Note: The sample dictations below are not intended to be used as templates. They are variations on procedures and should not substitute for the surgeon's own dictation. They are provided to help visualize the procedure from beginning to end and to illustrate key points and staff preferences. Click on the large blue title of the procedure to move to the actual protocol.

1. Case Example Posterior Cordotomy for Bilateral Vocal Cord Paralysis

Modified Operative Note:

The sample dictations below are not intended to be used as a template. It is a variation on this procedure and should not substitute for the surgeon's own dictation. It is provided to help visualize the procedure from beginning to end and to illustrate key points and staff preferences.

Findings: Bilateral vocal cord paralysis, cords in adducted position, mobile arytenoids bilaterally, slight defect in the left vocal cord immediately anterior to vocal process

Tracheotomy performed, #4 Shiley placed Left posterior cordotomy performed with CO2 laser on 8 Watts continuous superpulse.

Indications:... with bilateral vocal cord paralysis after TT 10 years ago. S/p left posterior cordotomy 5 years ago. Now with difficulty breathing, progressive stridor and dyspnea.

Procedure:

MicroDL with palpation of arytenoids and photography

Tracheotomy #4 Shiley

MicroDL with posterior left cordotomy

Procedure Details: Risks, benefits, indications, alternatives and procedure were explained to the patient. All questions were answered. Informed consent was reviewed and a timeout performed.

General anesthesia was induced with mask ventilation with the patient supine. A microdirect laryngoscopy was performed after dental protection placed and the larynx exposed. The cords were sprayed with 2 cc of 4% lidocaine. A 5.0 MLT tube was placed and the cuff inflated. The arytenoids were then palpated and found to be mobile bilaterally. The Lindholm scope was then placed and put into suspension, and the airway, glottis, and subglottis were visualized and photo documented. The cords were noted to be in adducted position. The patient was taken out of suspension and the Lindholm removed. Attention was directed to the neck. The neck was injected with 1% lidocaine with 1:100,000 epinephrine. At the site of planned tracheostomy, a vertical incision was planned. The patient was prepped and draped in the usual sterile fashion. A vertical incision was made with a #15 blade and carried down through the median raphe with blunt dissection and cautery. The trachea was identified. There was no thyroid, consistent with her previous total thyroidectomy. An inferior based Bjork flap was created after Anesthesia advanced the tube down to the right main stem. The tube was repositioned, as the cuff had not been damaged, and careful hemostasis was achieved. The Bjork flap was sutured to the inferior skin with three 3-0 Vicryl sutures. A 4.0 Shiley with cuff was placed and the cuff was inflated. A trach strap was placed and the trach was secured in place. Attention was placed back to the oropharynx and glottis and the Lindholm was reinserted and the patient was placed in suspension. Moist towels were placed around the scope and careful note was made to ensure that no plastic tape was on the patient. The eyes were covered with cloth tape with saline-soaked pads. The vocal cords were identified and spreaders were used to open the adducted cords. The trach was noted to be placed just below the first tracheal ring with packing placed above the flange (moist neurosurgical cottonoids). The cords were again examined and the arytenoids palpated and found to be mobile. The left cord was examined and the area just anterior to the left vocal process was noted. A CO2 laser on 8 watts continuous super-pulse was used to perform a posterior cordotomy on the left side, just anterior to the vocal process with the lateral margin deemed the perichondrium immediately overlying the thyroid cartilage. Hemostasis was achieved with the laser and no cartilage was exposed. Photo documentation was taken throughout the case and after the cordotomy there was noted to be an improved patent airway. The patient tolerated the procedure well. Additional lidocaine was sprayed onto the cords and the char was wiped off with saline-soaked pledgets. The patient was turned back over to Anesthesia and awoke without difficulty. The patient tolerated the procedure well.

2. Supracricoid Laryngectomy case example

Modified Operative Note:

The sample dictation below is not intended to be used as a template. It is a variation on this procedure and should not substitute for the surgeon's own dictation. It is provided to help visualize the procedure from beginning to end and to illustrate key points and staff preferences.

Procedure: Supracricoid laryngectomy with right modified radical neck dissection sparing cranial nerve XI following effort at endoscopic laser resection of T2aN1 squamous cell carcinoma of the supraglottic larynx.　

