DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Unknown primary, head and neck.
POSTOPERATIVE DIAGNOSIS: Squamous cell carcinoma, left base of tongue.
OPERATION PERFORMED: Direct laryngoscopy with biopsy.
SURGEON: John Doe, MD
ASSISTANT: None.
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: Less than 5 mL.
SPECIMEN: Left base of tongue.
COMPLICATIONS: None apparent.
OPERATIVE FINDINGS: The patient had a very small lesion of the left base of tongue, which was biopsied and sent for frozen diagnosis. The frozen diagnosis was squamous cell carcinoma.
INDICATION FOR OPERATION: The patient is a (XX)-year-old male with a history of left neck masses. Outside biopsy was performed, which revealed squamous cell carcinoma of the neck. Examination in the office did not reveal the source of the primary lesion. A PET/CT scan did not offer a source of the primary lesion. The patient was recommended to go to the operating room for direct laryngoscopy with biopsy of Waldeyer’s ring to find the primary tumor.
DESCRIPTION OF OPERATION: The patient came to the operating room and was placed in the supine position on the operating room table. General face mask anesthesia was given until a deep plane of anesthesia was obtained. At that point, an endotracheal tube was placed by the anesthesiology service without difficulty.
The table was turned, and a direct laryngoscopy was performed. There were no lesions or masses noted in the piriform sinuses bilaterally, the true or false vocal folds bilaterally, the aryepiglottic folds bilaterally, the vallecula, or epiglottis. The right base of tongue appeared normal. The left base of tongue had a very small area, which appeared to be abnormal in nature. Biopsies were taken of this area and sent for frozen section. Further biopsies were taken and sent for permanent pathology. Frozen section came back as squamous cell carcinoma of the left base of tongue.
At that point, the direct laryngoscope was removed. The patient was awakened from general anesthesia, extubated, and sent to the postanesthesia care unit in stable condition.
