Headed to Denver tomorrow

General
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Report from my CT scan has been posted. I probably won’t get Dr. Hepworth’s opinion on it until December. The head scan didn’t have much to say but here is the neck report.

FINDINGS:
VENOUS STRUCTURES/AREA OF INTEREST:
The right styloid process measures approximately 1.8 cm. This abuts the right internal jugular vein, just distal to the jugular bulb, without significant narrowing. The right internal jugular vein is otherwise widely patent.

The left styloid process measures approximately 1.9 cm and is truncated at the tip, new compared to the prior exam, consistent with reported surgery. The styloid process previously measured approximately 3.0 cm measured in similar fashion. There is mass effect and moderate subjective narrowing of the left internal jugular vein, just distal to the jugular bulb, similar to the prior exam. Narrowing of the more distal left internal jugular vein is similar to slightly improved. The left internal jugular vein measures 0.3 cm in transverse dimension at the area of narrowing. The more distal left internal jugular vein is widely patent.
AORTA:
The visualized thoracic aorta and great vessel origins appear normal.

RIGHT CAROTID VASCULATURE:
The common, internal and external carotid arteries appear normal, without stenosis, aneurysm, or dissection.

LEFT CAROTID VASCULATURE:
The common, internal and external carotid arteries appear normal, without stenosis, aneurysm, or dissection.

VERTEBRAL VASCULATURE:
The bilateral vertebral arteries grossly appear normal, without stenosis, aneurysm, or dissection.

CRANIOFACIAL/SINONASAL:
See separately dictated CTV of the head for craniofacial and sinonasal findings.

NECK:
The visualized larynx, thyroid gland and soft tissues appear normal. No lymphadenopathy present.

SPINE:
Mild cervical spondylosis.

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I am bit confused here. Did they just remove 1.1 cm of the left Styloid if it previously measured 3.0 cm and the remaining Styloid measures 1.9? I thought Hepworth removes it to the skull base. Am I reading the report wrong.

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I’m kind of confused by that as well. I thought he would remove the entire thing.

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Looks like the narrowing has not changed much although the report says slightly improved .3 cm (3mm) of transverse dimension appears to be significant narrowing. I think you should demand answers here.

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@stuuke The reason why Dr H always has a vascular surgeon co-operate is to ensure that, at the time of surgery, the IJV flow is unobstructed. It does not guarantee it will stay open. In my case, it was open but then required a balloon angioplasty several months later which was fabulous. As far as how much of the styloid is removed, he gets as close as safely possible to the base. The origin of the styloid is precariously close to the jugular foramen which houses very delicate structures (Cranial nerves IX,X,XI and IJV). The styloid presentation (width at base, length, angle) varies greatly with each person’s anatomical differences and can only be a game day call. Imaging is not clear enough for these details.

This may help explain his referral to another closer to you. The upcoming visit with Dr H will clarify all of your questions.

I do know someone who had bilateral styloidectomy with little relief and later found vascular thoracic outlet syndrome as unknown comorbidity. Once the first rib was resected she had full relief and has returned to her prior life. Both surgeries needed to be done for this to happen as the vascular stenosis was a “double crush” situation.

Hope this is helpful. We are complicated beings and rarely is it black and white but multilayered and elusive - but the answer is there. Hang in there!

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86

Hi, I can relate to your sense of feeling struggle back to health is never ending and do you just accept your bad health situation and make the best of it you can. I have thought about doing that myself during my journey. Living as a health tourist, at great expense and with serious impacts on your career and on family time are all very tough to endure. For me the love for my young family members and needing to be there for them for longer in some functioning state has driven me to find a solution. After 6 operations I still don’t yet know if I have solved my big issues and there does come a point where you have to say enough. For me the symptoms were so severe I knew I’d have an extremely poor quality of life if I gave up. It’s an individual decision for each of us. But feeling like giving up is a natural thing if the journey is as tough and long as it often is for members of this group. Stay strong. D

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87

It’s certainly worth discussing further with Dr H when you can, I’d ask about the ‘mass effect’ on the left IJV- is that still styloid compression or something else? Although if your right side is fine & patent as the report says, then I would’ve thought it might be enough to drain all the blood okay, so would be good to see if there are other issues in your head as you mentioned before…

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I’m just hoping the new scans provide some insight for Dr. Hepworth.

