how turbinate reduction surgery improved Eustachian tube dysfunction and helped to avoid ear surgery

Bilateral enlarged posterior end of inferior turbinate or Choanal polyp were found to block Eustachian tubes. Simply reduction of posterior end of inferior turbinates helped to avoid tympanoplasty and Mastoidectomy in a young patient. # turbinate reduction Surgery #Choanal polyp #Eustachian tube dysfunction #कान का ऑपरेशन # Tympanoplasty # Mastoidectomy #Choanal polyp originating from inferior turbinates. #Septoturbinoplasty #CSOM #Eustachian tube black age This 29 year patient used to have frequent cold and ear discharge. He came for ear surgery to us. We advised him to undergo nasal surgery first because of his stuffy nose. On table, we found enlarged inferior turbinates and posterior end of turbinates was blocking opening of Eustachian tubes. We reduced the posterior end or Choanal polyp with help of microdebrider. Patient did very well postoperatively. Both his ears became dry and ear drum Perforation healed. So this case clearly shows importance of Eustachian tubes in normal functioning of ears. Dr Ajay Jain, MS (PGI Chd), DNB ENT Clinic: Shop No:1,2,3 DDA Market-1, G-block, Preet Vihar, Delhi. For appointment, Whatsapp or call at 9871166370 www.drajayjain.com Pls see other videos Must see video before ear surgery -कान के ऑपरेशन से पहले कम से कम एक बार इस वीडियो को देखें https://youtu.be/dmT1-hrL2XQ Cost of Ear Surgery in Delhi (India) https://youtu.be/ZxsCtZ4suUc Which Ear drop should I put in ear? कान में कौन सी बूंदें डालनी चाहिए https://youtu.be/RVi_zi3Yce8 Care of discharging ears (CSOM)-बहते हुए कानों की देखभाल https://youtu.be/skst8yH-kkU Tinnitus-Ringing Sensation in Ear during Coronavirus Pandemic. Taking my silence away https://youtu.be/8Scp-1YXqUk Secretly recorded ENT Doctor’s clinic proceedings and released on YouTube. https://youtu.be/S3NxkHrJDkQ

Informed consent for endoscopic sinus surgery

Informed Consent for

ENDOSCOPIC SINUS/NASAL SURGERY

 (Approved by All India Rhinology Society)

 

Name:
son/daughter/wife of:
Age &sex:
Reg.No.:
Address

PLEASE READ THIS DOCUMENT CAREFULLY AND ASK ABOUT ANYTHING YOU DO NOT FULLY UNDERSTAND. AFTER YOU HAVE READ IT, PLEASE SIGN FOR THE SURGERY OR PROCEDURE.

1. I have spoken to the doctor (s) who has/ have explained that I/my  have/ has (condition/symptoms/provisional diagnosis)

2. What might happen to me/my if we do not treat this condition has been explained to me. The different ways to treat the conditions and the advantages and disadvantages of each of these was discussed with me. The Doctor has informed me that my problem may have arisen as a consequence of an allergy and has accordingly asked me to be treated for it as the surgery itself is only a part of the treatment.

3. The doctor wants (suggested) me/ my to have the following operation (s) or procedure (s): ESS/Septal Surgery/Turbinate Surgery

4. The doctor talked to me about how this surgery or treatment might help me. The doctor explained that the treatment might change if there was a change in my condition or if they find something different during treatment. The doctor also told me about how long it would take me to recover.

5. I am fully aware that the treatment/ surgery/ procedure is being performed in good faith and no guarantee/ assurance has been given as to the result that may be obtained. The doctor gave me an opportunity to ask questions about my condition and different ways to treat it.The doctor answered my questions. I am satisfied with the answers about my treatment.

6. I have been fully explained that there can be risks, complications or side-effects about any operation or medical procedure or anaesthesia. I know the doctor cannot tell me about every possible risk, complication or side-effect. We did talk about the major ones (for example : bleeding, infection, pneumonia, heart complications, blood clots, risk to life) that could happen if I have the operation or procedure. However the chances of these major complications are very rare. One to two percent of the patients can have bleeding which may require controlling it under anesthesia.

