DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left vocal fold paralysis secondary to lung carcinoma.
POSTOPERATIVE DIAGNOSIS: Left vocal fold paralysis secondary to lung carcinoma.
OPERATION PERFORMED: Left medialization laryngoplasty.
SURGEON: John Doe, MD
ESTIMATED BLOOD LOSS: 25 mL.
ANESTHESIA: Local sedation.
COMPLICATIONS: None.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in the supine position. He was placed on a shoulder roll. He had received IV Versed as well as fentanyl and was receiving oxygen via nasal cannula. With the neck in extension, the laryngeal landmarks were palpated. Approximately 6 mL of 1% Xylocaine with 1:100,000 epinephrine was infiltrated into the skin and subcutaneous tissues from the midline of the laryngeal cartilage laterally approximately 4 cm. Next, the neck was prepped and draped in the usual fashion. A pledget with Afrin and Pontocaine was placed into the right nasal cavity for vasoconstriction. He received preoperative clindamycin and 10 mg of Decadron. The thyroid notch, cricoid cartilage and midline of the cricoid cartilage were identified.
An incision just below the midpoint of the thyroid cartilage was made through skin and subcutaneous tissue. The incision was approximately 5 cm through skin and subcutaneous tissue. Superior and inferior skin flaps were elevated with the Bovie. The flaps were retracted superiorly and inferiorly. The strap muscles were identified in the midline and divided along the midline raphe and dissected off of the thyroid cartilage. The perichondrium of the thyroid lamina was divided with the Bovie and elevated to the posterior aspect of the thyroid lamina with the Freer elevator. Hemostasis was achieved with bipolar cautery. There was some transient significant bleeding from the edge of the strap muscle, which was controlled with bipolar cautery.
The template for the implant, which measured approximately 0.5 cm x 1 cm, was obtained. The dimensions of the larynx were measured. The vertical height of the thyroid cartilage measured 20 mm. The midline of the thyroid cartilage was marked with the Bovie at 10 cm from the inferior aspect of the thyroid cartilage. The template was brought posterior to the midline approximately 9 mm. The template was then used to demarcate the area of the thyroid cartilage, where our thyroplasty window would be created. This was marked with a #11 blade and then a Bovie. A 3 mm cutting bur was then used to create a window into the thyroid lamina. After this had been egg-shelled, the remaining thyroid cartilage over the window was then removed with a Freer elevator, keeping the inner perichondrium intact.
The inner perichondrium was then elevated with a perichondrial elevator circumferentially around the medial aspect of our thyroplasty window. A 5 mm implant was placed through the thyroplasty window; however, this appeared too big, as the patient had developed some stridor after the sizing implant was placed. A 4 mm implant device was then placed and the patient asked to phonate. His voice remained hoarse when the implant was in the anterior portion of the window. The implant was positioned in the most posterior aspect of the thyroplasty window and this afforded him an excellent voice without stridor. So, the sizing device was then removed. The actual hydroxyapatite implant was placed through the thyroplasty window and rotated into its vertical position and slid posteriorly. The patient was asked again to phonate, which revealed a very satisfactory voice. A 0 mm hydroxyapatite shim was then placed in the anterior aspect of the thyroplasty window and snapped into place to secure the implant.
A flexible fiberoptic laryngoscopy was then performed, which showed excellent medialization of the left cord. The wound was then copiously irrigated. A Penrose drain was placed between the inner perichondrium and the implant to allow for drainage. The strap muscles were approximated in the midline with 3-0 Vicryl and the skin closed with 4-0 Vicryl and 5-0 nylon sutures. A fluff and Kling dressing were placed on the neck. The patient was awakened from the sedation and transferred to the recovery room, having tolerated the procedure well.