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The thoracic outlet syndrome seems interesting. I’ve definitely felt like my traps and scalenes on the left side have something to do with my issue. It has felt like they’re tugging my neck, jaw and ear area out of whack since my injury. I’ve had massage therapist and chiropractors tell me to relax the area and I explain that I can’t. Is Thoracic Outlet Syndrome something that Dr. Hepworth is familiar with and would be looking for or do I need to bring it up when I talk to him and see if it’s something we can look into?

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He is familiar with it for sure but worth bring up at your appt. Who was your vascular surgeon with Dr H? Dr Annest at VIR is the world renowned pioneer in the subject and typically partners with Dr H. The US Dr H orders usually looks at possible muscular stenosis sites in the neck but not necessarily if it is the first rib, that is lower down and a vascular surgeon would be more thorough for this investigation. Typical muscle involved would be the omohyoid and scalenes. The UT is more often a secondary issue, upregulated but weak thus massage is not the answer and can make matters worse. Dry needling by a skilled PT can be very helpful followed by the appropriate strengthening.

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As @JustBreathe mentioned there could be many reasons why the whole styloid is not removed but I am surprised that was not communicated to you after the surgery. For example by telling you that only 1/3 of the left styloid was removed due to fear of nerve/vascular injury. I mean I can understand if they leave 1 cm but leaving ~ 2 cm seems bit high unless the radiologist measurement is inaccurate.

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92

It looks like my vascular surgeon was Dr. Alex Leung.

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SURGEON: Alexander D Leung, MD

PREOPERATIVE DIAGNOSES: Left jugular vein compression, Eagle syndrome,
cephalgia, cervicalgia.

POSTOPERATIVE DIAGNOSES: Left jugular vein compression, Eagle syndrome,
cephalgia, cervicalgia.

PROCEDURES PERFORMED:

  1. Access of right common femoral vein under ultrasound guidance with an 8-
    French sheath.
  2. Venogram of bilateral internal jugular vein, innominate vein, SVC.
  3. Intravascular ultrasound evaluation of left internal jugular vein,
    innominate vein, SVC.
  4. Hemodynamic pressure measurements of left internal jugular vein.

ASSISTANT: None.

ANESTHESIA: General endotracheal.

FLUORO TIME: 4.7 minutes.

AIR KERMA: 26 mGy.

CONTRAST: 15 cc.

ESTIMATED BLOOD LOSS: Less than 10 cc.

SPECIMENS OBTAINED: None for vascular portion.

COMPLICATIONS: None.

FINDINGS: Bilateral internal jugular veins were patent without focal stenosis.
There were collaterals present on both sides; 1 mmHg pressure gradient along
the length of the vein.

DESCRIPTION OF PROCEDURE: The patient was identified preoperatively, marked
for the procedure. The risks, benefits, and alternatives were discussed. The
patient wished to proceed. He was taken to the operating room, placed in
supine position. A multidisciplinary time-out was performed. General endotracheal anesthesia was induced. Dr. Hepworth performed left styloidectomy, and a completion venogram was requested to determine if the jugular vein was adequately decompressed following styloidectomy. I accessed
the right common femoral vein under ultrasound guidance. Image of ultrasound
was stored in the patient’s chart for documentation, demonstrated patent common
femoral vein without stenosis or DVT. I then inserted the micropuncture sheath
and inserted an Advantage Glidewire into the SVC. I upsized to an 8-French
Pinnacle sheath. I then directed our Kumpe catheter, Advantage Glidewire into
the left internal jugular vein. From here, I performed venogram, which
demonstrated patent internal jugular vein and some collaterals present.
However, there was no focal stenosis identified. I then advanced our
intravascular ultrasound, and this demonstrated area 24 mm2 (4 x 8 mm) at the
base of the skull, area 46 mm2 (6 x 10 mm) at C1, area 95 mm2 (10 x 12 mm) at
C4, area 139 mm2 (12 x 15 mm) at C7, area 213 mm2 (14 x 19 mm) in the left
innominate vein, area 257 mm2 (17 x 20 mm) of the SVC. There was no focal
stenosis or evidence of DVT or chronic venous scarring of the veins image. I
then performed hemodynamic pressure measurements across the left internal
jugular vein. This demonstrated 5 mmHg at the base of the skull, 5 mmHg at C1,
4 mmHg at C4, 4 mmHg at C7. I then directed our Kumpe catheter as well as
Advantage Glidewire into the right internal jugular vein and performed
venogram, which demonstrated widely patent right internal jugular vein with
some collaterals present, but no focal stenosis. We then withdrew our sheath
and held manual pressure until the groin was hemostatic. The case was then
turned over to Dr. Hepworth for conclusion.

