DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Nasal septal deformity with nasal airway obstruction.
2. Nasal stenosis.
3. Chronic sinusitis.
POSTOPERATIVE DIAGNOSES:
1. Nasal septal deformity with nasal airway obstruction.
2. Nasal stenosis.
3. Chronic sinusitis.
OPERATION PERFORMED:
1. Nasal septal reconstruction with open reduction of septum and septoplasty.
2. Repair of nasal stenosis.
3. Bilateral nasal endoscopy.
4. Bilateral maxillary antrostomies.
SURGEON: John Doe, MD
ANESTHESIA: General supplemented with 1% Xylocaine with 1:100,000 adrenaline and Afrin solution.
POSTOPERATIVE CONDITION: Stable.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in a supine position on the operating table. General anesthesia was introduced via endotracheal intubation. Local anesthesia was infiltrated nasally. Routine sterile draping was carried out. The inside of the nose was examined, and the septum was markedly deviated to the left with nasal airway obstruction, and there appeared to be stenosis near the valve area. The middle turbinates were infractured. Bilateral endoscopy was carried out using a 0-degree endoscope following which bilateral maxillary antrostomies were performed.
A right hemitransfixion incision was then done. Mucoperichondrial flap was elevated off the left side as a separate cartilage. Mucoperiosteal flaps were elevated off the adjacent ethmoid and vomer bones. The septal cartilage was disarticulated from the ethmoid and vomer bones. A heavy elevator was then inserted into the left nasal cavity, and the bony cartilaginous nasal septum was infractured to the middle line. The hemitransfixion incision was closed with 4-0 chromic catgut interrupted sutures. Reuter bivalve splints were placed on each side of septum and held in place with 4-0 chromic catgut horizontal mattress suture.
The stenotic area was opened and repaired. Both inferior turbinates were outfractured. Maxillary antrostomies had been previously performed at the beginning. A half-inch Vaseline gauze packing was placed in both nasal cavities. A moustache dressing was placed underneath the nose. The patient was sent to the recovery room in stable condition.