7. The doctor also explained me about these other risks :severe bleeding possibly requiring transfusions and possibly leading to stroke and/or death, bleeding into the eye and/or brain requiring external incisions for drainage, persistent nasal crusting, persistent tearing and/or damage to the tear ducts, damage to the nasal septum including hole formation in the septum, numbness and/or chronic pain to the forehead, face, and/or teeth, new or persistent infection with possible spread or infection to form brain infection or abscess, loss of or damage to sense of smell and/or taste, eye infection or abscess, and infection in distant spots of the body, damage to the eyes including permanent blurred vision and/or blindness, brain damage including damage to the lining of the brain, temporary or permanent scarring of the sinuses, with brain fluid leak, the need for further sinus, eye, or brain operations including operations that lead to external scarring, heart attack, stroke and/or death, and other unanticipated risks. Again these complications are extremely rare.

8. The doctor gave me a chance to ask questions about these risks and any other risks I wanted to know about. The doctor answered my questions. lam satisfied with the answers about the risks.

9. The doctor has explained to me that the doctor or whosoever may be designated as assistant may be doing important tasks related to surgery or procedure under the direction of the doctor.

l0 This surgery will be performed under local/ general anaesthesia.The doctor has explained to me about the general/complications of drug interactions, blood transfusion and risk to life.

11. If something unexpected happens or is found during the procedure or operation, that in the doctors opinion. Pose an immediate and substantial risk to my health and needs treatment in addition to or different from what is described above,  also agree that the doctor (s) may at that time provide the treatment that is immediately necessary.

12. In the event of any systemic complications, I authorize the doctor (s) to transfer the case to an appropriate medical centre for necessary treatment.

13. Any tissues or parts surgically removed may be sent for examination/disposed off in accordance with accustomed practice.

14. I consent to pictures or videos being recorded or televised during my treatment for medical, research or educational purposes, as long as my identity is not shared. 

NASAL POLYPS WITH ORBITAL INVOLVEMENT

NASAL POLYPS WITH ORBITAL INVOLVEMENT
Dr. V. P. Sood New Delhi.
Past President : Association of Otolaryngologists of India.
Past President : All India Rhinology Society.

Although patients with nasal polyps are common in E.N.T. practice but the aetiology of this condition still remains a mystery. The etiopathogenesis of nasal polyps has long been a subject of study, yet there is little agreement as to the mechanism of polyp formation. So far two main theories have emerged, allergic & infectious. Recently, sensitivity to aspirin and fungal infections have also been implicated as etiologic factors. Nasal polyps has been referred to as "benign allergic polyps" but research suggests that they are not more common in allergic patients. But now allergy has again been considered and there is a possibility that localized nasal allergy may have a role in the aetiology of polyps. The role of fungal infection in the aetiology of nasal polyps has been the source of great debate amongst rhinologists, since allergic fungal sinusitis has recently come to limelight.

In long standing infective polyposis most of the time there is bony necrosis of medial wall of maxillary sinus, lamina papyracia, ethmoid cells and anterior wall of the sphenoid sinuses. Chronic infective polyps degenerate to form into cheesy and muddy material, a condition referred to as necrotising ethmoiditis which should rather be called necrotising sinusitis since disease process is not only localized to ethmoid sinuses but can involve all the sinuses. The extent of endoscopic surgery should be planned and adapted to the requirement of individual cases. For circumscribed pathology minimum invasive endoscopic interventions are indicated. For diffuse polyposis of all sinuses a complete endoscopic ethmoidectomy together with the fenestration of the frontal, sphenoidal and maxillary sinuses is done. The disease is cleared from within the sinus cavities through the enlarged opening of the respective sinus. The end result should be as open ethmoidal cavity lined by moist mucosa and having free communication with the frontal, sphenoidal and maxillary sinuses. In multiple nasal polyps initial clearing is generally done with the help of microdebrider. Surgical results improve by carefull pre-operative planing, use of systemic antibiotics and steroids pre and post operatively. Use of thru-cut forceps and microdebrider also helps to preserve mucosa to achieve better results. Reconstructing adequate antrostomy is also conductive for better results. In diffuse polyposis a short course of systemic steroids pre operatively and post operatively is mandatory followed by topical steroid sprays.

