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NEUROSURGEON-IN-CHIEF ANTHONY A. ANIGBO B.SC. (HONS) MD, JD, MBA,
FACS, FICS ATTENDING NEUROSURGEONS CHARLES UGWUANYI MD, FMCS, FNIMC EMEKA NWARIBE MD, FWACS
NEURO-ANAESTHESIA & CRITICAL CARE DR. SOLANKE OLAGBALEKAN MD, FRCA MORAYO SALAWU FMCA NEUROLOGY DR. YAHAYA JUBRIL MD, M.SC. NEUROL(UCH LONDON) DIRECTOR OF ADMINISTRATIONS EGWUOBA NKECHINYERE
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MEDICAL
REPORT/DISCHARGE SUMMARY
NAME:
P. N
AGE:
40 YEARS
SEX:
FEMALE
HOSPITAL
NUMBER: WCA/ 5351/2022
DATE OF ADMISSION:
02/03/2023
DATE OF OPERATION: 04/03/2023
DATE OF DISCHARGE:
14/03/2023
DIAGNOSIS:
Anterior Skull Base Tumor- Potts Puffy Tumor
OPERATION PERFORMED: - STAGED
·
Stage 1-Anterior
skull base approach- Extended sub-frontal craniectomy for tumor excision
·
Stage 2-
Endoscopic fenestration of the left maxillary sinus and evacuation of pus and
necrotic tissues
NAME OF SURGEONS:
Dr Ugwuanyi Charles MD, FICS
Dr Ayogu
Obinna
Dr Jabir
ANAESTHESIOLOGIST: Dr. Salawu M.
BACKGROUND INFORMATION:
She is a known case of frontal skull base tumor being worked for surgery. She
presented to this facility 2 days ago on account of severe headaches of 4 days
duration, extensive swelling over the
left fore head extending to the peri orbital region of 3 Days duration and proptopic left eye of 1 year duration.
There is associated double vision, reduced smell and history of recurrent
sinusitis with recurrent bloody nasal discharge of 1 year duration.
She is a known
hypertensive on Tab Amlodipine. She doesn’t smoke, however drinks alcohol
socially. No history of use of anticoagulant use but she has a significant past
history of chronic sinusitis
She was fully
conscious, with swelling and tenderness over left forehead. Left eyeball was
proptotic and deviated outwards and down wards.
She has purulent and odoriferous discharge from the left nostril. Rest
of cranial nerves essentially normal. Power, tone and reflexes are normal. It
is important to note the profound cellulitis and inflammation on the left
periorbital region which first required initial admission for IV Rocephine and
metronidazole. This was noted to have been substantially resolved after 72
hours before the recommencement of pre-op plans.
Neuroimaging and
Diagnosis- MRI Brain Gad+ (below) shows Ill defined, inhomogeneous contrast enhancing
mass with mixed signal intensities on both T1 and T2 MRI sequences, and
situated mostly on the left anterior skull base with osteolytic destruction of
the overlying frontal bone and left orbital roof. And also extending through
the through the frontal sinuses to the ethmoid sinuses and involving maximally
the left maxillary sinus. The left frontal lobe is seen to be compressed and
displaced posteriorly but well demarcated by the intact dura. Chest Xray and ECG were all essentially
normal.
A clinical Diagnosis of
Potts puffy tumor following a complicated chronic sinusitis was made with other
differentials such as esthesioneuroblastoma, chondrosarcoma etc was made. This diagnosis
was explained to the patient as well as the surgical treatment options and
complications. Following informed consent surgery was planned and executed as
detailed below.
Pre Op Investigations:
Operative Findings:
Details of operative Intervention
Stage 1 – Neurosurgery.
WHO Checklist, GA,
Mayfield Pins, skin prep and draping, pre-op antibiotics
·
Extended subfrontal approach
·
Above findings noted
·
Dura overlying the left Frontal lobes
carefully separated from the fleshy mass while the fleshy was was carefully
dissected off the fronto-ethmoidal sinuses, left orbital roof , through the
destroyed lamina pappyracea and down wards towards the left maxillary sinus.
·
Hemostasis secured and thorough saline
irrigation performed.
·
Reconstruction of torn areas of the left
frontal dura with harvested pericranium and reinforcement of dural seal with
glue.
·
Reconstruction of the left orbital roof
with dural substituted reinforced with quick setting glue to improve the
strength.
·
Closure- scalp closure in layers with
vicryl 2.0 and skin staples
·
Removal from Mayfield pins and wound
dressing. Set for next stage
Stage 2- ENT
·
Under same anesthesia, head
positioning for Endoscopic access to the
left nostril perfected
·
Endoscopic access and and fenestratin of
the left maxillary sinus, revealing above findings
·
Evacuation of all purulent and necrotic
tissues conducted until the cavity is emptied completely
·
Nasal packs.
OPERATIVE
FIDINGS;
PROCEDURE;
In supine point under
GA with hard ring to stabilize the jaw and head tilt to the right. Nasal
preparation done, A O* telescope was used to introduce into left nasal cavity
and abnormal findings noted. With the aid of ?, the intramural mass was removed
in piece meal. With aid of cult ?, the left maxillary meatus was asssed and pus
cleaned. A wide ? done, irrigation done
and nose packed. Patient transferred to ICU and tissue sent for histology.
POST-OP
INSTRUCTIONS/MEDICATION;
·
IVF
0.9% n/s 1L 8hrly.
·
iv
meropenem 1g 12hrly
·
iv
vancomycin 750mg 8hrly
·
iv
metronidazole 500mg 8hrly
·
iv
pcm 600mg 8hrly
·
iv
phenytoin 1g stat then 300mg nocte for 1/52
·
iv
tramadol 50mg 8hrly
·
elective
mechanical ventilation + sedation
·
monitor
vital signs closely.
·
Take
specimen for mcs and fungal studies and histology
·
Iv
dexamethasone 4mg 8hrly for 48hrly.
·
Tab Zinnat
500mg bd x 1/52
·
Tab
Metronidazole 400mg tds x 1/52
·
Tab Amlodipine
10mg dly
·
Tab Lisinopril
10mg dly
·
Tabs Actifed 1 nocte x 10/7
·
Avamys nasal
spray 2puffs b.d x 6/52
·
To see ENT in
2weeks time
·
Follow Up visit
at Wellington clinic on 28th March 2023
Kindly
revert to us for clarifications where necessary.
Sincerely yours
Dr
Ukandu Chinedu
For Consultant Neurosurgeon