CONSENT INFORMATION – PATIENT COPY
LARYNGOSCOPY
PLEASE READ THIS SHEET BEFORE YOU CONSENT FOR YOUR PROCEDURE
This information sheet provides general information to a person having a Laryngoscopy. It does not provide advice to the individual. It is important that the content is discussed between the patient and the concerned doctors who understand the level of fitness and medical condition.
What is “Laryngoscopy”?
Laryngoscopy is an examination that lets your doctor look at the back of your throat, your voice box (larynx), and vocal cords with a scope (laryngoscope). There are two types of laryngoscopy, and each uses different equipment.
Indirect laryngoscopy:
Indirect laryngoscopy is done in a doctor's office using a small hand mirror held at the back of the throat. Your doctor shines a light in your mouth and wears a mirror on his or her head to reflect light to the back of your throat. Some doctors now use headgear with a bright light.
Indirect laryngoscopy is not done as much now because new flexible laryngoscopes let your doctor see better and are more comfortable for you.
Direct fiber-optic (flexible or rigid) laryngoscopy:
Direct laryngoscopy lets your doctor see deeper into your throat with a fiber-optic scope. The scope is either flexible or rigid. Flexible scopes show the throat better and are more comfortable for you. Rigid scopes are often used in surgery.
Why is it done?
An indirect or direct laryngoscopy helps a doctor:
* Find the cause of voice problems, such as a breathy voice, hoarse voice, weak voice, or no voice.
* Find the cause of throat and ear pain.
* Find the cause for difficulty in swallowing, a feeling of a lump in the throat, or mucus with blood in it.
* Check injuries to the throat, narrowing of the throat (strictures), or blockages in the airway.
Direct rigid laryngoscopy may be used as a surgical procedure to remove foreign objects in the throat, collect tissue samples (biopsy), remove polyps from the vocal cords, or perform laser treatment. Direct rigid laryngoscopy may also be used to help find cancer of the voice box (larynx).
How to prepare for the procedure?
Indirect and direct flexible laryngoscopy
Your doctor will give you instructions about not eating or drinking before the examination to prevent vomiting. If you wear dentures, you will remove them just before the examination.
Direct rigid laryngoscopy
Before a rigid laryngoscopy, tell your doctor if you:
* Are allergic to any medicines, including anesthetics.
* Are taking any medicines.
* Have bleeding problems or take blood-thinning medicine, such as warfarin (Coumadin).
* Have heart problems.
* Are or might be pregnant.
* Have had surgery or radiation treatments to your mouth or throat.
Rigid laryngoscopy is done with a general anesthetic. Do not eat or drink for 8 hours before the procedure. If you have this test in your doctor's office or at a surgery center, arrange to have someone drive you home after the procedure.
What happens during the procedure?
Flexible laryngoscopy examinations are generally done in a doctor's office. Most fiber-optic laryngoscopies are done by an ear, nose, and throat specialist (ENT). Some other doctors may also do this examination, such as family medicine doctors, internists, emergency medicine doctors, critical care medicine specialists, allergy specialists, and pulmonologists.
Indirect laryngoscopy:
You will sit straight up in a chair and stick out your tongue as far as you can. The doctor will hold your tongue down with some gauze. This lets the doctor see your throat more clearly. If you gag easily, the doctor may spray a numbing medicine (local anesthetic) into your throat to help with the gaggy feeling.
The doctor will hold a small mirror at the back of your throat and shine a light into your mouth. He or she will wear a head mirror to reflect the light to the back of your throat. He or she may ask you to make a high-pitched "e-e-e-e" sound or a low-pitched "a-a-a-a" sound. Making these noises helps the doctor see your vocal cords.
The examination takes 5 to 10 minutes.
If a local (topical) anesthetic is used during the examination, it will last about 30 minutes. You can eat or drink when your throat is no longer numb.
Direct flexible laryngoscopy
The doctor may also use a thin, flexible scope to look at your throat. You may get a medicine to dry up the secretions in your nose and throat. This lets your doctor see more clearly. A local anesthetic may be sprayed on your throat to numb it. The scope is put in your nose and then gently moved down into your throat. As the scope is passed down your throat, your doctor may spray more medicine to keep your throat numb during the examination. The doctor may also swab or spray a medicine inside your nose that opens your nasal passages to give a better view of your airway.
Direct rigid laryngoscopy
Before you have a rigid laryngoscopy, remove all your jewelry, dentures, and eyeglasses. You will empty your bladder before the examination. You will be given a cloth or paper gown to wear.
Direct rigid laryngoscopy is done in a surgery room. You will go to sleep (general anesthetic) and not feel the scope in your throat.
You will lie on your back during this procedure. After you are asleep, the rigid laryngoscope is put in your mouth and down your throat. Your doctor will be able to see your voice box (larynx) and vocal cords.
