DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Lichen planus.
POSTOPERATIVE DIAGNOSIS: Lichen planus.
PROCEDURES PERFORMED:
1. Biopsy of tongue lesion.
2. Direct laryngoscopy.
SURGEON: John Doe, MD
COMPLICATIONS: None.
DISPOSITION: To the recovery room.
CONDITION: Good.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old lady with a longstanding history of lichen planus. She had a worrisome lesion on the left posterolateral border of the tongue, on the left-hand side. The patient has undergone a biopsy on the right-hand side previously, which did not reveal any malignancy. The dermatologist had requested a more formal examination of the hypopharynx and larynx to rule out mucosal lesions in that location.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room, placed supine on the operating room table, and put to sleep using an oral endotracheal tube without any difficulty whatsoever. The tube was secured in the right side of the mouth. The tongue was grasped, and 1% Xylocaine with 1:100,000 epinephrine was used to inject the left lateral posterior border of the tongue with approximately 10 mL of 1% Xylocaine with 1:100,000 epinephrine.
A Dedo laryngoscope was then used to perform a formal direct laryngoscopy while waiting for the effect of local anesthesia. The base of the tongue, lateral pharyngeal wall, both surfaces of the epiglottis, pyriform sinuses and vocal cords showed no other signs of lichen planus or premalignant change. The Dedo scope was then removed.
The tongue was grasped with a towel clamp. The left lateral border was examined, and an elliptical incision was made with a 15 blade. There was no bleeding due to the presence of epinephrine and the Xylocaine. A very superficial biopsy was obtained, removing only a minimal amount of tongue musculature. The Bovie was not required.
The wound was closed with interrupted buried 3-0 chromic sutures. A gauze pack was placed in the mouth, and the patient was awakened, extubated, and taken to the recovery room in good condition with no apparent complications.