Local application of amphotercin-B is now used especially when polyps are associated with fungal infections. Even in extensive polyposis, I prefer to do endoscopic sinus surgery under L.A. because the pupillary reflexes can be monitored and patient's subjective feedback of excessive pain sensation when the instruments are touching the orbital plate, cribriform plate or fovea ethmoidalis can be warning signals to the surgeon, which increase the safety index in endoscopic sinus surgery. I follow up my patients endoscopically for suction clearance of crusts and discharge. If I find any adhesion in middle meatus that is incised. If any small polyp is visible that is also removed without any pain or discomfort to the patient.

The follow up of patients in our country is poor. Patient must be told about importance of follow up. Modem technology, CT scanning and endoscopy enables us to make an early and appropriate diagnosis of nasal polyposis and Endoscopic Sinus Surgery offers precise and complete removal of polyps. Image guided surgery increase the safety index during endoscpoic sinus surgery. In future, the key to successful management of nasal polyps will be an understanding of the underlying mucosa inflammation, mechanism of polyp formation and the genetic control of etiopathogenesis of nasal polyps.. 

Pediatric rhinosinusitis

Case of 11 year child with history of mouth breathing having Adenotonsillar hypertrophy. Patient was not referred but came on her own very late. In our country, timely referrals from paediatrician is rare. All cases of mouth breathing should have an ENT opinion at earliest.

Unilateral Pansinusitis

This patient presented with six month history of gradually progressing nasal obstruction. CT shows complete opacification of left side sinuses. Soft tissue cuts were suggestive of Fungal mass because of heterogeneous opacities. To my surprise, it was just thick secretions in Frontal, ethmoid and sphenoid sinus. The nose and maxillary sinus was filled up with very thick walled mass with secretions inside.
Lesson: Thick secretions can mimick as fungal mass.

Consent, Endoscopic Sinus Surgery

PLEASE READ THIS SHEET BEFORE YOU CONSENT FOR YOUR PROCEDURE

This information sheet provides general information to a person having an Endoscopic Sinus Surgery. It does not provide advice to the individual. It is important that the content is discussed between the patient and the concerned doctors who understand the level of fitness and medical condition.

What are the “sinuses”?

The sinuses are spaces filled with air in some of the bones of the skull. Air passes in and out of these spaces, and mucus drains through them and out of the nose. They also reduce the weight of the skull and give our voices a nicer sound.

There are four main pairs of sinus openings, sometimes called sinus cavities, in the face:
* Maxillary - in the cheekbones
* Ethmoid - between the eye sockets
* Frontal - in the forehead and above the eyebrows
* Sphenoid - deep in the head at the back of the nose

 What is Endoscopic Sinus Surgery?

Endoscopic sinus surgery - also called endoscopy or sinoscopy - is a procedure used to remove blockages in the sinuses (the spaces filled with air in some of the bones of the skull). These blockages cause sinusitis, a condition in which the sinuses swell and become clogged, causing pain and impaired breathing.
A thin, lighted instrument called an endoscope is inserted into the nose, and the doctor looks inside through an eyepiece. Much like a telescope with a wide-angle camera lens, the endoscope beams light into different parts of the nose and sinuses, allowing the doctor to see what is causing blockages. Surgical instruments can then be used along with the endoscope to remove the blockages and improve breathing.

This surgery does not involve cutting through the skin, as it is performed entirely through the nostrils.

Therefore, most people can go home the same day.

When is it indicated?

Endoscopic sinus surgery is used to treat:
* Sinusitis
* Deviated septum
* Polyps
* Tumors

How does a doctor determine if surgery is necessary?

The first thing a doctor will do is take a detailed medical history and make note of all symptoms, as well as how long the symptoms have been present. The doctor will need to know any medications being taken, as well as any other conditions such as high blood pressure, eye diseases or bleeding disorders.
* If there is another course of treatment besides surgery that has not yet been tried, the doctor may prescribe new medications.
* If surgery appears to be the best course of action, a CT scan, which is a special type of x-ray, is usually taken so that the doctor can see all of the sinuses prior to using the endoscope. The CT scan serves as a kind of road map for the endoscopic examination.
* Before the endoscopic examination, a nasal spray is used to shrink and anesthetize sinus tissues. The doctor will then insert the endoscope into the nostrils to determine what is causing the sinusitis symptoms, such as thick mucus, swelling, small openings, deviated septum, or polyps.
* The doctor will only perform surgery if the examination shows problems that can be surgically corrected.

