PRE OP Pena, Jason 01151997.pptx sinuses

sinuss surgery

1. Disclaimer The patient has consented for all the photographs appended in this presentation. These pictures will be solely used for the purposes of medical teaching, surgical planning, and will become part of their medical record.

2. Patient Profile J.P. 27/Male 1/15/1997 Filipino Single Catholic Quezon City Chief Complaint: Nasal Congestion, Bilateral

3. History of Present Illness 1 year PTC, noted (+) nasal discharge (+) nasal congestion (+) minimal epistaxis (-) facial pain, headache, dizziness, anosmia, hyposmia (-) consult (-) intervention done Interim, persistence of symptoms, still no consult done and intervention 6 months PTC (+) nasal discharge (+) nasal congestion (+) minimal epistaxis (+) hyposmia (-) facial pain, headache, dizziness Consult done at our OPD and was given with Flo sinus and Fluticasone which offered some relief.

4. History of Present Illness 3 months PTC (+) nasal discharge (+) nasal congestion (+) minimal epistaxis (+) Anosmia (-) facial pain, headache, dizziness continued use of Flo Sinus, followed up at our OPD still with the same symptoms hence was advised for CT scan which revealed sinonasal polyposis. Due to persistence of symptoms despite maximizing medical management thus advised surgical intervention

5. Past Medical History (-) Hypertension (-) Diabetes Mellitus (-) Pulmonary Tuberculosis (-) Asthma (-) Allergy (-) Previous Surgery and Hospitalization

6. Family History (-) Hypertension (-) Diabetes Mellitus (-) Pulmonary Tuberculosis (-) Asthma (-) Allergy

7. Personal & Social History Non alcoholic beverage drinker Non smoker Unemployed (Previous Waiter)

8. Physical Examination

9. Patient Profile No CLADS No Gross deformities

10. Patient Profile No CLADS No Gross deformities

11. Anterior Rhinoscopy Right: No mass No bleeding No discharge Left: (+) Mucoid discharge No bleeding

12. Anterior Rhinoscopy Right: (-) mass (-) bleeding (-) discharge Left: (+) Mucoid discharge (+) Polypoid translucent pinkish mass, occupying the left nasal cavity No bleeding

13. Anterior Rhinoscopy Right: No mass No bleeding No discharge Left: (+) Mucoid discharge (+) Fleshy non friable mass No bleeding

14. Nasal Endoscopy Right: (+) Translucent polypoid mass confined at the middle meatus (-) bleeding (+) discharge Left: (+) Mucoid discharge (+) Translucent polypoid pinkish mass, occupying the nasal cavity

15. Oral Cavity / Palate (-) palatal bulge (-) mass (-) bleeding

16. Oral Cavity / Palate (-) palatal bulge (-) mass (-) bleeding

17. ENT PE Otoscopy: Intact TM, Patent EAC, (-) discharges Head and Neck PE: No CLADS, No Deformities

18. Imaging

19. Peñacerrada, Jason PNS CT w/ IVC 02/08/24

20. Plain

21. Coronal

22. Axial

23. Sagittal

24. Contrast

25. Coronal

26. Axial

27. Sagittal

28. Rhinosinusitis Staging

29. Patient: Peñacerrada , Jason Sex: 27 M x F ☐ Birthdate (MM/DD/YYYY):___/_____/______ Date of CT Scan (MM/DD/YYYY): 10/26/22 Evaluated by: Arnaiz/ Avena Date accomplished: 02/16/2024 Coronal Section Right Left Frontal cell (Axial/Sagittal) Interfrontal sinus septal cell Agger nasi cell (sagittal) Supraorbital cell (sagittal) Uncinate process attachment Keros type Skull base asymmetry AEA type Paradoxic MT MT pneumatization Haller’s cell LP dehiscence ST pneumatization K1 x K2 ☐ K3 ☐ K4 ☐ A ☐ P x A x P ☐ A ☐ P x LP x SB ☐ MT ☐ Type I ☐ II ☐ III x A x P ☐ Type I x II ☐ III ☐ A x P ☐ A x P ☐ A ☐ P x A x P ☐ A x P ☐ K1 x K2 ☐ K3 ☐ K4 ☐ A x P ☐ A x P ☐ A x P ☐ LP x SB ☐ MT ☐ Type I ☐ II x III ☐ A x P ☐ Type I x II ☐ III ☐ A x P ☐ A x P ☐ A ☐ P x A x P ☐ A x P ☐