Pre and Postoperative Diagnosis: T3-N2a squamous cell carcinoma of the supraglottic larynx

Description of Operation:

PROCEDURE: The patient was brought into the room. General anesthesia was administered by the anesthesiologists using a laser-safe 6.0 endotracheal tube. The patient was turned 90 degrees and prepped and draped in the usual fashion for laser supraglottic laryngectomy. The Weerda supraglottic laryngoscope was inserted into the mouth, opened and then suspended so that the supraglottic mass on the laryngeal surface of the epiglottis could be visualized. There was some difficulty visualizing the entire lesion, therefore, the procedure was begun by debulking a portion of the suprahyoid epiglottis using the laser on a setting of 8 watts super-pulse mode. Dissection then proceeded to remove the epiglottic mass using the laser on a setting of 10 watts super-pulse mode. The tumor was removed in a piece-meal fashion. Dissection proceeded into the pre-epiglottic space up to the inner-perichondrium of the thyroid lamina. As dissection proceeded inferiorly to the anterior commissure and the anterior true vocal cords were visualized, there was some irregularity noted of the true vocal folds bilaterally. Therefore, a biopsy was taken of the left and right anterior true vocal cords and sent for frozen section analysis. During this time, the right false vocal fold was removed. The lateral most portion of this excision still showed evidence of cancer growth on gross inspection. At this time the frozen section analysis had returned positive for squamous cell carcinoma, therefore, it was deemed necessary to perform a supracricoid laryngectomy and the laser resection was abandoned. The microscope and laser were removed from the field. The laser-safe endotracheal tube was changed to an 8.0 cuffed endotracheal tube by the Anesthesiology Service. The patient was turned another 90 degrees and prepped and draped in the usual fashion for a neck dissection, laryngeal surgery and tracheotomy.

The planned incision was marked down to the skin which was then incised with subplatysmal flap was then elevated inferiorly to the level of the clavicles, to the sternal notch and posteriorly to visualize the trapezius muscle. During this elevation of the posterior portion of the flap, the cranial nerve XI was identified and dissected from its surrounding tissues. A superior subplatysmal skin flap was then elevated to the level of the mandible. During this dissection the marginal mandibular nerve was identified and preserved and reflected superiorly with the skin flap. The neck dissection was begun from a medial to lateral direction, beginning with dissection of the submandibular gland from the surrounding tissue. The gland was released from the surrounding tissue. The facial artery was ligated twice along with the facial vein. The lingual nerve was identified and preserved with division of the submandibular ganglion. The hypoglossal nerve was also identified inferior to the submandibular gland and preserved. The fascia was brought up off of the digastric muscle and retracted laterally with the neck dissection specimen. Dissection proceeded in this medial plane until the omohyoid muscle.  The dissection proceeded along this muscle inferiorly in a lateral direction reflecting the contents of the neck laterally. Dissection proceeded medially until the entire submandibular gland was completely free from the surrounding structures. Attention was then turned posteriorly and the entire free edge of the trapezius muscle was identified. Once this was completed, the spinal accessory nerve was dissected out from the surrounding tissues in level V to its entrance into the sternocleidomastoid muscle. The nerve was then dissected out from this muscle from a lateral to medial direction. Branches to the sternocleidomastoid muscle were cut. Dissection proceeded medially until the internal jugular vein was identified. Attention was then turned inferiorly as the omohyoid passed underneath the sternocleidomastoid approximately 1 cm superior to the clavicle. The sternocleidomastoid muscle was divided sharply until the internal jugular vein could be seen underneath the muscle. Now that the medial, superior, inferior and posterior portions of the neck dissection had been identified, the neck contents were elevated off the fascial carpet from an inferior to superior direction. Once the internal jugular vein was sufficiently exposed, it was doubly ligated superiorly with 2-0 silk, doubly ligated inferiorly with 2-0 silk and then suture ligated with 3-0 silk. It was then cut and this was brought up along with the neck contents. Care was taken to ensure that the carotid artery and vagus nerve were identified and not ligated along with the internal jugular vein. While lifting this specimen off the fascial carpet, the phrenic nerve was identified and preserved. Dissection continued in a superior direction up to the level of the large level II neck mass. The internal jugular vein was further exposed superiorly and then ligated in a similar fashion as below. The entire neck contents were then elevated off the fascial carpet from the medial to lateral direction taking care to take the fascia off of the vagus and carotid artery leaving a small amount of fascia over the carotid artery. Once the contents had been removed, they were divided on the back table into the appropriate levels. The entire levels I through V were taken out in an en bloc fashion along with the internal jugular vein and sternocleidomastoid muscle preserving the spinal accessory nerve.

