HEAD AND NECK SURGERY

TAR / TONSILLECTOMY

Procedure:
Pt lying supine under GA
Mouth area was cleaned and drapped.
Boyle's Davis mouth gag is applied.
Throat pack inserted.
Adenoid checked.
Finding as noted.
Adenoidectomy performed.
Bilateral tonsillectomy performed.
Haemostasis secured.
Throat pack removed.
Xylocaine sprayed

Plan:  :   
BP/PR 1/2 hourly till stable then 4 hourly.
Allow orally if patient fully conscious
Tonsillectomy diet.
T. PCM 1g tds
Difflam gargle tds

MODIFIED RADICAL MASTOIDECTOMY (MRM)

Procedure:
Pt lying supine under GA
Cleaned and draped
Rt postauricular incision site identified and marked
Infiltration using adrenaline and mepivacaine given
Incision made
Layers separated
Temporal bone drilled using microdrill
Finding as noted
Meatoplasty done
Hemostasis secured
BIPP dressing inserted
Incision closed with Vicryl 4/0
Skin closed with Daflon 3/0
Mastoid dressing applied

Plan: :   
BP/PR/T monitoring hrly till stable then 4hrly
Allow orally once fully conscious
Keep mastoid dressing till cm
WI cm
To check for Weber test post op
To observe for facial nerve palsy post op
T.Augmentin 625 mg bd
C.Celebrex 200 mg od
Keep BIPP X7 days
STO day 7
MEDIAL MAXILLECTOMY

Procedure
Pt lying supine under GA
IV Cefuroxime / Flagyl commenced
Face area cleaned and draped
Left nasal packing with ribbon gauze soaked with Modified Moffat then removed
Lateral rhinotomy incison site identified and marked
Infiltration with Adrenalin / Mapivacaine made
Insicion made over the marked line
Layer sepated
Periosteum flap made and elevated
Anterior wall of left maxillary opened with Mallet and Hammer then widened with Bony
Nibble
Floor of the the maxillary sinus cut with Giggly saw
Superior bony cut with Hajek bony cutter just below the inferior orbital rim
Medial wall cut with heavy scissor
Finding as noted
Nasolacrimal sac identified and marsupilization done
Hemostasis secured
Maxillary and nasal cavity packed with 4 ribbon gauze which tight together soaked
with Whitehead's Varnish
Mucosa sutured with Vicryl 4/0
Skin suture with Brilon 4/0

Plan  BP / PR monitoring 1/2 hourly till stable then 4 hourly

Cont IV Cefuroxime 750 mg tds/ IV Flagyl 500 mg tds
IV Tramal 50 mg tds
Keep Whitehead's Varnish packed x 10/7
STO D5
Watch out for numbness/ paraeasthesia of left cheeck
Watch out for dacyocystitis
Observed for bleeding
CMC Eye drop 4 hourly
CMC ointment on night

SUPERFICIAL PAROTIDECTOMY

Procedure:
Pt lying supine under GA
Cleaned and draped
Skin marked and tatooed
Infiltration given by adrenaline and mepivacaine
Modified Bailey incision done
Skin flap raised above the parotid fascia superiorly and subplatysma inferiorly
Tragal pointer identified and facial nerve trunk identified
Branches of facial nerve identified and followed
Superficial parotidectomy done
Wash with warm saline
Hemostasis secured
Radivac drain inserted (size 10) and anchored
Subcutaneous layer closed with vicryl 4/0
Skin closed with ethilon 4/0

Plan:
BP/PR/T monitoring hourly till stable then 4hrly
Check for facial nerve palsy post op
IV Cefuroxime 750 mg tds
C.Celebrex 200 mg od
WI cm
Keep drain
Drain chart
STO day 7

TOTAL LARYNGECTOMY

Prosedure:
Pt lying supine under GA.
Neck area was cleaned and drapped.
IV cefuroxime 1.5g stat and IV metronidazole 500mg stat given.
J tube inserted and secured
Infiltration adrenaline + mepivacaine given.
Collar incision made.
Subplastima flap raised.
Bilateral selective neck dissection done
Finding as noted.
The inferior and superior thyroid arteries ligated.
The strap muscles divided.
The hyoid is detached and the pharynx entered.
The trachea is transected with bevelled method and separated with esophagus
Total laryngectomy performed
Tracheoesophageal punctured performed
Pharyngeal mucosa sutured to base of tongue in two layers
Water test done to ensure complete sealed
Saline wash performed
Hemostasis secured.
Radivex drain size 10 inserted.
Ryles tube inserted
Subcutaneous layers closed with Vicryl
Skin closed with stapplers.