30. Axial Section Right Left LP dehiscence Optic nerve course Onodi cell Agger nasi cell   Sphenoid sinus -No. intersphenoidal septa -Contact to carotid protuberance -Wall dehiscence (Carotid) (Coronal) -Wall dehiscence (Optic n.) (Coronal) -Natural ostium distance       -Pneumatization type (Sagittal) A x P ☐ Type I x II ☐ III ☐ IV ☐ A x P ☐ A x P ☐   A x P ☐ A x P ☐ A x P ☐ A x P ☐ Septum – 9.07mm Lateral wall – 12.04mm   Conchal x Presellar ☐ A x P ☐ Type I x II ☐ III ☐ IV ☐ A x P ☐ A x P ☐   A ☐ P x A x P ☐ A x P ☐ A x P ☐ Septum – 4.85mm Lateral wall – 13.19mm  Conchal ☐ Presellar x

31. Sagittal Section Right Left Frontal sinus outflow tract obstruction Frontal cell (Axial/Sagittal) Agger nasi cell (sagittal) Supraorbital cell (sagittal) Suprabullar cell A x P ☐ K1 x K2 ☐ K3 ☐ K4 ☐ A x P ☐ A ☐ P x A x P ☐ A ☐ P x K1 x K2 ☐ K3 ☐ K4 ☐ A x P ☐ A x P ☐ A x P ☐

32. Radiological Grading Sinus Systems (0-2) Right Left Maxillary 2 2 Anterior Ethmoids 2 2 Posterior Ethmoids 2 2 Sphenoid 2 2 Frontal 2 OMC (0 or 2) 2 2 Total 10 12 CT SCAN ASSESSMENT: (0-2) Each sinus group is graded between 0 and 2 0- no abnormality 1- partial opacification 2- total opacification *For the Ostiomeatal Complex (OMC) 0- not obstructed 2- obstructed

33. Radiological Grading Anatomic Variants (0-1) Right Left Absent frontal sinus Concha bullosa Paradoxical middle turbinate Everted uncinate process Haller cells 1 1 Agger nasi cells PRESENCE OF ANATOMIC VARIANTS: (0-1) 0- absent 1- present

34. Surgical Score (0-1) Right Left Uncinectomy Middle meatal antrostomy Anterior ethmoidectomy Posterior ethmoidectomy Sphenoidotomy Frontal recess surgery Reduction of middle turbinate Total SURGICAL SCORE: (0-1) 0- not performed 1- undertaken Maximum score of 7 per side *to be filled up after surgery Yes No Septal Surgery Previous Surgery

35. Symptom Score (0-10) Preop 3/12 6/12 12/12 24/12 Nasal blockage/ Congestion/ Pressure 8 Headache Facial pain Problems of smell 7 Nasal discharge 5 Overall 20 SYMPTOM SCORE: (0-10) Symptoms are assessed by the patient on a visual analogue score (VAS) of 0-10 0- no symptom 10- most severe *Evaluated at Baseline (preop), 3 months, 6 months, 1 year, 2 years

36. Endoscopic Appearances (0-2) Preop 3/12 6/12 12/12 24/12 R L R L R L R L R L Polyp 2 2 Discharge 1 1 Edema Scars or Adhesions Crusting ENDOSCOPIC APPEARANCE: (0-2) Quantified based on a 0-2 point basis for the presence of: POLYPS 0- none 1- confined to middle meatus 2- beyond middle meatus DISCHARGE 0- no discharge 1- clear and thin 2- thick and purulent EDEMA/SCARRING/CRUSTING 0- absent 1- mild 2- severe *Evaluated at Baseline (preop), 3 months, 6 months, 1 year, 2 years

37. SNOT 22

38. Diagnosis   Chronic Rhinosinusitis, Grade 2 Right, Grade 3 Left;

39. Plan Referred to Dr. Timbungco 2/16/24 For Endoscopic Sinus Surgery with possible Endoscopic Medial Maxillectomy via Prelacrimal approach/GA  Start Methylprednisolone 16mg/tab 1 tab BID