The rigid laryngoscope may also be used to remove foreign objects in the throat, collect tissue samples (biopsy), remove polyps from the vocal cords, or perform laser treatment.
The examination takes 15 to 30 minutes. You may get an ice pack to use on your throat to prevent swelling.
What happens after the procedure?
After the procedure, you will be watched by a nurse for a few hours until you are fully awake and able to swallow.
* Do not eat or drink anything for about 2 hours after a laryngoscopy or until you are able to swallow without choking. You can then start with sips of water and eat a normal diet.
* Do not clear your throat or cough hard for several hours after the laryngoscopy.
* If your vocal cords were affected during the laryngoscopy, rest your voice completely for 3 days.
* If you speak, do so in your normal tone of voice and do not talk for very long. Whispering or shouting can strain your vocal cords as they are trying to heal.
* You may sound hoarse for about 3 weeks after the laryngoscopy if tissue was removed.
Call your doctor immediately if you:
* Have a lot of bleeding or if the bleeding lasts for 24 hours.
* Have any difficulty breathing.
General Risks of having the procedure:
These have been mentioned in the “Anesthesia Consent Form.” Please discuss this with your Anesthetist before signing the Anesthesia Consent Form.
What are the risks of the procedure?
While majority of patients have an uneventful procedure and recovery, few cases may be associated with complications. These are seen infrequently and not all the ones listed below are applicable to one individual. However it is important that you are aware of the complications/risks that may arise out of this procedure which are as below:
There are some risks/ complications, which include:
(a) Injury to the lips, teeth, gums or tongue. Dental injury may result in teeth being chipped, broken or dislodged. Crowns may also be dislodged.
(b) Swelling of the tissues of the airway. This may lead to difficulty breathing requiring the insertion of a breathing tube through the mouth and support with breathing until the swelling resolves. Rarely, a tracheostomy (insertion of a breathing tube through the neck) may be required.
(c) Bleeding into the airway. This may lead to difficulty breathing requiring the insertion of a breathing tube through the mouth, until the bleeding is controlled. Rarely, a tracheostomy (insertion of a breathing tube through the neck) may be required.
(d) Collapsed lung (Pneumothorax). A small hole in the surface of the lung. Air then leaks from the lung, causing the lung to collapse. The lung may come back up itself, or a tube may need to be put into the chest through the skin to remove the air from around the lung. This may need a longer hospital stay.
(e) Voice change. The larynx (voice box) or the nerves controlling the larynx may be injured by the instruments used for the microlaryngoscopy. Voice change may also result from excision or biopsy of the abnormal tissue in the larynx. The voice change may be persistent and not respond to further treatment.
(f) Persistence or recurrence of the original disease may occur.
(g) Undiagnosed neck/spinal problems.
Consent Acknowledgement:
* The doctor has explained my medical condition and the proposed surgical procedure.
* I understand the risks of the procedure, including the risks that are specific to me, and the likely outcomes. The doctor has explained other relevant treatment options and their associated risks, the prognosis and the risks of not having the procedure.
* I have been given an Anesthesia Informed Consent Form.
* I have been given a Patient Information Sheet about the Condition, the Procedure, and associated risks.
* I was able to ask questions and raise concerns with the doctor about my condition, the procedure and its risks, and my treatment options.
* My questions and concerns have been discussed and answered to my satisfaction.
* I understand that the procedure may include a blood / blood product transfusion.
* I understand that if organs or tissues are removed during the surgery, that these may be retained for tests for a period of time and then disposed of sensitively by the hospital.
* The doctor has explained to me that if immediate life-threatening events happen during the procedure, they will be treated as appropriate.
* It has been explained to me, that during the course of or subsequent to the Operation/Procedure, unforeseen conditions may be revealed or encountered which may necessitate urgent surgical or other procedures in addition to or different from those contemplated. In such exigency, I further request and authorize the above named Physician / Surgeon or his designee to perform such additional surgical or other procedures as he or they consider necessary or desirable.
On the basis of the above statements,
I REQUEST TO HAVE THE PROCEDURE.
Name of Patient/Substitute Decision Maker…………………………………………….
Relationship …………………………………….
Signature………………………………………
Date………………………………………………
Name of the Witness…………………………
Relationship/Designation………………………
Signature………………………………………..
Date……………………………
INFORMED CONSENT: LARYNGOSCOPY
Patient Identification Label to be affixed here
A. INTERPRETER
An interpreter service is required.Yes______________No_______________
If Yes, is a qualified interpreter present.Yes_____________No___________
B. CONDITION AND PROCEDURE
The doctor has explained that I have the following condition:
(Doctor to document in patient’s own words)
_______________________________________________and I have been advised to undergo the following treatment/procedure____________________________________________________________________________________________________________________________________________________________
See patient information sheet- “Laryngoscopy” for more
C.ANAESTHETIC
Please see your “Anesthesia Consent Form”. This gives you information of the General Risks of Surgery. If you have any concern, talk these over with your anesthetist.
