DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Laryngeal papillomas.
POSTOPERATIVE DIAGNOSIS: Laryngeal papillomas.
PROCEDURE PERFORMED: Microlaryngoscopy and shave excision of true vocal cord papillomas.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: None.
PROCEDURE FINDINGS: Exophytic polypoid disease of the anterior one-third of the true vocal cord, left greater than right. Papilloma noticed on the superior surface of the true vocal cord as well as the vocal surface and undersurface. The anterior few millimeters of the true vocal cord were clear. The left false vocal cord had an isolated papilloma. Subglottis is normal.
INDICATIONS FOR PROCEDURE: This is a (XX)-year-old gentleman with a history of multiple excisions of true vocal cord papillomas in the past, who has increasing hoarseness. Videostroboscopy was performed showing mainly left anterior vocal cord polyp, papillomas.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed on the table in the supine position. Once suitable plane of anesthesia was obtained, the anesthesia personnel performed endotracheal intubation with a 6.0 endotracheal tube. The tube was secured. The table was turned 90 degrees. Dedo laryngoscope was then inserted into the oral cavity after tooth guard was placed. The epiglottis appeared normal. The Dedo was placed in position to expose the true vocal cords bilaterally and laryngoscope was placed in suspension.
At this point, anterior cricoid pressure was applied with tape across the neck to further expose the anterior commissure. Operating microscope was then used to visualize the true vocal cords, with the above findings, using a suction to lateralize the left true vocal cord. Laryngeal shaver was then used to remove focal papillomas from the left false vocal cord and left true vocal cord, taking care not to remove any tissue from the right vocal cord to avoid future scar tissue. All visible disease was able to be removed from the left true vocal cord; although, there was significant edema of the left true vocal cord.
At the conclusion of the procedure, there was remnant papilloma disease at the right anterior commissure that was left alone. There was no bleeding at this point, and the operating microscope was removed. The patient was removed from suspension. Dedo laryngoscope was removed and care was turned over to anesthesia for extubation. The patient was successfully extubated without difficulty and stable upon transport to PACU.
