DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Laryngeal papillomatosis, left.
POSTOPERATIVE DIAGNOSIS: Laryngeal papillomatosis, left.
OPERATION PERFORMED: Laryngoscopy with excision of laryngeal papilloma, left vocal fold with operating microscope.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal anesthesia.
ESTIMATED BLOOD LOSS: Zero.
INDICATION FOR OPERATION: The patient is a (XX)-year-old gentleman with a history of laryngeal papillomatosis. He has undergone previous operations with recurrence of the papillomas. The patient is referred to me for a revision laryngoscopy with excision of papillomas. The risks and benefits were explained to the patient, and he agreed to proceed.
OPERATIVE FINDINGS: The patient has extensive laryngeal papillomatosis along the left true vocal fold up to the anterior commissure.
DESCRIPTION OF OPERATION: The patient came into 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. A tooth guard was placed.
Surgery began with direct laryngoscopy. This allowed visualization of the vocal folds. Right vocal fold had no evidence of papillomatosis. The left vocal fold had papillomatosis from the mid half up to the anterior commissure. Video laryngoscope was then placed in suspension. Operating microscope was brought into field for visualization. Half by half pledgets were placed on to the vocal folds for topical decongestion. After 3 minutes, those were removed, and approximately 0.4 mL of 1% lidocaine and 1:100,000 epinephrine was injected lateral to the papillomatosis into the left vocal fold. Afrin-soaked pledgets were then placed. After another 3 minutes, allowing for decongestion, the procedure began with protection of the right vocal fold with half by half pledget. A 3.5 mm laryngeal microdebrider was then used to remove the papillomatosis from the left vocal fold up to, but not including, the anterior commissure.
After removal, an Afrin-soaked pledget was placed for hemostasis. The Afrin-soaked pledget was then removed. Approximately 1 mL of cidofovir was then injected into the left vocal fold and anterior commissure. After completion of the cidofovir injection, the Afrin-soaked pledget was replaced. After 3 minutes, the Afrin-soaked pledget was removed. There was no further bleeding. An Afrin-soaked pledget was then replaced. The patient was taken out of suspension. The microscope was then removed, and prior to extubation, the half by half Afrin-soaked pledget was removed. The patient was then awoken from general anesthesia, extubated, and sent to the postanesthesia care unit in stable condition.