D.RISKS OF THIS PROCEDURE
While majority of patients have an uneventful surgery/procedure and recovery, few cases may be associated with complications. These are seen infrequently and not all the ones listed below are applicable to one individual. However it is important that you are aware of the complications/risks that may arise out of this procedure which are as below:
There are some risks/ complications, which include:
(a) Injury to the lips, teeth, gums or tongue. Dental injury may result in teeth being chipped, broken or dislodged. Crowns may also be dislodged.
(b) Swelling of the tissues of the airway. This may lead to difficulty breathing requiring the insertion of a breathing tube through the mouth and support with breathing until the swelling resolves. Rarely, a tracheostomy (insertion of a breathing tube through the neck) may be required.
(c) Bleeding into the airway. This may lead to difficulty breathing requiring the insertion of a breathing tube through the mouth, until the bleeding is controlled. Rarely, a tracheostomy (insertion of a breathing tube through the neck) may be required.
(d) Collapsed lung (Pneumothorax). A small hole in the surface of the lung. Air then leaks from the lung, causing the lung to collapse. The lung may come back up itself, or a tube may need to be put into the chest through the skin to remove the air from around the lung. This may need a longer hospital stay.
(e) Voice change. The larynx (voice box) or the nerves controlling the larynx may be injured by the instruments used for the microlaryngoscopy. Voice change may also result from excision or biopsy of the abnormal tissue in the larynx. The voice change may be persistent and not respond to further treatment.
(f) Persistence or recurrence of the original disease may occur.
(g) Undiagnosed neck/spinal problems.
SIGNIFICANT RISKS AND RELEVANT TREATMENT OPTIONS:F. SIGNIFICANT RISKS AND
The doctor has explained any significant risks and problems specific to me, and the likely outcomes if complications occur.
The doctor has also explained relevant treatment options as well as the risks of not having the procedure.
(Doctor to document in Medical Record if necessary. Cross out if not applicable. )
PATIENT CONSENT: CONSENT
I acknowledge that:
* The doctor has explained my medical condition and the proposed procedure. I understand the risks of the procedure, including the risks that are specific to me, and the likely outcomes.
* The doctor has explained other relevant treatment options and their associated risks. The doctor has explained my prognosis and the risks of not having the procedure.
* I have been given a Patient Information Sheet on Anesthesia.
* I have been given the patient information sheet regarding the condition, procedure, risks and other associated information.
* I was able to ask questions and raise concerns with the doctor about my condition, the procedure and its risks, and my treatment options. My questions and concerns have been discussed and answered to my satisfaction.
* I understand that the procedure may include a blood transfusion.
* I understand that if organs or tissues are removed during the surgery, that these may be retained for tests for a period of time and then disposed of sensitively by the hospital.
* The doctor has explained to me that if immediate life-threatening events happen during the procedure, they will be treated accordingly.
* I understand that photographs or video footage maybe taken during my operation. These may then be used for teaching health professionals. (You will not be identified in any photo or video).
* I understand that no guarantee has been made that the procedure will improve the condition, and that the procedure may make my condition worse.
On the basis of the above statements,
I hereby authorize Dr……………………………………………………………………and those he may designate as associates or assistants to perform upon me the following medical treatment, surgical operation and / or diagnostic / therapeutic procedure…………………………………………………………..
I REQUEST TO HAVE THE PROCEDURE
Name of Patient/Substitute Decision Maker…………………………………………….
Relationship …………………………………………………………………………………….
Signature……………………………………………Date……………………………………….
Name of the Witness…………………………………………………………………………
Relationship/Designation………………………………………………………………………
Signature……………………………………………Date………………………………………
FERENCES
INTERPRETER’S STATEMENT:
I have given a translation in……………………………………………………………………
Name of interpreter…………………………………………………………………………….
Signature……………………………………………Date………………………………………
DOCTOR’S STATEMENTS
I have explained
* The patient ‘s condition
* Need for treatment
* The procedure and the risks
* Relevant treatment options and their risks
* Likely consequences if those risks occur
* The significant risks and problems specific to this patient
I have given the Patient/ Guardian an opportunity to:
* Ask questions about any of the above matters
* Raise any other concerns, which I have answered as fully as possible.
I am of the opinion that the Patient/ Substitute Decision Maker understood the above information.
Name of doctor…………………………………………………………………………..
Designation………………………………………………………………………………
Signature………………………………………Date……………………………………
Patients Initials _____________
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