NOT SURE HOW TO CODE THIS, HERE IS THE OP REPORT:
PLAN: FUNCTIONAL ENDOSCOPIC SINUS SURGERY OF THE RIGHT MAXILLARY ETHMOID SINUSES WITH INTRAORBITAL COMPLICATION
The patient was placed in supine position and general endotraceal intubation was inducted. Strips of cottonoids soaked in Neo-Synephrine 1% were inserted into both nasal chambers and after some time, they were retrieved.
The uncinate process of the inferior turbinates was identified and this was followed up laterally and the ostia of the right maxillary sinus was identified and this was further enlarged with the Kerrison punch. We were able to enlarge the opening and a right-angle forceps was inserted, which the intention was to go into the antral cavity and during the process of cleansing, it was noted that the right orbital area was getting swollen, so considering the possibility of an intraorbital inadvertent entrance, I decided to do a Caldwell -Luc by making an incision at the right superior gingival sulcus area by first injecting it the Xylocaine 1% with 1:200,000 epinephrine and utilizing a #15 knife blade, an incision was made over this are and a superior flap was developed. A small opening was made at the right antral wall and the antral cavity was visualized and this was inspected. The antral cannula, which was used as a guide at this juncture was not noted. There was a progression of the swelling right eye. Suspecting that there was a progressive hematoma formation, an incision was made over the infraorbital area utilizing a #15 knife blade and this was carried down through the muscle and to the infraorbital rim. The periosteum was then dissected and there was minimal to moderate amount of bloody discharge that came out and this in effect finally reduced the size of the exophthalmus and it was noted there was a reduction of the swelling. Consult was made to a ocular plastic surgeon, and gave suggestions; by putting a little pressure on the eyeball and give some steroid medication and he will see the patient tomorrow.
PLAN: FUNCTIONAL ENDOSCOPIC SINUS SURGERY OF THE RIGHT MAXILLARY ETHMOID SINUSES WITH INTRAORBITAL COMPLICATION
The patient was placed in supine position and general endotraceal intubation was inducted. Strips of cottonoids soaked in Neo-Synephrine 1% were inserted into both nasal chambers and after some time, they were retrieved.
The uncinate process of the inferior turbinates was identified and this was followed up laterally and the ostia of the right maxillary sinus was identified and this was further enlarged with the Kerrison punch. We were able to enlarge the opening and a right-angle forceps was inserted, which the intention was to go into the antral cavity and during the process of cleansing, it was noted that the right orbital area was getting swollen, so considering the possibility of an intraorbital inadvertent entrance, I decided to do a Caldwell -Luc by making an incision at the right superior gingival sulcus area by first injecting it the Xylocaine 1% with 1:200,000 epinephrine and utilizing a #15 knife blade, an incision was made over this are and a superior flap was developed. A small opening was made at the right antral wall and the antral cavity was visualized and this was inspected. The antral cannula, which was used as a guide at this juncture was not noted. There was a progression of the swelling right eye. Suspecting that there was a progressive hematoma formation, an incision was made over the infraorbital area utilizing a #15 knife blade and this was carried down through the muscle and to the infraorbital rim. The periosteum was then dissected and there was minimal to moderate amount of bloody discharge that came out and this in effect finally reduced the size of the exophthalmus and it was noted there was a reduction of the swelling. Consult was made to a ocular plastic surgeon, and gave suggestions; by putting a little pressure on the eyeball and give some steroid medication and he will see the patient tomorrow.