OT notes · ENT

Direct laryngoscopy and biopsy

Usual anaesthesia
General anaesthesia with a small-bore microlaryngoscopy endotracheal tube
Position
Supine, Boyce-Jackson position with a pillow under the head, chest piece of the laryngoscope resting on a Mayo trolley
Setting
elective

Operative note template for direct (suspension micro-) laryngoscopy with biopsy, with a filled example for a suspected glottic carcinoma biopsied under general anaesthesia.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • injury to lips, teeth, tongue or throat from the laryngoscope
  • bleeding from the biopsy site
  • airway swelling and breathing difficulty after the procedure
  • tracheostomy if the airway is at risk
  • change in voice, web formation if the front of the cords is operated
  • biopsy may not be representative and may need to be repeated

Pre-operative details for this operation

  1. IndicationSuspected malignancyLeukoplakia / premalignant lesionBenign vocal fold lesionAssessment of extent before treatmentsymptoms and duration, tobacco and alcohol use
  2. Pre-op laryngoscopy (flexible / rigid / stroboscopy)site of lesion, side, vocal cord mobility, airway size; photo or video saved
  3. Airway statusNo stridorStridor: tracheostomy plan discussed
  4. Dentitionloose, capped or missing teeth recorded before surgery
  5. Neck examination and imagingnodes; CT neck if done
  6. Mallampati grade / anaesthetist's airway assessment
  7. Consent for tracheostomy if neededTakenNot applicable

Anaesthesia and position

  1. AnaesthesiaGeneral with microlaryngoscopy tubeGeneral with laser-safe tubetube size (usually 5 to 6)
  2. PositionBoyce-JacksonFlexion-flexion (anterior larynx)
  3. Teeth protectedmethod
  4. Laryngoscopetype and size; suspended; chest piece on Mayo trolley
  5. MagnificationOperating microscope0 degree telescope30 / 70 degree telescope
  6. External counter-pressure on cricoidNot neededApplied (bandage to table)

Operative findings

  1. Lesiontype (ulcerative / proliferative / white patch / red patch), side, size
  2. Supraglottisepiglottis (supra/infrahyoid), aryepiglottic folds, false cords, ventricles, arytenoids
  3. Glottiseach vocal cord by thirds; anterior commissure; posterior commissure
  4. Subglottisextent below the cords
  5. Hypopharynx and oropharynxpyriform sinuses, postcricoid, posterior pharyngeal wall, vallecula, base of tongue
  6. ExposureGood, anterior commissure seenDifficult (reason)
  7. Photographs / video recordedYesNo

Procedure (steps)

  1. Laryngoscope introducedmouth opened with the right hand, blade passed along the tongue, epiglottis lifted; lips and tongue protected
  2. Laryngoscope suspended and microscope brought inboth cords, both commissures and the ventricles in view
  3. Systematic examination of all subsitestelescope for hidden areas (ventricle, subglottis, anterior commissure)
  4. Subepithelial infiltration (for mucosal lesions)Not doneSaline with adrenalinestrength and volume; lifted or tethered ('doughnut')
  5. Cottonoid in subglottisPlacedNot placed
  6. BiopsyIncision biopsyExcision biopsyMultiple mapping biopsiesinstrument (microlaryngeal crocodile forceps / scissors / CO2 laser); site of each bite; number
  7. Frozen sectionNot sentSent: result
  8. Haemostasisadrenaline-soaked cottonoid; suction cautery if needed
  9. Cottonoid removed and counted
  10. Laryngoscope removed, oral cavity and teeth checked

Closure, drains and dressing

  1. Airway at the endExtubated, no stridorKept intubated (reason)Tracheostomy done (see separate note)
  2. Topical laryngeal anaesthesia at endNot usedLignocaine spray
  3. Teeth, lips and tongueNo injuryInjury (describe)

Specimens and implants

  1. Specimen for HPEone container per site; label with side and subsite (e.g. 'right vocal cord, middle third'); fixative
  2. Orientationmounted on filter paper with a drawing of the cords, anterior / posterior / medial / lateral marked, if excision biopsy
  3. Requisition formclinical details, tobacco history, lesion site, frozen result if any

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Airway watchstridor, SpO2, respiratory rate; frequency
  2. Oxygenas needed
  3. Oral intakewhen to start, after full recovery from anaesthesia
  4. Bleedingwatch for blood in sputum beyond streaks
  5. Analgesiadrug, dose, frequency
  6. Tobaccostop all forms of tobacco; counselling
  7. Dischargesame day or next day if airway stable
  8. Follow-upHPE review date; tumour board if malignant

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mr. R.K., 58 years, bidi smoker for 30 years, hoarseness for 3 months. Videolaryngoscopy shows a proliferative growth on the right vocal cord with both cords mobile. No stridor. No neck nodes.

Case details

Date: 03/08/2026. Elective. ENT OT 2.

In OT 08:45. Induction 08:55. Scope in 09:05. Scope out 09:25.

Surgeon: Dr A. (2nd-year resident, ENT). Assistant: Dr B. (1st-year resident). Consultant: Dr C., present in OT.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Pre-op diagnosis: growth right vocal cord, suspected carcinoma.

Procedure planned and performed: suspension microlaryngoscopy and biopsy.

Pre-op videolaryngoscopy (28/07/2026) photos saved. Both cords mobile. Airway adequate, no stridor.

Upper central incisors capped, noted before surgery. Mallampati grade 2.