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REOPERATIVE DIAGNOSES:

  1. Chronic ethmoid sinusitis.
  2. Skull-base defect, left ethmoid region.
  3. Cerebrospinal fluid rhinorrhea, left nasal cavity.
  4. Left jugular venous compression.
  5. Left Eagle syndrome.
  6. Headaches.
  7. Cervicalgia.

POSTOPERATIVE DIAGNOSES:

  1. Chronic ethmoid sinusitis.
  2. Skull-base defect, left ethmoid region.
  3. Cerebrospinal fluid rhinorrhea, left nasal cavity.
  4. Left jugular venous compression.
  5. Left Eagle syndrome.
  6. Headaches.
  7. Cervicalgia.

PROCEDURES:

  1. Left deep neck space exploration with jugular venous decompression.
  2. Left infratemporal fossa approach to remove styloid.
  3. Left styloidectomy with lower cranial nerve monitoring by outside
    institute.
  4. Left endoscopic total ethmoidectomy for inflammatory sinus disease.
  5. Repair of ethmoid roof skull base defect, left side.
  6. Left anterior cranial fossa floor duraplasty.
  7. Septal mucosal rotational advancement flap, approximately 10 square cm.
  8. Stereotactic surgical navigation.

ANESTHESIA: General endotracheal.
FLUIDS: 1000 mL crystalloid.
ESTIMATED BLOOD LOSS: 25 mL.
COMPLICATIONS: None.
DRAINS: None.
PACKING: Tisseel and Gelfoam to left ethmoid region.

INDICATIONS FOR PROCEDURE: Patient has been struggling after
multiple head traumas and concussive injuries with intermittent left-sided
clear nasal drainage, headaches, and postural instability. Incidental to all
of these, he has been found to have intracranial pressure imbalance, likely due
to bilateral venous compression, left side worse than right. Our workup, while
being extensive, has revealed the isolated problems appearing to be left
jugular stenosis and left ethmoid roof skull base defect. There is
inflammatory sinus disease within the ethmoid cavity, left more so than right,
which we are addressing today as a separate endeavor.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and
placed supine on the table. General anesthesia was induced and a monitored
endotracheal tube was inserted. After sufficient anesthesia was accomplished,
the electrode pairs were implanted temporarily into the left palate, tip of
tongue, and soft tissues of the chin as well as the trapezius bellies. The
left neck was then prepared and draped sterilely and a skin crease 2
fingerbreadths below the angle of mandible was infiltrated with anesthetic.
This was then incised to the subplatysmal plane and subplatysmal flaps were
elevated to visualize the anterior border of the sternocleidomastoid muscle.

Deep to this was found the carotid sheath and within it the jugular vein. The
jugular vein was explored down to the omohyoid muscle inferiorly and up to the
jugular foramen superiorly. It was detached from its fibrous surroundings
throughout so they could be mobilized anteriorly away from the C1 transverse
process. The C1 transverse process was seemed to be intimately associated with
the styloid. The stylohyoid ligament and stylomandibular ligament as well as
styloid process muscle were dissected away from the styloid itself so that it
could be amputated within a few mm of its origin on the temporal bone inferior
aspect. This allowed the jugular vein to restore its own caliber up to and
through the jugular foramen. Venogram assessment was then performed by the
Vascular Surgery service and Dr. Leon who determined it to be restored
adequately without further intervention necessary. The wound was then closed
with 3-0 interrupted Vicryl suture at the platysma, followed by 4-0
subcuticular interrupted Vicryl and then finally 5-0 running horizontally
mattressed Prolene at the skin. After this, Steri-Strips and Mastisol dressing
was applied.