What are the advantages of this surgery?

There are other types of surgeries that can correct blockages in the nose and sinuses, but endoscopic sinus surgery is becoming the procedure of choice for more and more doctors. It is:
* Is less painful
* Leaves no visible scars
* Causes less bleeding
* Creates less discomfort after surgery
* Requires less packing in the nose after surgery
* Has a faster recovery period
* Has a higher success rate

How do I prepare for this surgery?

Prior to endoscopic sinus surgery, your doctor may recommend that you do the following:
* Discontinue taking any pain relievers that contain aspirin for at least two weeks prior to surgery, as aspirin thins the blood and promotes bleeding.
* Discontinue taking any other medications the day of surgery.
* Do not drink or eat anything after midnight the night before surgery.

What happens during the procedure?


The surgery itself lasts 60 to 90 minutes, after which the patient spends an hour or two in a recovery room.
A simple clearing of the intersection between the two sides of the nose is often all that is needed to relieve symptoms. In this case, a local anesthetic, where the patient remains awake during the procedure, is enough. Some crunching sounds may be heard and a sensation of tightness may be felt during the surgery, but there is no pain.
If there are several blockages deeper in the sinuses or polyps to be removed, a general anesthetic, where the patient is fully asleep, is recommended. The doctor typically begins by clearing the ethmoid sinuses, followed by the sphenoid sinuses, the frontal sinuses, and finally the maxillary sinuses, if necessary.
 Endoscopic sinus surgery is carried out with the use of an endoscope, which is a small telescope. This telescope, inserted through the nostrils, provides the surgeon with a magnified view of the nose and sinuses. A camera is attached to the eyepiece of the endoscope and the image from the eyepiece is then projected onto a video screen. The surgeon is then able to operate by looking at the video screen while holding the endoscope with one hand and using the other to insert various instruments through the nostril (see below).

Once the procedure is completed, nasal packing may or may not be used, depending on the risk of bleeding. Nasal packing can take on many different forms, including a gauze strip (a long string of gauze coated with an ointment), as well as a variety of pre-made and commercially available packs of varying shape and size.

 What happens after surgery?

* The nose is usually covered with a gauze dressing that will need to be changed whenever it becomes dirty or wet.
* A packing is placed in the nose after surgery, which requires breathing through the mouth for a short time during the healing process. The packing usually has to be worn for only a few days, and the doctor will advise when it can be removed. It may have a bad odor, however, or cause bad breath.
* Nose blowing should be avoided entirely for at least a week after surgery.
* Sleep on at least two pillows to keep the head elevated.
* It is not uncommon to experience discomfort in the nose and face for a short time after surgery. Mild headaches are also normal.
* Do not take pain relievers containing aspirin without consulting a doctor. Aspirin can promote bleeding and cause problems after surgery.
* Keep the nose as free from dry crusting as possible. A saline spray may be used six to eight times per day to keep the nose moist. Sometimes, the doctor will want to take care of cleaning the area in the office two to three times a week.
* Keep activities to a minimum for a couple of weeks, as too much activity can increase the chances of bleeding.
* Do not lift heavy objects, swim, scuba dive, or fly for a few weeks following surgery.
* Avoid caffeine, alcoholic beverages, spicy foods, and medications, which can cause drying of the sinus passages.
* Do not use decongestant nasal sprays unless prescribed by a doctor, as these sprays can become addictive after a few days of continuous use.
* Avoid eating dairy products, which can promote excess mucus production.
* Avoid anything that causes allergic reactions.
* Do not smoke, and avoid secondhand smoke.
* Drink plenty of fluids, especially water.
* Use a humidifier, if necessary, to moisten dry air.
* Finish all prescribed antibiotic medication.
* Within a week after surgery, the doctor will set an appointment to check the progress of healing.

