DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Squamous cell carcinoma of the left neck, suspicious for squamous cell carcinoma of the larynx.
POSTOPERATIVE DIAGNOSIS: Squamous cell carcinoma of the left neck and larynx.
PROCEDURE PERFORMED: Direct laryngoscopy with biopsy.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: Less than 10 mL.
SPECIMENS:
1. Left aryepiglottic fold.
2. Vallecula.
CONDITION: Stable.
INDICATION FOR PROCEDURE: The patient is a (XX)-year-old female with a history of squamous cell carcinoma of the left supraglottis with left neck squamous cell carcinoma treated with chemotherapy and radiation. She is six months out from treatment and is complaining of left otalgia and new left neck mass and a PET scan suspicious for persistent tumor of the larynx. An FNA of the neck today in the office revealed squamous cell carcinoma. The plan was to go to the operating room for direct laryngoscopy with biopsy of the larynx.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and was placed in the supine position on the operating room table. Endotracheal tube was placed by the anesthesiology service without difficulty.
The procedure began with a direct laryngoscopy. There were no lesions or masses noted in the base of the tongue. There was mild granulation tissue of the vallecula, which was biopsied and sent for frozen section, which was negative. The lingual surface of the epiglottis appeared to be normal. The laryngeal surface of the epiglottis and aryepiglottic fold had ulcerative lesions wrapped around the anterior surface of the laryngeal epiglottis contralateral side.
Multiple biopsies were taken of this region and sent for frozen pathology. Frozen section came back as positive for viable squamous cell carcinoma. The left and right pyriform sinuses were free of tumor. True vocal folds were free of tumor. The right false cord was free of tumor. The Dedo laryngoscope was then removed.
The patient tolerated the procedure well. There were no complications. She was awakened from general anesthesia, extubated, and sent to the postanesthesia care unit in stable condition.
