and taken to the recovery room in stable condition with plans for further outpatient care.