Ethmoidectomy, Sphenoidotomy, and Septoplasty

Ethmoidectomy, Sphenoidotomy, and Septoplasty

Ready for a challenge? This case will give your coding skills an excellent workout. There will be five service codes and five diagnosis codes. The most extensive procedure is the septoplasty, and that code will be sequenced first.

LOCATION: Outpatient, Hospital

PATIENT: Russell Price

ATTENDING PHYSICIAN: Jeff King, MD

SURGEON: Jeff King, MD

PREOPERATIVE DIAGNOSES

1 Septal deviation.

2 Bilateral sinonasal polyposis.

3 Pansinusitis.

4 Bilateral inferior turbinate hypertrophy.

5 Nasal obstruction.

POSTOPERATIVE DIAGNOSIS: Same as Preoperative.

PROCEDURES PERFORMED

Bilateral endoscopic total ethmoidectomy.
Bilateral endoscopic maxillary antrostomy with removal of polyps from maxillary sinus.
Bilateral endoscopic sphenoidotomy.

Bilateral inferior turbinate overfracture.
ANESTHESIA: Endotracheal.

INDICATIONS: A 43-year-old male with history of nasal trauma that resulted in a septal deviation. He also has a history of bilateral sinonasal polyposis and has undergone prior polypectomy and sinus surgery. The patient now has recurrent disease. This was confirmed on examination and the CT scan. He also has bilateral inferior turbinate hypertrophy. The patient also has a history of severe snoring. He is to undergo correction of his nasal obstruction and sinusitis to see if that will help. If not, further evaluation of his snoring will be done.

PROCEDURE: After consent was obtained, the patient was taken to the operating room and placed on the operating table in supine position. After an adequate level of general endotracheal anesthesia was obtained, the patient was positioned for nasal and sinus surgery. The patient’s nose was packed with cotton pledgets soaked with 4% cocaine. After several minutes, 1% Xylocaine with 1:100,000 epinephrine was infiltrated into the nasal portion of the polyps as well as the septum bilaterally and the inferior turbinates. Nasal hairs were trimmed. Attention was first focused on the right side. Using the 5-degree sinuscope and the microdebrider, the nasal portions of the polyps were removed. Polyps were noted both medial and lateral to the middle turbinate. There was also some scarring from the middle turbinate to the lateral nasal wall. This scar tissue was also removed with a microdebrider. Subsequently, polyps in the middle meatus and anterior posterior ethmoid areas were removed with microdebrider.

The maxillary sinus ostia area was cleared of polyps, and then the ostium was widened in a posterior-to-inferior direction. Polyps within the sinus near the ostia were also removed. The area was then packed with cotton pledgets soaked with 1:50,000 units of epinephrine. Attention was then focused on the left side, where a similar procedure was performed. Again, polyps were noted to be both medial and lateral to the middle turbinate remnant. Polyps were obstructing the maxillary sinus drainage area and were also cleared. The left side was packed with a pledget soaked with epinephrine solution. Attention was refocused on the right side, where further polyps were removed from the sphenoid/ethmoid area. Remnant of the superior turbinate was also cleared of polyps. The sphenoid sinus ostium was cleared of polyps. The area was then packed with cotton pledget soaked with epinephrine solution. Similar procedure was then performed on the left side. Attention was then focused on the nasal septum. Utilizing a right hemitransfixion incision, mucoperichondrium and mucoperiosteal flaps were elevated. The cartilaginous septum was noted to be severely attenuated and deviated with several fractured areas. Deviated portions were removed. This does not leave much support for the nasal tip area. If this is a problem in the future, this will need to be reconstructed. The deviated portion of the bony septum and spurs off the maxillary crest were then removed.

Attention was then focused on the inferior turbinates, which were outfractured. The hemitransfixion incision was then closed with an interrupted 4-0 chromic suture. A quilting suture of 4-0 plain gut was then performed. The pledgets in the sinus area were then removed. There was some oozing from the ethmoid as well as the sphenoid sinus areas. As such, these areas were coated with FloSeal and then packed lightly with strips of Surgicel soaked with local solutions. Bacitracin ointment was then applied. Silastic splints were then placed on both sides of the nasal septum and secured with nylon suture. The nose was then packed bilaterally. Packs consisted of a Merocel sponge with a gloved finger coated with Bacitracin ointment. It was inflated with location solution. Nasal dressing was applied.

The patient tolerated the procedure well, and there was no break in technique. The patient was extubated and taken to the postanesthetic care unit in good condition. Fluids administered included 2000 cc RL. Blood loss was less than 150 cc. Preoperative medications included 12 mg Decadron and 1 gram Ancef IV.

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