He took it all the way down to the bone - I will post his summary.
Procedure Date: 06/29/2022
PREOPERATIVE DIAGNOSIS: Symptomatic left Eagles syndrome.
POSTOPERATIVE DIAGNOSIS: Symptomatic left Eagles syndrome.
OPERATIVE PROCEDURE PERFORMED:
- Left neck exploration with excision of posterior belly of digastric muscle.
a. Excision of styloid process and stylohyoid ligament/stylohyoid muscle/styloglossus muscle. - Nasal intubation with mandibular subluxation.
SURGEON: William Omlie, MD
FIRST ASSISTANT: James Omlie, M.D. DDS (Maxillofacial Surgery).
ANESTHESIA: General with nasal intubation.
PREOPERATIVE MEDICATIONS:
- Ancef 2 grams IV.
- Tylenol 1000 mg orally.
INDICATIONS FOR PROCEDURE: A 53-year-old patient has had longstanding cerebral symptoms. She is documented to have significant compression of the left internal jugular vein that exits the skull between the styloid process and transverse process of C1 along with the digastric muscle. We feel this is the likely cause of her symptoms, though not necessarily and this has been discussed at length. We felt that surgical decompression was indicated. She is aware that this may not resolve her symptoms, may have some temporary or permanent numbness of the left ear, and potential facial nerve issues from retraction. She comes to the operating room today under informed consent.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room, induced under general anesthesia and nasally intubated with no difficulty. Calf pneumatic compression boots were used and pillows placed under her knees. A rolled towel under shoulders.
Mandibular subluxation: Dr. James Omlie of Maxillofacial Surgery then performed a very good subluxation of her mandible as dictated in his separate operative report to allow for appropriate exposure.
Neck exploration: Left neck was prepped and draped. Timeout was called again. A 4 cm incision was made from the mid posterior ear down towards the angle of the mandible. Dissection was carried with electrocautery. We identified a very generous brachial cutaneous nerve and this was mobilized, dissected free with minimal retraction. We then dissected down to the border of the sternocleidomastoid muscle.
Division posterior belly of the digastric muscle: We then identified the posterior belly of the digastric muscle. This did not appear to be overly enlarged. This was dissected free of the surrounding vessels including a small branch of the external carotid artery that was ligated between 4-0 silk suture. We identified the tendinous portion distally as it went into the anterior belly of the digastric. The digastric muscle was then removed off its attachment to the mastoid bone with electrocautery. We retracted this with a mosquito clamp and divided at the tendinous segment and removed this in entirety with absolute hemostasis.
Styloidectomy: With a light retraction, we identified the styloid bone along with adjacent tendons and muscles. We mobilized the external carotid artery and retracted this distally. This allowed us to divide the stylohyoid ligament. The bone measured at least 4 cm in length. It was very firm. With loupe magnification excellent visualization, we divided and excised segments of the styloglossus muscle and stylohyoid muscle. We then freed up the styloid bone with minimal retraction to its attachment off the skull. This was cut with a bone cutter, removed and a rongeur was used until it was flush with the bony attachment.
We had an excellent dry field. There was no evidence of any extrinsic compression remaining. We could see the internal jugular vein that was somewhat tender due to the turning of the head and set up position, but there was no evidence of any extrinsic compression. We did not mobilize the vein to help prevent scar tissue from developing.
Wounds were infiltrated with 0.5% Marcaine for post-analgesia along with Toradol 30 mg IV. Subcutaneous tissue was approximated with interrupted 3-0 Vicryl and the skin was closed with 4-0 Monocryl in subcuticular fashion followed by Exofin surgical adhesive.
At this time, Dr. James Omlie removed the mandibular fixation wires, allowing the mandible to return to its normal anatomical position. The patient was extubated without difficulty and returned to recovery room.
ESTIMATED BLOOD LOSS: Less than 2 mL
COMPLICATIONS: None.
Dr. James Omlie was involved in not only the mandibular subluxation but what the first assistant on this procedure to allow for safe completion of the operation. He was involved in the entire procedure from the start to finish.
William R. Omlie, MD