General Risks of having the procedure:

These have been mentioned in the “Anesthesia Consent Form.” Please discuss this with your Anesthetist before signing the Anesthesia Consent Form.

What are the risks of the procedure?

While majority of patients have an uneventful procedure and recovery, few cases may be associated with complications. These are seen infrequently and not all the ones listed below are applicable to one individual. However it is important that you are aware of the complications/risks that may arise out of this procedure which are as below:
There are some risks/ complications, which include:
(a) Bleeding. This may occur either at the time of surgery or in the first few weeks after surgery. Bleeding at the time of surgery may require termination of the procedure and nasal packing.
Bleeding after surgery may require packing of the nose under local anesthesia or may require another operation to stop the bleeding.
A blood transfusion may be necessary depending on the amount of blood lost
(b) Eye injury. This may lead to bruising or swelling around the eye. Rarely, permanent damage causing double vision or partial or complete loss of vision.
(c) Brain injury. CSF (brain / spinal fluid) leak, meningitis or brain abscess may occur. Further surgery to repair the CSF leak may be necessary
(d) Tear duct injury with tearing of the eye can occasionally occur and may be ongoing.
(e) Infection of the nose and sinuses. Usually temporary but may be ongoing which requires antibiotic therapy
(f) Altered taste and smell which may be permanent.
(g) Scar tissue may grow inside the nose which may need sinus drainage requiring further surgery
(h) Hole in the partition inside the nose. This does not usually cause any problems. Sometimes it may cause whistling, crusting or bleeding and may require further surgery to close the hole.
This may cause disfigurement.
(i) The disease may not be cured or may come back. This may need further medical or surgical treatment.

Consent Acknowledgement:

* The doctor has explained my medical condition and the proposed surgical procedure.
* I understand the risks of the procedure, including the risks that are specific to me, and the likely outcomes. The doctor has explained other relevant treatment options and their associated risks, the prognosis and the risks of not having the procedure.
* I have been given an Anesthesia Informed Consent Form.
* I have been given a Patient Information Sheet about the Condition, the Procedure, and associated risks.
* I was able to ask questions and raise concerns with the doctor about my condition, the procedure and its risks, and my treatment options.
* My questions and concerns have been discussed and answered to my satisfaction.
* I understand that the procedure may include a blood / blood product transfusion.
* I understand that if organs or tissues are removed during the surgery, that these may be retained for tests for a period of time and then disposed of sensitively by the hospital.
* The doctor has explained to me that if immediate life-threatening events happen during the procedure, they will be treated as appropriate.
* It has been explained to me, that during the course of or subsequent to the Operation/Procedure, unforeseen conditions may be revealed or encountered which may necessitate urgent surgical or other procedures in addition to or different from those contemplated. In such exigency, I further request and authorize the above named Physician / Surgeon or his designee to perform such additional surgical or other procedures as he or they consider necessary or desirable.

On the basis of the above statements,
I REQUEST TO HAVE THE PROCEDURE.
Name of Patient/Substitute Decision Maker…………………………………………….
Relationship …………………………………….
Signature………………………………………
Date………………………………………………
Name of the Witness…………………………
Relationship/Designation………………………
Signature………………………………………..
Date……………………………


INFORMED CONSENT: ENDOSCOPIC SINUS SURGERY


Patient Identification Label to be affixed here





A. INTERPRETER
An interpreter service is required.Yes______________No_______________
If Yes, is a qualified interpreter present.Yes_____________No___________

B. CONDITION AND PROCEDURE
The doctor has explained that I have the following condition:
(Doctor to document in patient’s own words)
_______________________________________________and I have been advised to undergo the following treatment/procedure____________________________________________________________________________________________________________________________________________________________
 
See patient information sheet- “Endoscopic Sinus Surgery” for more
C.ANAESTHETIC
Please see your “Anesthesia Consent Form”. This gives you information of the General Risks of Surgery. If you have any concern, talk these over with your anesthetist.

