DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Bilateral vocal cord polyps and inflammation of posterior commissure.
POSTOPERATIVE DIAGNOSIS:
Bilateral vocal cord polyps and inflammation of posterior commissure plus vallecular cyst.
PROCEDURE PERFORMED:
Microlaryngoscopy and excision of bilateral vocal cord polyps and vallecular cyst and biopsy of posterior commissure of the larynx.
SURGEON: John Doe, MD
SEDATION: General.
INDICATIONS FOR PROCEDURE: The patient smokes two packs a day and has had chronic hoarseness, which has gotten worse the last few months. He was found to have bilateral vocal cord polyps and also some inflammation and irregular mucosa along the posterior commissure. The patient was treated with Prevacid but did not improve.
DESCRIPTION OF PROCEDURE: With the patient under general anesthesia and an oral endotracheal tube in place, an operating microscope was inserted orally and held in place with a laryngoscope holder. Microscope was brought into place. There were bilateral polypoid vocal cords, which involved most of both vocal cords. These polyps were removed by grasping with microcup forceps and dissecting out submucosally with microscissors. As much of the mucosa as possible was spared and a flap of mucosa was left intact along the medial surface of each vocal cord after removal. The right and left polyps were sent as separate lesions to pathology.
The laryngoscope was then maneuvered to push the endotracheal tube anteriorly and see the posterior commissure. This looked like just inflamed mucosa, and a biopsy was taken from this area. The rest of the larynx and hypopharynx were then examined with the laryngoscope, and there was noted to be two vallecular cysts in the midline adjacent to each other. The laryngoscope holder was then used to hold the laryngoscope in place and the microscope was brought in again. These cysts were then grasped with, again, microcup forceps and dissected out with the microscissors. These were sent again as a separate specimen to pathology. The patient was then awakened in the operating room and brought to recovery in good condition.
The patient will be discharged today and told to rest his voice. I will see him in the office in a week. He was given a prescription for Vicodin one to two q. 4 h. p.r.n. pain. He can have a general diet.