At this point attention was turned to the supracricoid laryngectomy. The strap muscles were identified and then divided in the midline and retracted slightly laterally. This was done from the level of the hyoid inferiorly to the sternal notch. The trachea was then exposed from the cricoid down into the mediastinum until the innominate artery could be palpated. Once this was completed, the thyroid isthmus was clamped, divided and then suture ligated. The thyroid lobes were then elevated slightly off of the trachea until the anterior 180 degrees could be easily seen. The strap muscles and pharyngeal constrictors were then elevated off of the thyroid cartilage using a combination of cautery and a No. 15 blade until the superior cornu, inferior cornu and posterior edge of the thyroid cartilage were all easily seen. The cricothyroid joint was then divided sharply taking care to stay very close to the cartilage to preserve the recurrent laryngeal nerve. The superior cornu was exposed taking care to preserve the hypoglossal nerve and the superior laryngeal nerves as much as possible. Once the supracricoid larynx had been adequately exposed for resection, the thyrohyoid space was entered in the midline. Initially dissection proceeded superficially into into the vallecula in order to avoid epiglottic tumor. Once the vallecula was entered, the entire thyrohyoid space was opened and the tumor could be seen along the thyroid lamina. Putting the larynx on traction, the piriform mucosa was then incised freeing the thyroid cartilage first on the right side. The entire thyroid lamina on the right side was now free.  The cut was then made on the left side. On both sides the cut went through the true vocal fold just anterior to the vocal process leaving the arytenoids intact. The cricoid cartilage was left intact. An incision was made in the cricothyroid membrane taking care to preserve the cricoid cartilage. The supracricoid larynx was removed. Frozen sections were taken. The wound was thoroughly irrigated. Frozen sections returned negative.

0-Vicryl sutures were placed first in the midline through the cricoid and then around the hyoid bone submucosally. Similar sutures were then placed 1 cm laterally to this on both sides. Placing the sutures on traction, approximating the hyoid and the cricoid, the approximate site of the tracheotomy was found. An incision was made into the skin and placed over the trachea which corresponded with approximately the fourth tracheal ring. This ring was then marked for excision. It was excised and the inferior portion of the stoma was sutured to the sub-dermis of the tracheotomy incision. Once this was completed, an anode tube was placed through the skin and into the trachea. The subdermal to tracheal sutures were then repeated on the superior portion of the stoma. Once the tracheotomy was completed attention was redirected to the laryngeal remnant with vicryl sutures were placed just lateral to the vocal process and then brought forward onto the cricoid just lateral to the midline. This was performed on both sides and loosely tied thereby tilting the arytenoids anteriorly.

The 0-Vicryl sutures were then tied into position, approximating the cricoid and the hyoid. The pharyngeal mucosa that was redundant on both sides was then sutured towards the midline using Vicryl sutures. The strap muscles were then approximated to the superior portion of the defect re-suspending them. The thyroid lobe was then tacked over the superior portion of the stoma in order to prevent air leak through this site. Once this was completed, the wound was thoroughly irrigated. Hemostasis was achieved. Suction drains were placed, two on the right side and one on the left and secured to the skin. The deep layer was then closed with Vicryl sutures and the skin was closed with staples. At the end of the case the anode tube was removed, a Shiley tube was placed and secured to the skin with silk sutures. The patient was then returned to anesthesia. He was awakened and taken to the recovery room in good condition. He tolerated the procedure well.

SUMMARY OF FINDINGS:

Carcinoma on initial pathologic review with frozen section identifying involvement at the anterior commissure.

Large right level II mass, probably metastatic disease representing N2a disease.

