DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Left vocal fold nodule.
POSTOPERATIVE DIAGNOSIS:
Left vocal fold polyp.
PROCEDURE PERFORMED:
Microsuspension laryngoscopy with excision of left vocal fold polyp.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal anesthesia.
ESTIMATED BLOOD LOSS: Zero.
SPECIMENS: Left vocal fold polyp.
OPERATIVE FINDINGS: The patient had a soft lesion consistent with a vocal fold polyp in the left anterior third of the vocal fold. The patient also had contralateral vocal fold inflammation.
DESCRIPTION OF OPERATION: The patient came to the operating room and was placed in the supine position on the operating room table. General facemask 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 then turned, and the patient was prepped and draped in a routine fashion.
A direct laryngoscope was then placed in the oral cavity and oropharynx, to the larynx, to visualize the vocal folds. Once the vocal folds were identified, a microsuspension system was used to hold the Dedo laryngoscope. The microscope was brought in, and the larynx was viewed through the microscope. The surgery began with palpation of the lesions in the left and right focal fold. The left vocal fold appeared to be full at the site of the lesion, but not hard in nature. This was inconsistent with a nodule and more consistent with a polyp. The right vocal fold lesion was soft and consistent with irrigation from contact damage from the left vocal fold mass.
At that point, approximately 0.2 mL of 1% lidocaine with 1:100,000 epinephrine was injected into the left and right vocal folds. Afrin pledgets were then placed on the vocal folds bilaterally. After allowing time for decongestion, the Afrin pledgets were removed. Under microscopic guidance, a small flap was made in the anterior posterior direction on the vocal fold just lateral to the lesion. The flap was raised with scissors. This confirmed the presence of a polyp and no nodule.
At that point, a left grasper was used to retract the flap. The vocal fold polyp was then excised with a scissors to the right. The vocal fold was then inspected, and there was no further evidence of pathology. At that point, attention was turned towards the granulation tissue on the right vocal fold. Approximately 0.2 mL of Kenalog 40 was injected just deep to the lesion on the right. Afrin-soaked pledgets were then placed on the vocal folds bilaterally. The suspension arm was removed. The Dedo laryngoscope was removed. At that point, the Afrin-soaked pledgets were removed. The patient was then awakened from general anesthesia, extubated, and sent to the postanesthesia care unit in stable condition.