Plan:
BP / PR monitoring 1/2 hourly till stable then 4 hourly
Keep drain tube and drain chart
Cont IV Zinacef 750 mg tds , IV flagyl 500mg tds.
Keep neck in flexion.
Suction prn.
Cont ICU Mx for analgesic and hydration
RT on chest not for feeding ( TE punture tubing )
WI cm
CXR post operatively
 

TRACHEOSTOMY
ptn supine under GA
neck extended , sandbag applied over the shoulder
area cleaned + drapped
infiltration marcain + adrenaline over the incision site
horizontal skin incision done 2 finger breath above the suprasternal notch
wound opened in layer
thyroid identified and retracted upward
trachea identified- confirm with bubble test
cruciate incision made over the trachea ring
tracheostomy tube size 7.5 inserted-connected with ventilator
heamostasis secured
skin closed with dafilon 4/0
tube secured with dafilon4/0 & ribbon tape

plan;
- cont ICU care
- regular suction
-keep cuff inflated when ptn still ventilated
- to inform ent once ptn is off ventilator ( to change to uncuff tube)
- STO day 7

OTOLOGY

MYRINGOPLASTY

Procedures:
Pt lying supine under GA
Left ear area cleaned and draped
Infiltration adrenaline + mepivacaine given at Lt tragus.
Incision madeat left tragus
Layer separated and perichondrium identified.
Graft elevated and incised.
Haemostasis secured and skin closed with dafilon 4/0.
EUM performed, finding as noted.
Edge of perforation freshened and underscored.
Posterior tympanomeatal flap raised.
Gelfoam applied in the middle ear cavity.
Graft inserted underlay technique.
Gelfoam applied over the graft.
EAC packed with silk and cotton soaked with sofradex.

Plan: :   
BP/PR monitoring 1/2 hourly till stable then 4 hourly.
Allow orally if pt is fully conscious.
T. Augmentin 625mg bd
T. Cetirizine 10mg OD
Keep ear pack x 10/7
STO D5.
T. PCM 1g tds
avoid straneous activity
For hearing assessment 3 months post op

CANALPLASTY

Procedure:
-Pt lying supine under GA.
-Left ear area was cleaned and drapped.
-EUM performed, findings as noted
-Incision done vertically at the 6 o'clock and 12 o'clock position and horizontal incision
made to joint them
-Posterior based flap raised
-overhanging bone curretted
-polyps and keratin removed
-haemostasis secured
-Flap repositioned back over the exposed bone
-Cavity packed with otosilk and cooton soaked with adrenaline.

Plan  :   
BP/PR monitoring 1/2 hourly till stable then 4 hourly.
Allow orally if patinet is fully conscious.
T. augmentin 625mg bd
C. celebrex 200mg OD
Keep ear pack for 10/7

MYRINGOTOMY AND GROMMET INSERTION

Prosedure
Pt lying supine under GA
Mouth area and ears area cleaned and draped
Examination under microscope performed bilaterally
Bilateral EAC identified and cleaned
Finding as noted
Myringotomy performed bilaterally
Grommet size 1.14 inserted bilaterally
Hemostasis secured

EXCISION OF PREAURICULAR SINUS

Procedure:
Pt lying supine under GA.
Area was cleaned and drapped.
Infiltration adrenaline + mepivicaine given
Methyline blue injected.
Sinus tract identified.
Insicion made and followed to the sac.
Tract and sac removed in total with part of helical cartilage.
Finding as noted.
Hamostasis secured.
Closed with Vicryl 4/0 and Dafilon 4/0

RHINOLOGY
RHINOPLASTY

Prosedure
Pt lying supine under GA
Nasal packing using modified moffat solution then removed
Cleaned and draped
Infiltration using adrenaline and mepivacaine -given at nasal septum,inferior turbinate and both
anterior aperture.
Bone graft taken at left inferior turbinate
Bilateral marginal incision made
Skin elevated at muscular layer until nasal bone
Lateral osteotomy done both side
Bony correction done both side
Bone from inferior turbinate placed at the midline from nasal bone until doom of alar cartilages
and achored by vicryl 4/0
Skin closed by dafilon 5/0
Nasofix applied.
Haemostasis secured

