I wanted to share the surgical notes for those that might be interested:
"HCA HealthONE PRESBYTERIAN ST. LUKE’S
1719 EAST 19TH AVENUE
DENVER CO 80218
OPERATIVE NOTE
REPORT#:1111-0309
REPORT STATUS: Signed
DATE OF SURGERY: 11/11/2024
SURGEON: Edward Hepworth, MD
PREOPERATIVE DIAGNOSES: Right chronic maxillary sinus, right chronic ethmoid sinusitis, right jugular venous compression, headaches, tinnitus, dyspraxia, cervicalgia, cognitive decline.
POSTOPERATIVE DIAGNOSES: Right chronic maxillary sinus, right chronic ethmoid sinusitis, right jugular venous compression, headaches, tinnitus, dyspraxia, cervicalgia, cognitive decline.
PROCEDURES:
- Right deep neck space exploration.
- Right selective neck dissection.
- Right jugular venous decompression and repair.
- Right infratemporal fossa approach with lower cranial nerve monitoring by outside entity.
- Right endoscopic total ethmoidectomy.
- Right endoscopic maxillary sinusotomy with tissue removal.
ASSISTANT: Nia Cook, SA.
ANESTHESIA: General endotracheal.
FLUIDS: 1000 mL crystalloid.
ESTIMATED BLOOD LOSS: 25 mL.
COMPLICATIONS: None.
DRAINS: None.
PACKING: None.
IMPLANTS: Myriad Matrix to anterior tubercle of C1 after reduction so that the jugular vein would remain unattached to it.
DISPOSITION: To recovery room in stable condition.
INDICATIONS FOR PROCEDURE: Mr. R has been struggling with jugular venous inadequacy and all of its attendant symptoms some of which improved with anticoagulation but not enough to allow him to continue work and lifestyle function. He has had attempted styloidectomy before but continues to have jugular venous insufficiency, which we are coming to remedy today as well as sinus disease which may be contributing to many of his symptoms.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed supine on the table. General anesthesia was induced. An oral endotracheal tube with monitoring electrodes was placed. After sufficient anesthesia was achieved, the right neck was then prepared and draped sterilely after electrode arrays were temporarily implanted into the tip of tongue, soft
tissues of palate, chin, and trapezius muscles for monitoring and stimulating the lower cranial nerves.
A skin crease 2 fingerbreadths below the angle of the mandible was identified and infiltrated with anesthetic. This was then incised. Old scar was excised in an elliptical manner. An incision to the subplatysmal plane was performed so that subplatysmal flaps could be elevated to visualize the anterior border of the sternocleidomastoid muscle.
Neck dissection and exploration ensued. The carotid sheath was identified, and obstructive lymphatics were seen to be imposing upon the jugular vein above the
thyroid lamina. These were removed by careful scissor and bipolar dissection off the recurrent laryngeal nerve, the spinal accessory nerve, the carotid artery and the jugular vein. They were sent as specimen, level 2 neck
contents. The jugular vein was then followed inferiorly and seen to be diminutive, seeming to be because of disrupted flow cephalad from the dissection area. As the dissection ensued, more flow and larger caliber of the vein was seen and restored. Above the hyoid bone, further lymphatics were removed and labeled as retrofacial lymph nodes.
These were sent for pathology and culture. Dissection then revealed that the jugular vein was being compressed quite significantly from its posterior geometry by the C1 tubercle which was hypertrophied and osteophytic into the carotid sheath. The overlying fascia was divided with scissors and bipolar and then a Sonopet was used to reduce the bulk of the C1 tubercle until a normal flat contour of it was restored. Over this was then placed a layer of Myriad Matrix to prevent adhesion of the jugular vein to the underlying bone.
The vein was then followed superiorly all the way into the foramen where it was seen to be unadulterated and unfettered by external masses or fibers and expanded entirely into a normal and uniform caliber along its length. The wound was then evaluated under Valsalva maneuvering, and a small ooze was seen from the posterior jugular vein overlying the inferior aspect of the C1 tubercle. This area was repaired with bipolar and suture ligation of a small branch emanating into the occipital region. The wound was closed then with 3-0 Vicryl suture in interrupted fashion, followed by 4-0 Vicryl at the subcuticular planes, followed by 5-0 horizontally mattressed Prolene at the skin after which a Mastisol, Steri-Strip dressing was applied. The electrodes were then removed, and attention was directed to the nasal cavity.
The nares were decongested with Afrin-soaked cottonoids and endoscopy ensued. The middle turbinate on the right side was seen to be widened by a concha bullosa/solar lamella cell formation, which was removed using a vertical
incision with turbinate scissors, leaving the medial portion of the turbinate intact and stable against the skull base. The uncinate was seen to be fenestrated by an accessory ostium and its inferoposterior margin was removed in its entirety up into the frontal recess, and a second ostium in the maxillary sinus medial wall was seen lateral to this, causing a second variety of mucus recirculation. Tissue removal from the maxillary sinus was then performed to allow singular outflow of drainage from the maxillary sinus which was seen to be partly filled with mucopus. This was suctioned and sent for culture and then lavaged until clear. Behind this, the ethmoidal bulla was removed as well as the retrobulbar and suprabullar septations, one of which was filled with mucopus as well, abutting the olfactory groove at its anterior terminus. After removal of the pus from within this, Valsalva maneuvering revealed no CSF emanations through what appeared to be fragile skull base on preoperative imaging.
The ethmoid region was then cleared entirely by
fenestrating the middle turbinate basal lamella and entering of the posteriorethmoid sinus to remove edematous mucosa which was obstructive of the posterior ethmoid outflow and sphenoid at the sphenoethmoid recess. Again, Valsalva maneuvering was performed to assess whether there was any clear fluid
emanations through thin base of skull and this was seen to be intact.
The patient was then suctioned, awakened from anesthesia, extubated, and brought to the recovery room in satisfactory condition."
