DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Dysphonia.
2. Left vocal cord paralysis.
3. Dysphagia.
4. Globus pharyngeus/elongated uvula.
5. Cricopharyngeal muscle dysfunction.
POSTOPERATIVE DIAGNOSES:
1. Dysphonia.
2. Left vocal cord paralysis.
3. Dysphagia.
4. Globus pharyngeus/elongated uvula.
5. Cricopharyngeal muscle dysfunction.
PROCEDURES PERFORMED:
1. Rigid diagnostic esophagoscopy.
2. Esophageal bougie dilatation.
3. Partial uvulectomy.
4. Microscope (direct laryngoscopy, diagnostic).
5. Microscope (direct laryngoscopy, diagnostic), left vocal cord augmentation.
SURGEON: John Doe, MD
ANESTHESIA: General/local.
SPECIMENS REMOVED: Uvula tip (inferior portion) and parauvular pharyngeal soft tissue for reasons of asymmetry.
ESTIMATED BLOOD LOSS: Minimal.
DRAINS: None.
PACKING: None.
PROSTHESIS: None.
CULTURES: None.
COMPLICATIONS: None.
POSTPROCEDURE CONDITION: Satisfactory.
DESCRIPTION OF PROCEDURE: The patient was placed on the operating room table in the supine position for rigid diagnostic esophagoscopy and procedures noted above. General anesthesia was induced via endotracheal intubation, which was done without difficulty. A small-caliber tube was used, 5.5, enabling easier access to the vocal cords. The patient was placed in mild neck extension cognizant of longstanding history of osteoarthritis. He had adequate range of motion to permit mild neck extension. Antibiotics were administered per routine. Steroids were administered at the discretion of the anesthesia service. A 30 cm esophagoscope was prepared. A light source and suction were made available. The instrument and the patient’s oral structures were copiously lubricated to minimize friction effect. The pharynx was suctioned as needed with the Yankauer instrument. A dental guard was utilized. The absent right upper teeth permitted access on occasion off the dental guard. Inspection of the tongue base and epiglottis was unremarkable. The false vocal cords were seen as intact with respect to the mucosa. The true vocal cords were also examined with no overt pathology. Laryngoscopy was subsequently performed to provide greater detail.
The esophagoscope passed with little difficulty into the proximal esophagus to the upper esophageal sphincter. Despite his dysphagia, the cricopharyngeal muscle was lax enough to permit the rigid metal scope. Once in the esophagus, it was passed without difficultly to 30 cm with no mucosa lesion seen. No strictures were present. The esophagoscope was then removed. A 34 French bougie was lubricated and advanced with little difficulty into the upper esophagus. It was advanced to 35 cm and then withdrawn. Sequential bougie dilations were then performed. The 36 and 38 were passed without difficulty. A 40 French sensed a degree of tightness suggesting this was his degree of dysphagia. Bougie dilatation then continued at intervals of 2 French until 52 French was reached. Much more slowly and with finger guide 54-French and 56-French bougies were placed. This was felt to give him an optimal opportunity to sense expansion of the sphincter. Each of the last 3 bougies remained in place for approximately 1 minute each before removal. To assure that no esophageal wall injury took place, the esophagoscope was again passed. There was no free air emanating from the lungs. No bleeding was seen. There was no suspicion of a wall breach.
The esophagoscope was removed. The pharynx was suctioned. The dental guard was removed. With the patient in the same position, it was felt to be more practical to perform the partial uvulectomy procedures. A Crowe-Davis mouth gag was lubricated and placed in the surgical field. It was positioned in the oral cavity with little difficulty. A #4 tunnel retractor was used. The device was opened and suspended to the Mayo stand. Lidocaine 1% with 1:100,000 units of epinephrine was injected in the base of the uvula to diminish blood flow. The tissue absorbed the medication over the course of approximately 2 minutes. This was facilitated by digital massage. Forceps was used to grasp the inferior tip of the uvula. A clamp was placed at 30 degree angles off the tip. This crimped the muscle and mucosa. A small amount of mucosa extended beyond the muscle layer. This was susceptible to edema and aggravated by his coughing.
The Metzenbaum scissor was then used to trim the excess soft tissue and muscle at the crimp line. This reduced the patient’s uvula by approximately one third. The needle tip cautery at 10 watts of coagulation power was used for hemostasis, distended to round out irregular soft tissue left behind after cutting. The forceps elevated the uvula, and the posterior underlying muscle and mucosa was incised with a Metzenbaum scissor and removed using the needle tip cautery to transect it. The parauvular region was asymmetric. Forceps was used to grasp the lower hanging right side. This was removed en bloc with a needle tip cautery. The left side was trimmed slightly to allow for the creation of the oral mucosa surfaces. Interrupted 3-0 chromic sutures were then placed to achieve symmetry and to provide soft tissue suspension. Given the patient’s anticoagulated status, the uvula as well as tissue surface slowly oozed. This was repeatedly irrigated with saline. It did not prevent the next step from being performed.
The microscope was brought into the field. A Dedo laryngoscope was lubricated and placed in the oral cavity. The dental guard was again used. The scope was advanced to position itself over the larynx. The left true vocal cord appeared lax consistent with loss of neurogenic activity. The right true vocal cord appeared fuller and more medial. The left arytenoid bone was medialized and inferior whereas the right arytenoid bone was upright and more lateral. No pathological lesions were seen. The Radiesse gel compound was prepared with a long needle and a disposable syringe. The first injection was placed lateral at mid cord level to provide a diffuse augmentation. This consisted of approximately 0.3 ml. The left true cord was then injected with 0.2 mL to provide a fuller cord near the anterior commissure. An additional 0.2 mL was injected at the junction of the mid to posterior cord. A total of 0.7 mL was injected. The vocal cord appeared full and beyond the midline. Any additional supplement may have contributed to a degree of airway obstruction postoperatively and this thus was held.
Pharynx was once again suctioned. A small amount of ooze was noted from the uvula surface edges. Following withdrawal of the laryngoscope and removal of the dental guard, hydrogen peroxide mixed 1:1 with normal saline was flushed into the oropharynx to act as a topical coagulant. This proved effective. After 50 mL, the dilutant no longer appeared red. Pharynx was again inspected with no active bleeding seen along the uvula surface. An orogastric tube was passed and the gastric contents evacuated. The teeth were inspected with no evidence of injury. The lips were intact. There was no evidence of facial injury. The nurses reported that the needle and sponge count was correct. The patient was then weaned from the ventilator, extubated without difficultly, and transferred to the recovery room.
The patient had no chest pain on deep inspiration. He had no back pain on thumping with a fist to a moderate degree despite a longstanding history of low back pain. A postoperative chest x-ray did not reveal a pneumomediastinum or pneumothorax. Although the right supraclavicular region had a small amount of crepitus, a subsequent chest x-ray and neck x-ray were negative for pneumomediastinum and free air. The same was true on the followup film the following morning.