Consent: general and procedure-specific consent taken in Gujarati, including tracheostomy if needed. Injury to teeth, bleeding, airway swelling and repeat biopsy explained.

WHO checklist sign in and time out done. Antibiotic prophylaxis: not given (unit protocol for diagnostic endoscopy).

Anaesthesia and position

GA with 6.0 microlaryngoscopy cuffed tube.

Supine, Boyce-Jackson position with pillow under the head. Upper teeth protected with a tooth guard.

Findings

Proliferative growth on the right vocal cord, middle and anterior thirds, about 1 cm, not reaching the anterior commissure.

Left vocal cord, anterior and posterior commissures, both false cords, ventricles and subglottis (seen with 0 and 30 degree telescopes) free of disease.

Epiglottis, aryepiglottic folds, arytenoids, both pyriform sinuses, postcricoid area, vallecula and base of tongue normal.

Exposure good. Still photographs taken.

Procedure

Laryngoscope introduced along the tongue, epiglottis lifted, and suspended with the chest piece on a Mayo trolley. Operating microscope used.

Saline-soaked cottonoid placed in the subglottis.

Three bites taken from the growth with microlaryngeal crocodile forceps: two from the middle third, one from the anterior third edge.

Haemostasis with adrenaline 1:100,000 soaked cottonoid for 2 minutes. No active bleeding.

Cottonoids removed and counted. Laryngoscope removed. Lips, tongue and teeth checked, no injury.

Closure

Extubated in theatre. No stridor. SpO2 98% on room air.

Specimens and implants

Two formalin containers: 'right vocal cord, middle third' (two bits) and 'right vocal cord, anterior third' (one bit). Sent for HPE with requisition noting tobacco use and site.

No frozen section. No implants.

End of procedure

Blood loss negligible, less than 5 ml.

Cottonoid and instrument count correct, confirmed by scrub nurse.

No intra-operative complications.

Shifted to recovery in stable condition. Pulse 80/min, BP 130/84 mmHg.

Post-op orders

Watch for stridor and SpO2 every 30 min for 2 hours, then 2-hourly.

Oxygen by mask if SpO2 falls.

Sips of water after full recovery, then soft diet.

Analgesic as per drug chart.

Stop bidi and all tobacco; tobacco cessation counselling.

Discharge tomorrow if airway stable. HPE review in ENT OPD on 12/08/2026.

Signature

Dr A., JR-2, ENT. Reg. no. ________. 03/08/2026, 09:40.

Must document for this operation

  • Every subsite examined, including negative findings. Staging and the choice between laser, radiotherapy or open surgery depend on the recorded extent, and 'normal' areas must be shown to have been seen.
  • Whether the anterior commissure and the subglottis were involved or clearly seen. These change the stage and the treatment, and poor exposure must be stated so a repeat look can be planned.
  • Site of each biopsy and how each container was labelled. The pathologist and the next surgeon must link each report to one exact site.
  • Teeth status before and after the procedure. Dental injury is a common complaint after laryngoscopy, and a pre-existing problem must be on record.
  • Airway status at the end and any plan for tracheostomy. Swelling after instrumentation can block an already narrow airway, and the ward team must know the risk.
  • Photographs or video taken. They allow comparison at follow-up and support the recorded extent in a tumour board or audit.

Common mistakes in these notes

  • Writing 'growth seen, biopsy taken' without the subsites examined.
  • One container for biopsies from different sites.
  • Not recording pre-existing loose or capped teeth.
  • Leaving out whether the anterior commissure was seen.
  • Not writing whether a cottonoid placed in the subglottis was removed.

Indian practice and paperwork

  • Discarded formalin from specimen containers is yellow (f) chemical waste. Tissue not sent for HPE is yellow (a) human anatomical waste. (Bio-Medical Waste Management Rules 2016, CPCB guidelines)
  • Consent must explain the procedure, risks, benefits, alternatives and who will operate, in a language the patient understands. (NABH 5th ed., PRE.4(c))
  • If a tracheostomy is added during the procedure, the note must say whether it was covered by the written consent or was done to save life and could not wait. (Samira Kohli v. Dr Prabha Manchanda, (2008) 2 SCC 1)
  • NABH expects the operative note to be written before the patient leaves recovery, and post-op care to follow a written plan. (NABH 5th ed., COP.14(e) and (f))

Sources

  • Hathiram BT, Khattar VS, eds. Atlas of Operative Otorhinolaryngology and Head and Neck Surgery. Jaypee Brothers, Ch 112, Principles of phonomicrosurgery (Khattar VS, Hathiram BT), pp. 1109-1117.
  • Hathiram BT, Khattar VS, eds. Atlas of Operative Otorhinolaryngology and Head and Neck Surgery. Jaypee Brothers, Ch 113, Leukoplakia of the vocal folds; Ch 114, Premalignant lesions of the larynx, pp. 1118-1129.
  • Hathiram BT, Khattar VS, eds. Atlas of Operative Otorhinolaryngology and Head and Neck Surgery. Jaypee Brothers, Ch 116, Transoral microlaryngoscopic laser surgery for cancer of larynx and hypopharynx (Tubachi J, et al.), pp. 1135-1146.
  • Hathiram BT, Khattar VS, eds. Atlas of Operative Otorhinolaryngology and Head and Neck Surgery. Jaypee Brothers, Ch 120, Diagnostic laryngo-tracheo-bronchoscopy (Bajaj Y), pp. 1163-1164.

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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