Initially T2 squamous cell carcinoma of the supraglottic but identified as T3 supraglottic (pre-epiglottic space involvement)

3. Case example Thyroplasty with arytenoid adduction under General Anesthesia

Modified Operative Note:

Female with history of glomus tumor resected in July 2009. Since that time has had left vocal cord paralysis along with dysarthria (hypoglossal nerve paralysis) and velopharyngeal incompetence (palatal weakness).

Procedure Details:

After informed written consent was obtained, the patients identity confirmed and a brief time-out effected.   The patient was placed in the supine position and monitors were placed. The patient was intubated with 4-0 MLT endotracheal tube.

We began with the direct laryngoscopy using an anesthesia MAC blade. Cords were visualized and the arytenoid was palpated to confirm its mobility on the right and left sides. Next, flexible gastroscope was placed transorally with visualization of the glottis. This was taped in place with visualization of the glottis on the television screen throughout the course of the case. Next, the neck was prepped and draped in the usual sterile fashion with injection of 1% lidocaine, 1: 100,000 epinephrine along the planned incision.

Laryngeal landmarks were palpated and marked. A transverse incision just lateral to midline approximately 3 cm was made over the thyroid cartilage. Dissection exposed the strap muscle. The upper aspect of the left sternothyroid muscle was partially transected with the bovie. The perichondrium was sharply incised in the midline, and superior border permitting elevation of soft tissue from the left thyroid alar cartilage in a subperichondrial plane.

The oblique line was identified on the lateral aspect of the thyroid cartilage. The constrictor muscle was freed from thyroid cartilage. The posterior aspect of the cartilage was identified. Starting at the inferior aspect, the thyroid cornu was identified and medial blunt dissection curved around the posterior border of the cartilage (Padget and Woodson elevators) to ensure the dissection avoided entry into the piriform sinus.

A Kerrison rongeur was used to remove portions of cartilage from the posterior aspect of the thyroid lamina with care to leave the attachment of the inferior cornu to the cricoid intact. The broadly based fan shaped PCA muscle was identified and traced supero-medially to its attachment to the muscular process of the arytenoid.

A 4-0 Prolene (or, in the example, clear nylon) suture was placed through the PCA muscle at its attachment to the muscular process. With superior traction on the two ends of the suture, a second pass was made with the needle through the muscular process with the figure of eight suture (two passes) tied.

The thyroplasty window was created with a small cutting burr. A second fenestration in the anterior thyroid cartilage was made 0.5 cm from the midline and 0.3-0.5 cm above the lower border with a #2 cutting burr (as low along the lower border of the cartilage as can reliably preserve a solid inferior strut).

A slightly bent Keith needle was placed retrograde through the small anterior fenestration, visualized through the thyroplasty window, and positioned adjacent the muscular process where the free end of the aa’ suture was threaded into the needle. The needle was then pulled forward delivering the suture through the fenestration

The second end of the 'aa’ suture (still with needle attached) was place (dull end first) into the thyroplasty window, then (sharp end first) under the lower border of the thyroid cartilage (through the cricothyroid membrane).

Alternate pulling and releasing on the two sutures demonstrated appropriate ab- and ad- duction of the vocal process seen on the video monitor.

The Gore-Tex was placed in the paraglottic space through the thyroplasty window from an inferior approach and positioned (with visual monitoring of the vocal cord position) by manipulations with the sharp end of a Woodson elevator through the thyroplasty window.  The implant was superficial (lateral) the the 'aa’ sutures.

The implant was then trimmed and was sutured in place with a 5-0 Prolene suture passed around through the implant around the lower border of the thyroplasty window.  A second prolene suture was used to further secure the implant with placement through the thyroid cartilage above the window.

With direct monitoring via the esophagoscope, gentle traction on the aa’ suture ends then permitted tying them together.

Next, the area was washed with copious amounts of saline irrigation. The strap muscles were reapproximated with 4-0 Vicryl sutures. Deep tissue was reapproximated with 4-0 Vicryl sutures and a Penrose was placed to drain the wound. The skin was closed with interrupted 4-0 nylon sutures.

Next, our attention was turned back to the airway where the gastroscope was removed. Using a MAC blade to perform a laryngoscopy, we sprayed approximately 3 cc of 4% lidocaine onto the vocal cords as the patient was awakening and extubated her safely. She was an easy mask airway and she was transferred to the PACU in stable condition.