D.RISKS OF THIS PROCEDURE
While majority of patients have an uneventful surgery/procedure and recovery, few cases may be associated with complications. These are seen infrequently and not all the ones listed below are applicable to one individual. However it is important that you are aware of the complications/risks that may arise out of this procedure which are as below:

There are some risks/ complications, which include:
(a) Bleeding. This may occur either at the time of surgery or in the first few weeks after surgery. Bleeding at the time of surgery may require termination of the procedure and nasal packing.
Bleeding after surgery may require packing of the nose under local anesthesia or may require another operation to stop the bleeding.
A blood transfusion may be necessary depending on the amount of blood lost
(b) Eye injury. This may lead to bruising or swelling around the eye. Rarely, permanent damage causing double vision or partial or complete loss of vision.
(c) Brain injury. CSF (brain / spinal fluid) leak, meningitis or brain abscess may occur. Further surgery to repair the CSF leak may be necessary
(d) Tear duct injury with tearing of the eye can occasionally occur and may be ongoing.
(e) Infection of the nose and sinuses. Usually temporary but may be ongoing which requires antibiotic therapy
(f) Altered taste and smell which may be permanent.
(g) Scar tissue may grow inside the nose which may need sinus drainage requiring further surgery
(h) Hole in the partition inside the nose. This does not usually cause any problems. Sometimes it may cause whistling, crusting or bleeding and may require further surgery to close the hole.
This may cause disfigurement.
(i) The disease may not be cured or may come back. This may need further medical or surgical treatment.

SIGNIFICANT RISKS AND RELEVANT TREATMENT OPTIONS:F. SIGNIFICANT RISKS AND
The doctor has explained any significant risks and problems specific to me, and the likely outcomes if complications occur.
The doctor has also explained relevant treatment options as well as the risks of not having the procedure.
(Doctor to document in Medical Record if necessary. Cross out if not applicable. )

PATIENT CONSENT: CONSENT
I acknowledge that:
 
* The doctor has explained my medical condition and the proposed procedure. I understand the risks of the procedure, including the risks that are specific to me, and the likely outcomes.
* The doctor has explained other relevant treatment options and their associated risks. The doctor has explained my prognosis and the risks of not having the procedure.
* I have been given a Patient Information Sheet on Anesthesia.
* I have been given the patient information sheet regarding the condition, procedure, risks and other associated information.
* I was able to ask questions and raise concerns with the doctor about my condition, the procedure and its risks, and my treatment options. My questions and concerns have been discussed and answered to my satisfaction.
* I understand that the procedure may include a blood transfusion.
* I understand that if organs or tissues are removed during the surgery, that these may be retained for tests for a period of time and then disposed of sensitively by the hospital.
* The doctor has explained to me that if immediate life-threatening events happen during the procedure, they will be treated accordingly.
* I understand that photographs or video footage maybe taken during my operation. These may then be used for teaching health professionals. (You will not be identified in any photo or video).
* I understand that no guarantee has been made that the procedure will improve the condition, and that the procedure may make my condition worse.

On the basis of the above statements,
I hereby authorize Dr……………………………………………………………………and those he may designate as associates or assistants to perform upon me the following medical treatment, surgical operation and / or diagnostic / therapeutic procedure…………………………………………………………..

I REQUEST TO HAVE THE PROCEDURE

Name of Patient/Substitute Decision Maker…………………………………………….
Relationship …………………………………………………………………………………….
Signature……………………………………………Date……………………………………….

Name of the Witness…………………………………………………………………………
Relationship/Designation………………………………………………………………………
Signature……………………………………………Date………………………………………
FERENCES
INTERPRETER’S STATEMENT:
I have given a translation in……………………………………………………………………
Name of interpreter…………………………………………………………………………….
Signature……………………………………………Date………………………………………

DOCTOR’S STATEMENTS
I have explained
* The patient ‘s condition
* Need for treatment
* The procedure and the risks
* Relevant treatment options and their risks
* Likely consequences if those risks occur
* The significant risks and problems specific to this patient

I have given the Patient/ Guardian an opportunity to:
* Ask questions about any of the above matters
* Raise any other concerns, which I have answered as fully as possible.

I am of the opinion that the Patient/ Substitute Decision Maker understood the above information.

Name of doctor…………………………………………………………………………..
Designation………………………………………………………………………………
Signature………………………………………Date……………………………………

ENDOSCOPIC SINUS SURGERY