CHAPTER 1

Is it working now? No, it was a little bit better before - that's good. She has it. I have it. Let's get it set up on suspension.

Okay. We'll then get exposure. It's smaller back there in the picture. Can I see the suction? So she's had two prior surgeries, which led to this granuloma down there. (mumbles). So we've got the tube anterior, so we can see this lesion, and you can see that it kind of pulls away from the cartilage there - the arytenoid, so we can come underneath that base. Usually we don't operate on granulomas. We just get into the... (mumbles). And because there's a base to it, we can come under - the granuloma probably in this region around there and not expose any cartilage or perichondrium there. And remove that.

CHAPTER 2

All right, so that looks good, so you have a good view. Suction? Suction? You move the tube anteriorly - with your scope. So what we want to do is we want to remove this without exposing perichondrium or cartilage, or this will recur. If we can't get good enough retraction with suction, we'll have to use a little cup forceps to hold it. Yeah, I worry it's just going to drop it into it, so let's do that. Do you have cups, Laura? Yep. I just worry like as we're going to cross it, it'll drop out. You're telling me you see the mucosa tack as you retract the granuloma, your reserve is - possibly, you're going to have to switch to a straight scissors. I'm fighting my hands here... (mumbles). Maybe a cups would be better? Put your hand out of the way - that's straight scissors. Yeah. Can I see an upcut? And straight scissors. That might have too much of a curve. And you may even be getting the straight scissors upside down. Upside down. Thank you. Keep your hands separated. (mumbles). Can't see I'm moving the scope, but I'll leave you a bit more room. How's that? (mumbles). And sometimes the light carrier from the scope sticks out into the lumen. And so if we back that up just a little bit we will not roll - your instrument around the light cord. See these are battling again more. How's that?

CHAPTER 3

Good. Perfect. Good job, that looks very impressive. He did some trimming - that's why. (mumbles). Does it still look okay on the screen now? It does - it looks great. (mumbles). Hey, I mean it's more the technique and the work of it that's important though. (mumbles). (mumbles). All right, so you can see where that junction is. (mumbles). So we're going to come right underneath that margin. (mumbles). Wipe. Hold on. Okay. There's just that little mucosal fold there and some swelling. Can I see the suction, please? (mumbles). I mean, you could even try slide in just some scissors underneath it. It's kind of small and hard to grab - see if you can start getting it to elevate off. You might even get a curve with this one instead of straight. Can I see the right scissors, please? Yes. Yeah, see if you just kind of come right that looks pretty good. Why don't you pull the tissue where you can feel it. Put it up a little bit wider. There you go. Yes. Nice. Yeah, good. And now the granuloma's gone. (mumbles). Can I see an epi pledget? Yep. Now the key is you've got to get this to dry out. Mm. Perfectly dry, so that we don't have... (mumbles). So you put a pledget on there, and you put pressure until it stops. (mumbles) Can I have a spatula? Yep. It's a big one. That's fine. We're about done here. What do you want to call that? Left vocal fold granuloma. (mumbles). There was a… Okay. And again, these are regular pills. Yeah. Can I see another pledget? She's coming back next week, and then I'll see her in a month, and we'll just make sure it's healed and nothing's recurred. I think it was just a matter of focusing that lightning a little bit more… That and like she was saying that when she had them before - the two, and they would rub against each other- it's really irritating, and then even with the… she was still feeling a catch whenever she was eating, drinking, talking - that kind of thing. That's one of the rare cases you get where the... (mumbles). And then a total, right? (mumbles). And then she called back a couple weeks later and said I'm getting worse - and she had actually two granulomas. Mm. She's got a little pressure. You want one more, Scott? One more. I mean most granulomas mature and fall off, right? (mumbles). Those are the only ones that are critical. Yeah. Because you can see - you can pull it away from the cartilage. (mumbles). It is right on there, and if you cut that thing off, you are staring at raw cartilage. Mm. That's why those never work. (mumbles). And oftentimes it's really the - You pick up scissors, you come on it, you grab that stalk, you go right next to the thing, and you cut it off. Yeah. I think you're right. Pressure to make sure the stalk doesn't bleed, and lead to a new granuloma. I think being able to come out with the scissors from that last… Well this is a little too small to have two things done. (mumbles). When it's bigger, same thing, you kind of use a little suction and then once you see it, you take a scissors, and it's all by feel. One more, and I think she'll be really good. That's great. Can I have one more pledget? Yep. (mumbles). And it's - it looks good. Actually, you know what - wow... Pledget. Thank you. Just suction that blood out, maybe we can see… That distal blood? Yeah, just so she doesn't pop after the fact. Okay.