PREOPERATIVE DIAGNOSES:
1. Airway obstruction.
2. Laryngopyocele.
3. Laryngeal cancer.
PROCEDURES PERFORMED:
1. Awake tracheotomy.
2. Direct laryngoscopy with biopsy.
SURGEON: John Doe, MD
ANESTHESIA: Monitored anesthesia care and general.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old gentleman who presented to the emergency room with shortness of breath. Additionally, he had other numerous complaints consistent with aspiration, weight loss, hoarseness, neck pain, as well as left otalgia.
Flexible laryngoscopy was performed in the emergency department, which revealed the patient had significant supraglottic swelling as well as a suspicious pedunculated mass of the supraglottis.
Additionally, CT scan was obtained at that time that showed air-fluid levels extending through the thyroid cartilage into the pre-epiglottic space concerning laryngopyocele.
Due to the patient’s subjective shortness of breath and physical exam, the patient was informed of the risks and benefits of undergoing awake tracheotomy and diagnostic laparoscopy for diagnosis as well as possible I&D of this laryngopyocele. Consent was obtained and awake tracheotomy was proceeded with.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed in a sitting position for awake tracheotomy. Once an adequate plane of anxiolysis was obtained, 1% lidocaine with 1:100,000 epinephrine was injected into the subcutaneous tissues overlying his trachea.
Next, the neck was prepped and draped in the standard surgical fashion. A 15 blade was used to make a vertical incision in the skin. This dissection was carried into the subcutaneous tissues. Strap muscles were divided.
After this, the thyroid isthmus was encountered. This was divided with Bovie cautery allowing identification of the tracheal rings. The tracheal fascia was removed with Kitner sponge and a window of tracheal cartilage was removed from approximately the third ring. The trach spreader was inserted and an 8 cuffed trach tube was then inserted.
At this point in time, the patient was allowed to be supine and general anesthetic was started. Once an appropriate plane of general anesthesia was obtained, the head was turned 90 degrees, protective tooth guard was inserted.
The Dedo laryngoscope was then used to expose the patient’s larynx. This was somewhat challenging; however, upon doing so, it was evident that there was a fungating mass in a horseshoe pattern from the false vocal folds at the anterior commissure extending onto both false vocal folds. Biopsies were taken of this. The subglottis was not involved. The true vocal cords themselves did seem to be spared. The arytenoids were quite edematous bilaterally. The mobility of the vocal cords was not assessed at this time.
After this was performed, the patient was given back to Anesthesia and taken to the recovery room in stable condition. Trach ties and trach sutures were placed on the tracheostomy tube. Due to the size of the laryngopyocele and the difficulty with the I&D, the decision was made to treat with antibiotics.
