DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Bilateral Reinke’s edema of the vocal folds.
POSTOPERATIVE DIAGNOSIS: Bilateral Reinke’s edema of the vocal folds.
OPERATION PERFORMED: Microsuspension laryngoscopy with excision of bilateral vocal fold Reinke’s edema with operating microscope.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: Less than 5 mL.
SPECIMENS:
1. Left vocal fold tissue.
2. Right vocal fold tissue.
OPERATIVE FINDINGS: The patient had large, boggy, polypoid Reinke’s edema bilaterally on the vocal folds.
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, an endotracheal tube was placed without difficulty. Dedo laryngoscope was then used to visualize the larynx. Suspension was then performed.
An operating microscope was brought into the field to visualize the vocal folds. Approximately 0.1 mL of 1% lidocaine with 1:100,000 epinephrine was injected into the left and right vocal folds for decongestion. Afrin-soaked pledgets were then placed on the vocal folds without difficulty. The Afrin-soaked pledget was then removed. A sickle knife was then used to incise a lateral incision along the length of the left vocal fold. Frazier suction was then used to remove Reinke’s edema from underneath the lining of the vocal fold. Redundant tissue was excised with small scissors.
Attention was then turned toward the right vocal fold. Again, a sickle knife was used to incise a lateral incision along the length of the vocal fold. Suction was used to remove the Reinke’s edema from the vocal fold. Part of the Reinke’s edema was very scarred at that point, and left angled scissors was used to remove a portion of the epithelium of the vocal fold on the right.
At the completion of the procedure, Afrin-soaked pledgets were then again placed on the vocal folds. Dedo laryngoscope was taken out of suspension and removed. The operating microscope was removed. The pledget was removed prior to extubation. The patient was then extubated after awakening from anesthesia. The patient was sent to the postanesthesia care unit in stable condition.
