Direct Laryngoscopy Procedure Sample Report
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Squamous cell carcinoma of the right neck, unknown primary.
POSTOPERATIVE DIAGNOSIS: Squamous cell carcinoma of the right neck, unknown primary.
PROCEDURES PERFORMED:
1. Direct laryngoscopy with biopsies.
2. Direct esophagoscopy.
3. Direct bronchoscopy.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: Less than 10 mL.
SPECIMENS REMOVED: Right anterior vocal fold, right posterior glottis, right pyriform sinus, right tonsil, and right base of tongue.
PROCEDURE FINDINGS: The patient had no obvious site of primary disease.
INDICATION FOR PROCEDURE: The patient is a (XX)-year-old gentleman with a history of right neck mass, which was biopsied, positive squamous cell carcinoma. A PET-CT and physical examination was performed, which showed no evidence of primary disease. The plan was to take the patient to the operating room for direct laryngoscopy, esophagoscopy and bronchoscopy with biopsies.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and was placed in the supine position on the operating room table. An endotracheal tube was placed by the anesthesiology service without difficulty. The table was turned and the procedure began with direct laryngoscopy.
There were no lesions or masses noted in the tonsils, base of tongue, vallecula, epiglottis, bilateral pyriform sinus, aryepiglottic folds or false vocal folds. There was a small lesion in the right anterior true vocal fold less than 4 mm. There was a small area, less than 5 mm, of irregularity in the posterior glottic space in the right pyriform sinus. The decision was made to biopsy the right anterior true vocal fold, the right posterior glottic space, the right pyriform sinus, the right base of tongue and right tonsil. These were sent for frozen section diagnosis, and all were negative. Direct esophagoscopy was performed. There were no lesions or masses noted throughout the extent of the esophagus. Rigid bronchoscopy was then performed. Again, there were no lesions or masses noted in the proximal trachea down to the carina and the carina.
The endoscopes were then removed. There was no evidence of bleeding. The patient was awakened from general anesthesia, extubated and sent to the postanesthesia care unit in stable condition.
