DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Severe obstructive lingual tonsil hypertrophy.
2. Obstructive sleep apnea-hypopnea syndrome.
POSTOPERATIVE DIAGNOSES:
1. Severe obstructive lingual tonsil hypertrophy.
2. Obstructive sleep apnea-hypopnea syndrome.
PROCEDURE PERFORMED:
1. Tracheostomy.
2. Transoral OmniGuide laser excision of lingual tonsil.
SURGEON: John Doe, MD
ANESTHESIA: General.
FINDINGS: Severe diffuse obstructive lingual tonsil hypertrophy.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old male with a history of subjective dyspnea, mild snoring and observed apnea. Office evaluation with flexible fiberoptic laryngoscope revealed severe obstruction at the level of the tongue base from lingual tonsil hypertrophy.
The glottis was extremely difficult to visualize even with the flexible fiberoptic laryngoscope due to the extent of lingual tonsil hypertrophy. Options were discussed with the patient. He was evaluated with a polysomnogram.
We discussed the treatment option of CPAP; however, his subjective fullness and choking sensation during the daytime would not be addressed. We discussed the option of laser excision of lingual tonsil tissue.
We advised that this procedure would only be carried out safely by securing the patient’s airway with tracheostomy in the preoperative period.
The risks, benefits and alternatives including general anesthesia, persistent or recurrent airway obstruction, persistent sleep apnea, bleeding, infection, tracheal stenosis and the need for prolonged tracheostomy were discussed with the patient. He verbalized understanding of these risks and consented to the procedure.
DESCRIPTION OF PROCEDURE: After obtaining informed consent, the patient was brought to the operating room and placed supine on the operating table. He was intubated by the attending anesthesiologist using an awake fiberoptic technique. At that time, the skin at the anterior neck was prepped and draped in the sterile fashion.
A transverse incision was made 2 fingerbreadths above the sternal notch. Dissection was carried down through the subcutaneous tissue to the infrahyoid strap muscles that were separated in the midline and retracted laterally exposing the thyroid isthmus.
The thyroid isthmus was divided in the midline using Bovie electrocautery and the thyroid lobes were retracted laterally exposing the cricoid cartilage and upper trachea. The endotracheal cuff was temporarily let down and a cricoid hook was placed under the cricoid. The entire laryngotracheal complex was retracted cephalad. The cuff was again let down.
A transverse incision was made between tracheal rings 2 and 3. This was dilated using a hemostat and then a tracheal dilator. Stay sutures were placed around tracheal rings 2 and 3. As the endotracheal tube was withdrawn, a #6 cuffed Shiley tracheostomy tube was inserted into the incision. The cuff was inflated.
A suction catheter was passed without resistance and returned pulmonary secretions. The inner cannula was inserted. The patient was attached to the circuit and end-tidal CO2 was immediately observed.
The circumferential trach tie was placed and 4 interrupted silk sutures were used to attach the faceplate to the skin of the anterior neck. The table was then turned 90 degrees. The eyes were protected with ointment and tape. A head drape and dental guard were applied.
At this point, various laryngoscopes were used to visualize the hypopharynx and supraglottic. The patient was placed in suspension. The entire field was draped with wet towels.
Using the OmniGuide laser under the operating microscope, the anterior lingual tonsil tissue was grasped with microcup forceps and the lingual tonsil was gradually removed in an anterior to posterior fashion.
Hemostasis was obtained at certain points with monopolar suction Bovie electrocautery. The posterior-most extent of the dissection was the vallecula. The lingual surface of the epiglottis appeared to be invested and involved with lingual tonsil tissue.
At this time, we did not perform any resection of the tissue adherent to the lingual surface of the epiglottis. All removed tissue was sent fresh for pathology.
After adequate hemostasis, the patient was awakened and transferred to the intensive care unit without complication.