The patient was then treated with Afrin-soaked cottonoids in his nares. The
image guidance system was calibrated using fine cut axial images of CT and 3D
reconstruction and surface registration with the root mean square area of less
than 2 mm. The Afrin-soaked cottonoids were removed and nasal endoscopy
ensued. A left total ethmoidectomy was performed by first removal of the
uncinate process and ethmoidal bulla and polyp degenerated mucosal within and
around these structures. Suprabullar and retrobulbar septations were then
removed so that the anterior mucosa of the middle turbinate basal lamella could
be visualized. The middle turbinate basal lamella was then fenestrated and the
posterior ethmoid region entered. The superior turbinate was evaluated
carefully, and between the superior and middle turbinate and the mid ethmoid
roof was seen to be clear fluid emanating out of the lateral olfactory lamella.
Mucosa over this region was removed and the bony surroundings cauterized so
that the mucosal nests were eliminated. A duraplasty was then performed with
the usage of DuraGen through a defect in the bone of the lateral olfactory
lamella approximately 3 x 4 mm. Mucosal septal rotational flap was then
harvested and left pedicle to its posterior sphenopalatine branches on the
posterior aspect of the septum, but was rotated into place over the bony defect
and secured in place with Tisseel glue. After this, clear fluid emanation
through the base of skull was ceased and Gelfoam was then used to pack the
ethmoid cavity on the left side and this was used to protect the graft from
desiccation or air flow disruption. The patient was then suctioned, awakened
from anesthesia, extubated, and brought to the recovery room in satisfactory
condition.

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95

It looks like the surgery report says it was amputated at the base “could be amputated within a few mm of its origin on the temporal bone inferior aspect”. Not sure what’s going on.

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Few mm could be translated to anything but I hope the radiologist measurements were wrong.

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@KoolDude @stuuke
Per the operative reports:
Left IJV patent (open) post styloidectomy, as described. This is the goal of the surgery and it is performed with the least amount of intervention possible for the safety of the patient - that is the Hippocratic Oath every doctor takes.

Everyone here needs to take a breath. It is very hard not to reflexively turn on those you have trusted with good reason when things don’t turn out as you dreamed. Fueling the fire without first having the appropriate discussion with the surgeon - any surgeon - is not appropriate or helpful.
Stay calm, speak clearly, ask educated questions and listen. That goes for any situation where we are afraid and upset.

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I’m not really fired up, just sharing the information I have. The people on this board are much more knowledgeable than I am. I’ve only talked to Dr. Hepworth maybe 15-20 minutes over the past year so I don’t have nearly the understanding most people on here have regarding possible issues. I’m am curious about the report but unfortunately won’t know anything until I talk Dr. Hepworth in a few weeks. I appreciate everyones thoughts.

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@JustBreathe I hear you. My intent is not to doubt Dr Hepworth whom, by the way, I trust or plant doubt in anyones judgement. I think both Hepworth and the vascular surgeon appear to have done their job based on the report but I was surprised with the Styloid length. I am now leaning towards errors made by the Radiologist who measured the Styloid length.

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Below is the pathology report. It looks like they removed .6cm.

A. The specimen is received in formalin with matching requisition labeled “left styloid”,
is a cylindrical tapered fragment of markedly firm white-tan bone, 0.6 cm in length by
0.3-0.4 cm in diameter. Adherent to the surface are minimal fragments of red-pink skeletal
muscle, less than 0.1 cm in thickness. The specimen is longitudinally bisected and
entirely submitted in cassette A1.
The tissue is fixed in formalin and decalcified in RDO solution prior to processing.