KNLong
New
47-year-old male known disseminated Mycobacterium avium complex infection underwent bronchoscopy and mediastinoscopy in April 2021 for further work-up. Cultures and pathology were essentially negative at that time. Since April, the patient has developed a large left cervical chain lymph node with central necrosis which is contributing to symptoms of dysphagia. He presents for biopsy/drainage to rule out pathology other than MAC and provide symptomatic relief.
Intraoperative findings:
-Approximately 60 mL of necrotic purulent appearing fluid removed from the lymph node
-Dense adhesions from inflammatory changes of the lymph node to adjacent structures
-Excisional biopsy of the anterior wall of the lymph node submitted to pathology
Procedure in detail:
The patient had his history and physical updated prior to the procedure. He was transferred to the operating suite placed on the operating table he underwent general anesthesia with endotracheal intubation. Monitoring lines and devices were placed by anesthesia. The neck and chest were prepped and draped in usual sterile fashion using ChloraPrep solution. Timeout was used to confirm patient identity as well as the procedure to be performed. Antibiotics given prior to the incisions.
An oblique incision was made posterior to the left sternocleidomastoid, just above the clavicle. The deep dermis and subcutaneous tissues were divided with electrocautery. The platysma was divided with electrocautery. The posterior aspect of the sternocleidomastoid was adherent to the lymph node wall. This portion of the sternocleidomastoid was reflected medially. This allowed for access to the anterior wall of the cervical chain lymph node. The lymph node was quite enlarged, estimated at approximately 5 cm. There was dense inflammation between the wall of the lymph node and the adjacent muscular structures. The wall was noted to be extremely thin and easily entered into. Once entered into, roughly 60 mL of necrotic, purulent fluid was drained. This was collected in a trap and submitted for routine, AFB, and fungal cultures. The central portion of lymph node was completely evacuated. There was no obvious lymph welling up within the central portion of the lymph node. A large 1.5 x 2 cm portion of the anterior wall of the lymph node was excised using electrocautery and submitted to pathology for further evaluation.
Once hemostasis was achieved, the 15 French round Jackson-Pratt was placed and tunneled to the left subclavicular region for its exit point. The drain was placed within the central portion of the lymph node cavity and secured with a 3-0 Ethilon suture at its exit point. The incision was then irrigated with saline and suctioned out. The sternocleidomastoid was reapproximated to its native position using interrupted 2-0 Vicryl. The deep dermis was reapproximated with the same. The skin was closed with 4-0 Monocryl in a running subcuticular manner. The incision was injected with half percent Marcaine for local anesthesia prior to complete closure. Dermabond was then placed over the wound.
I was thinking 38510 and 10004 51, 59 ( because Dr drained before he biopsied, and then left a drain in for further drainage).
Intraoperative findings:
-Approximately 60 mL of necrotic purulent appearing fluid removed from the lymph node
-Dense adhesions from inflammatory changes of the lymph node to adjacent structures
-Excisional biopsy of the anterior wall of the lymph node submitted to pathology
Procedure in detail:
The patient had his history and physical updated prior to the procedure. He was transferred to the operating suite placed on the operating table he underwent general anesthesia with endotracheal intubation. Monitoring lines and devices were placed by anesthesia. The neck and chest were prepped and draped in usual sterile fashion using ChloraPrep solution. Timeout was used to confirm patient identity as well as the procedure to be performed. Antibiotics given prior to the incisions.
An oblique incision was made posterior to the left sternocleidomastoid, just above the clavicle. The deep dermis and subcutaneous tissues were divided with electrocautery. The platysma was divided with electrocautery. The posterior aspect of the sternocleidomastoid was adherent to the lymph node wall. This portion of the sternocleidomastoid was reflected medially. This allowed for access to the anterior wall of the cervical chain lymph node. The lymph node was quite enlarged, estimated at approximately 5 cm. There was dense inflammation between the wall of the lymph node and the adjacent muscular structures. The wall was noted to be extremely thin and easily entered into. Once entered into, roughly 60 mL of necrotic, purulent fluid was drained. This was collected in a trap and submitted for routine, AFB, and fungal cultures. The central portion of lymph node was completely evacuated. There was no obvious lymph welling up within the central portion of the lymph node. A large 1.5 x 2 cm portion of the anterior wall of the lymph node was excised using electrocautery and submitted to pathology for further evaluation.
Once hemostasis was achieved, the 15 French round Jackson-Pratt was placed and tunneled to the left subclavicular region for its exit point. The drain was placed within the central portion of the lymph node cavity and secured with a 3-0 Ethilon suture at its exit point. The incision was then irrigated with saline and suctioned out. The sternocleidomastoid was reapproximated to its native position using interrupted 2-0 Vicryl. The deep dermis was reapproximated with the same. The skin was closed with 4-0 Monocryl in a running subcuticular manner. The incision was injected with half percent Marcaine for local anesthesia prior to complete closure. Dermabond was then placed over the wound.
I was thinking 38510 and 10004 51, 59 ( because Dr drained before he biopsied, and then left a drain in for further drainage).