Plan  :   
BP/PR/T monitoring hrly till stable then 4hrly
Allow orally once fully conscious
Keep nasofix day and night for 1/52 then on night for another 1/52
STO day D
C.Celebrex 200 mg od
T. augmentin 625mg bd x 1/52

SEPTOPLASTY

Procedure:
Pt lying supine under GA
Nose area cleaned and draped
Nostril packed with cotton pledget socked with Moffat solution
Infiltration with Adrenalin/ Mapivacaine given at bilateral inferior turbinate
Incision made at the inferior turbinate
Mucosal layer separated
Inferior part of the inferior turbinate trimmed
Hemostasis secured
Proceed with septoplasty
Infiltration given at bilateral septum
Hemitranfixation incision made on the left septum
Left mucopericondrium flap raised on the left side
Bilateral mucoperiosteal flap raised above the perforation
Inferior tunnel created at on the left side
The superior edge of the septal perforation incised and flap elevated
the inferior edge of the perforation on the right side raised
the perforation covered with mucosal graft of the IT
Mucosal tear at the septal spur
The deviated part of septal cartilage removed leaving behind the anterior and dorsal part
Septal sutured with Vicryl 3/0
Internal septal splint inserted
Hemostasis secured
Merocel inserted in bilateral nostril

Plan:
BP /PR monitoring 1/2 hourly till stable then 4 hourly
Allow orally once pt fully conscious
Keep merocel x 1/7
T Augmentin 625 mg bd
C Tramal 50 mg tds

SEPTOPLASTY

Pt lying supine under GA

Nose area cleaned and draped
Nostril packed with ribbon gauze soaked with Moffat solution
Infiltration with Adrenalin/ Mapivacaine given at bilateral septum
Hemitransfixation incision made at left side of septum
Mucosal layer separated
Left mucoperichondrium flap raised on the left side
Bilateral mucoperiosteal flap raised
Inferior tunnel created at on the left side
Maxillary crust and anterior vomer removed
Inferior cartilage removed about 0.5 cm; dorsum and anterior part of septum preserved
Septal sutured with Vicryl 4/0
Internal septal splint inserted and secured with Dafilon 3/0
collumellar pocket created and anterior part of septum placed in the pocket
anterior incision apposed with Vicryl 4/0
Hemostasis secured
Merocel inserted in both nostril

ENDO DACRYOCYSTORHINOTOMY (EDCR)

Procedure
Pt supine under GA
Left nasal cavity packed with nasal packing soaked in modified moffat solution
Left nasal packing removed
Infiltration with mepivacaine and adrenaline given at incision site
Incision made at the axilla of the middle turbinate
Submucosal flap raised, bony covering of nasolacrimal sac and duct drilled.
Both canaliculi cannulated
Findings noted.
Nasolacrimal duct syringing done.
Haemostasis secured.

Plan:
BP/PR 1/2 hourly till stable then 4 hourly.
Allow orally if patient is fully conscious.
IV Augmentin 1.2g tds
T. PCM 1 g tds
CMC ointment ON
CMC eyedrop 4 hourly
Alkaline nasal douching tds
Butacort NS 11/11 bd
Eye syringing before discharge tomorrow
Eye massage
Keep splint till 10/7

FUNCTIONAL ENDOSCOPIC SINUS SURGERY (FESS – nasal polyposis)

Procedure:
Pt lying supine under GA
Face area clean and draped
Nasal packing done using ribbon gauze soaked in Modified Moffat solution then removed
Infiltration with Adrenaline / Mapivacaine given at middle turbinate, axillaae of middle
turbinate , uncinate process ans nasal septum bilaterally
Finding as noted
Polypectomy done using microdebrider
Middle meatal anthrostomy done
Anterior ethmoidal , post ethmoidal sinus widened
Hemostasis secured
Merocel inserted into both nostril

Plan:
BP /PR monitoring 1/2 hourly till stable then 4 hourly
Allow orally once pt fully conscious
Keep Merocel 1/7
C Celebrex 200 mg od
IV Augmentin 1.2 g tds
Alkaline nasal douching on Discharge