DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right vocal fold nodule.
POSTOPERATIVE DIAGNOSIS: Right vocal fold nodule.
OPERATION PERFORMED: Microsuspension laryngoscopy with excision of right vocal fold polyp.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: Less than 5 mL.
SPECIMENS: Right vocal fold polyp/nodule.
OPERATIVE FINDINGS: The patient had what appeared to be a right anterior third of vocal fold nodule. She had left vocal fold nodularity consistent with inflammatory tissue secondary to contact injury.
INDICATION FOR OPERATION: The patient is a (XX)-year-old female with a long history of hoarse voice. Examination in the office revealed a right vocal fold nodule versus polyp with contralateral reactive tissue. Decision was made to take the patient to the operating room after failure of conservative management with proton pump inhibitors. The risks and benefits of the procedure, including hoarse voice, were explained to the patient. The patient agreed to go ahead with the procedure.
DESCRIPTION OF OPERATION: The patient came to the operating room and was placed in the supine position on the operating table. General face mask anesthesia was given until a deep plane of anesthesia was obtained. At that point, endotracheal tube was placed by the anesthesiology service without difficulty. The table was then turned.
The surgery began with direct laryngoscopy to visualize the vocal folds. This was then suspended. An operating microscope was then brought into the field to visualize the larynx. There appeared to be a right vocal fold nodule on the right cord. The contralateral cord showed reactive tissue. Afrin-soaked pledgets were then placed in the vocal folds. Approximately 0.1 mL of 1% lidocaine with 1:100,000 epinephrine was injected into the right vocal fold. Afrin-soaked pledgets were replaced. After allowing time for decongestion, the Afrin-soaked pledgets were removed. 0.1 mL of Kenalog 40 was injected into the left vocal fold around the reactive tissue.
Attention was then turned toward the vocal fold nodule. The nodule was grasped with right triangle forceps. A sickle knife was used to incise the superficial mucosa. Dissection was then performed with scissors. This allowed release of the vocal fold nodule. The overlying mucosa could not be freed from the underlying nodule. This was taken with the specimen and sent for permanent pathology.
An Afrin-soaked pledget was then placed on the wound area for hemostasis. This was then removed and another 0.05 mL of Kenalog 40 was injected into the area around the wound bed of the surgery. At that point, the surgery was completed. The patient was then awakened from general anesthesia, extubated, and sent to the postanesthesia care unit in stable condition.
