DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right vocal cord lesion.
POSTOPERATIVE DIAGNOSIS: Respiratory papilloma.
PROCEDURE PERFORMED: Microscopic laryngoscopy with biopsy and papilloma shave.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal.
COMPLICATIONS: None.
SPECIMENS REMOVED: Biopsy samples sent from the anterior commissure of the vocal cord.
POSTOPERATIVE CONDITION: Stable.
INDICATION FOR PROCEDURE: The patient is a (XX)-year-old male with a six-month history of isolated hoarseness with a vocal cord lesion on direct laryngoscopy, who presents for biopsy of the vocal cord lesion.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room, and an appropriate plane of anesthesia was obtained via endotracheal intubation.
The head of the bed was turned 90 degrees. The Dedo laryngoscope was used to visualize the base of tongue, the bilateral vallecula, both surfaces of the epiglottis, the aryepiglottic folds, the bilateral pyriform sinuses and hypopharynx. All of these areas were clear of any lesions or mucosal abnormalities. The true vocal cords were noted to have papillomatous lesions on the right inferior aspect of the cord and the anterior commissure. The false cords and ventricles were clear.
The patient’s larynx was suspended via the laryngoscope. Biopsy samples were taken for frozen and permanent from the anterior commissure lesion. This came back to confirm papilloma. Next, the operating microscope was brought into the field to obtain a detailed visualization of the vocal cord lesion. A straight shaver was then utilized to remove the papillomatous tissue on the right vocal cord. Care was taken to preserve the mucosa on that side and not injure the vocal cord. This was done unilaterally again on the right. Appropriate hemostasis was obtained.
The patient tolerated the procedure well. The operating microscope was removed from the field. The patient was extubated and taken to the PACU in stable condition with no immediate complications.
