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Otolaryngology ( ENT ) Medical Transcription Operative Sample Report / Example

PREOPERATIVE DIAGNOSIS:  Recurrent respiratory papillomatosis.

POSTOPERATIVE DIAGNOSIS:  Recurrent respiratory papillomatosis

PROCEDURES PERFORMED:
1.  Direct laryngoscopy.
2.  Suspension microlaryngoscopy with shave excision of papillomas.

SURGEON:  John Doe, MD

COMPLICATIONS:  None.

SPECIMENS:  Laryngeal papilloma.

ESTIMATED BLOOD LOSS:  Approximately 100 mL.

IV FLUIDS:  Lactated Ringer's.

COMPLICATIONS:  None apparent.

DESCRIPTION OF PROCEDURE:  The patient was brought to the operative suite and placed in a supine position. A combination of IV and inhalational agents were used to bring the patient to an adequate plane of general anesthesia while breathing spontaneously. The patient was then rotated 90 degrees in appropriate position and the airway was turned over to the otolaryngology service. At this point, a time-out was performed and verified with all operative room personnel. Next, a moist gauze was placed over the maxillary alveolus and a Dedo laryngoscope was carefully inserted. The patient was noted to have significant bulky disease of the supraglottis and glottis with complete occlusion of the glottic introitus. With further expansion anteriorly, a small opening was able to be identified. This patient was then intubated with a 5.0 uncuffed endotracheal tube. The Dedo was removed and the airway was secured.

Next, the Dedo was carefully reinserted and the patient was suspended from the Mayo stand. The shaver was then brought up onto the field and was used to begin removing the supraglottic component of the papilloma. There was a significant amount noted on the posterior glottic region, right greater than left. This was aggressively debulked. Once an opening to the glottis was identified, the ET tube was pulled out and the shaver was used to remove the obstructing portion of the papillomas. This allowed identification of the remnant right true vocal cord. There was significant involvement of the ventricle and false cords, which was taken down. There was also significant amount in the anterior commissure, which was debrided on the right side, but the left portion was left intact. This provided an adequate airway and the endotracheal tube was easily able to pass through the glottic introitus. Next, the laryngoscope was readjusted to focus on the right piriform sinus/aryepiglottic fold as well as the postcricoid region. There was noted to be significant bulky disease in this region, which was partially debrided. Significant bleeding ensued with this; therefore, Afrin pledgets were intermittently used to stop the bleeding. This was then completed and the ET tube was removed and a 0-degree Hopkins rod was used to evaluate the distal airway. Because the patient was in suspension, only the proximal trachea and subglottis were able to be visualized and there was noted to be no significant disease distal to the glottis.

Therefore, given the concern for worsening airway edema and the significant improvement in the glottic airway, it was decided to terminate the procedure. Adequate hemostasis was again verified. The patient was then intubated with a cuffed endotracheal tube and the patient was then taken out of suspension. The patient was then returned to anesthesia. Once the patient was awake and breathing spontaneously with the endotracheal tube in place, the patient was extubated in the operating room. The patient tolerated this well and was breathing spontaneously without any difficulty. Therefore, the patient was transferred to the PACU.


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