Name: __________________________       Today’s date        _____ / ____ / 2007

PARQ (Procedure, Alternatives, Risks & Questions) conference

Procedure: Laryngoplasty:

__ Medialization

__ Arytenoid Adduction

__ ANSA nerve transfer graft

Side: ____ left ___ right ____ bilateral

Anesthesia: General

Case Time    1 hour   1 1/2 hours     2 hours

Preferred Date of Surgery:  _____ / ____ / _____    ASAP,      at patient convenience

Alternatives: might include speech therapy or no treatment

Risks: Anesthesia risk, chipped tooth, numb tongue, suboptimal result, laser burn

The procedure laryngoplasty to augment or correct a vocal weakness consists of passing a flexible scope through the nose to monitor the voice box and the surgical opening up the voicebox (thyroid cartilage). Medialization involves inserting an implant (most often Gore-Tex or Silastic) through an opening in the cartilage. Arytenoid adduction involves suturing one of the cartilages of the vocal cords. Nerve transfer involves borrowing a nerve from a neck muscle and attaching it to one of the nerves to the vocal cords. The main risks of surgery include, but are not limited to a reaction to anesthesia, which is uncommon but can be life threatening. The procedure could potentially cause swelling of the vocal folds. Bleeding or infection are possible anytime an incision is placed into the skin. Results with surgery cannot be guaranteed and a sub-optimal result consisting of a weak voice or a strained voice is possible.

Students may be involved in observing or assisting with procedures described above. Their name(s) are _________________________________________________________________________. They will be involved by holding retractors or placing sutures if appropriate for their level of training. ____ Patient's initials

All the above was explained to me. I have seen the extensive explanation and my questions have been answered to my satisfaction.

 

_________________________________     ____ / ____ / ____

   Patient signature                       Date

 

_________________________________

   Witness

 

_________________________________     ____ / ____ / ____ 

   James P. Thomas, MD                   Date          

 

Preferred hospital

Legacy Emanuel | Providence | Futures