Flexible Fiberoptic Laryngoscopy Procedure Note

Date/Time: [Procedure completion date and time]

Location: [clinic / ED / bedside / OR / other]

Operator: [Name, credentials]

Assistant(s): [Name(s), credentials] (Include only if applicable)

Indication & Pre-Procedure Context

[Primary indication for flexible fiberoptic laryngoscopy] [Pertinent targeted history supporting today's procedure: symptom onset, duration, progression; relevant risk factors such as tobacco use, recent intubation, prior head & neck surgery, professional voice use; prior evaluations if relevant] (2–5 sentences. Do not infer indication from findings. If history is limited, explicitly state the reason.)

Consent & Safety Verification

Consent type: [verbal / written]. [Statement that procedure purpose, alternatives, and risks—including discomfort, gagging, cough, epistaxis, vasovagal episode, and rare laryngospasm—were discussed and patient agreed]

Time-out performed: [yes / no] (If required by institutional policy and not performed, document the rationale.)

Topical Anesthesia & Medications

• [Medication agent] [concentration if known] [route: spray / pledgets / gel / nebulized / other]
• [Vasoconstrictor/decongestant agent] [concentration if known] [route] (Include only if used)

(If no topical anesthesia or vasoconstrictor was used, explicitly state "None.")

Procedure Description

[Patient position: seated / supine / other] [Approach: transnasal / transoral] [If transnasal: nare used; note if switched sides due to obstruction] [Equipment: flexible fiberoptic or digital endoscope; note NBI or other special imaging modes only if used] [Functional maneuvers performed: quiet breathing, sniff, sustained phonation, pitch glide, cough, Valsalva as applicable] [Anatomic extent examined: nasal cavity through larynx; note subglottis/proximal trachea only if visualized] (3–6 sentences describing technique only. If the exam was limited, document the reason and which regions were not visualized.)

Findings

Nasal Cavity & Nasopharynx

• Septum: [normal / deviation—describe laterality and severity]
• Turbinates: [normal / hypertrophy—describe laterality and degree]
• Mucosa: [normal / edema / erythema / crusting / other]
• Polyps or masses: [none / present—describe location and size]
• Secretions/bleeding: [none / present—describe character and laterality]
• Nasopharynx: [normal / adenoid tissue / lesion]; Eustachian tube orifices: [normal / abnormal]
• Visualization status: [complete / limited / not visualized] (If limited or not visualized, explain why.)

Oropharynx & Hypopharynx

• Base of tongue/lingual tonsils: [normal / abnormal—describe]
• Valleculae: [normal / abnormal—describe]
• Pyriform sinuses: [normal / abnormal—describe laterality]
• Posterior pharyngeal wall: [normal / abnormal—describe]
• Post-cricoid region: [normal / abnormal—describe]
• Pooling of secretions/saliva: [none / present—describe location and amount]
• Visualization status: [complete / limited / not visualized] (If limited or not visualized, explain why.)

Larynx

• Supraglottis: [normal / abnormal] (epiglottis, aryepiglottic folds, false vocal folds, arytenoids—describe edema, erythema, lesions with location, laterality, size estimate, and morphology if abnormal)
• Glottis: [normal / abnormal] (true vocal folds, anterior commissure—describe findings with location, laterality, size estimate, and morphology if abnormal)
• Subglottis/proximal trachea: [normal / abnormal / not visualized] (Include only if visualized)
• Visualization status: [complete / limited / not visualized] (If limited or not visualized, explain why.)

Vocal Fold Function

• Left vocal fold mobility: [normal / paresis / paralysis]; abduction: [normal / reduced / absent]; adduction: [normal / reduced / absent]
• Right vocal fold mobility: [normal / paresis / paralysis]; abduction: [normal / reduced / absent]; adduction: [normal / reduced / absent]
• Glottic closure: [complete / incomplete]; pattern: [posterior gap / spindle / hourglass / irregular / other]
• Supraglottic hyperfunction: [none / present—describe type and degree]
• Airway adequacy: [patent / narrowed—describe degree and level]

Lesions

(Include this subsection only if lesion identified. Present findings as observations; defer definitive diagnosis to Impression.)

• Lesion #1: [Precise location and laterality] [Estimated size] [Morphology: exophytic / ulcerative / smooth / irregular / pedunculated / sessile / color changes] [Functional impact observed] [Photo/video captured: yes / no]
• Lesion #2: [Details as above] (Add additional lesions as needed)

Complications & Tolerance

Complications: [none / epistaxis / vasovagal episode / laryngospasm / emesis / other]. [Actions taken if any]

EBL: [none / minimal / quantify]

Patient tolerance: [tolerated well / limiting factors—describe]. [Immediate post-procedure status and disposition if relevant]

Impression

[Synthesis of key findings into clinical interpretation; include working diagnosis or differential when appropriate; frame in way useful for downstream care] (1–3 sentences)

Plan

• [Medical therapy if indicated]
• [Referrals: voice therapy / oncology / airway team / other]
• [Imaging or additional diagnostics if indicated]
• [Biopsy/surgical referral if indicated]
• [Surveillance plan: follow-up timeframe and triggers for earlier return]
• [Pending results and communication plan]
• [Post-procedure precautions discussed: NPO timing if topical anesthesia used]

(Include only applicable items)

Specimens/Interventions

(Include this section only if biopsy, foreign body removal, or other intervention was performed. Otherwise omit entirely.)

• Intervention performed: [biopsy / foreign body removal / debridement / other]
• Site and details: [location, laterality, method]
• Specimen: [type, number, size, transport medium, destination lab]
• Intra-procedure hemostasis: [method and outcome]