ENT Templates

Received in [formalin / fresh] labeled with the patient’s name, medical record number and designated  “***” is a laryngectomy specimen measuring *** x *** x *** cm. The distal aspect has been resected across the [*** tracheal ring / cricoid cartilage / etc.].  The proximal margin is comprised of [base of tongue mucosa anteriorly, pyriform sinuses / lateral walls of the hypopharynx laterally and the posterior cricoid mucosa posteriorly vs. other if the field of resection is wider].  The specimen is [intact / focally disrupted – describe any disruptions or defects].

Examination of the external surface reveals the expected anatomic structures and shows [no areas of involvement by tumor / an area of tumor involvement – describe].  The specimen is opened along the posterior border, in the sagittal plane.  Pressure is applied to the thyroid cartilage; opening the larynx and exposing the interior elements.  A tumor is identified which has surface dimensions of *** x *** cm.  The tumor involves the [name all regions involved by tumor – supraglottis, glottis, and subglottis].  The epicenter is at the [supraglottis / glottis / subglottis].  The tumor involves [the right side, the left side, involves both the right and left sides, crossing the midline along the anterior / posterior aspect].  The surface of the tumor is [describe surface features: ulcerated, exophytic, plaque like, etc.].  The tumor [does / does not] impair vocal cord motility. A partial thickness section of the tumor is removed [this section is not subjected to decalcification].  The epithelial margins that are distant from the tumor are shaved [these sections are also not subjected to decalcification].

The specimen is differentially inked as follows: [use 4 colors, one anterior, one posterior, one right, one left]. The plane of sectioning is in the superior – inferior axis, beginning with an initial section through the epicenter of the tumor.  The tumor reaches *** cm in thickness.  It invades into [provide the anatomic structures involved by tumor and specifically provide the maximum extent of invasion – be specific].  The soft tissue margins are [free by *** cm / involved – state specifically the area of involvement or closest approach].   The remaining specimen is [free of gross lesions / remarkable for *** if additional lesions or abnormalities, describe here].

Lymph nodes [are / are not] identified [describe, give sizes, number of lymph node candidates].

Gross photographs are taken.

Cassette summary:

***: Inferior margin, shaved

***: Superior margin, anterior aspect, shaved

***: Superior margin, right aspect, shaved

***: Superior margin, left aspect, shaved

***: Superior margin posterior aspect, shaved

*** – ***: Tumor in area of deepest invasion

***: Tumor involving [show all areas of tumor involvement – supraglottis, subglottis,

and glottis; right, left, anterior, and posterior including cord involvement]

***: Random sections from uninvolved structures [name each and state which cassette

each is placed in]

***: Lymph nodes [if present]

Received [fresh/in formalin], labeled with the patient’s name “*** ” and labeled “*** ” is a total thyroidectomy specimen weighing ***g with attached orientation sutures (as per requisition slip). The specimen has the following dimensions: (Right lobe ***, isthmus ***, and left lobe ***). The external capsule is [tan/brown/lobulated/with adhesions/smooth/granular]. The anterior external section is inked blue, and the posterior capsule is inked black. The specimen is serially sectioned from superior to inferior. Sectioning reveals a well-defined tan-white nodule within the [upper/mid/inferior] pole of the [right/left/isthmus] lobe and measures *** cm. The lesion is located *** cm from the capsule.  Remaining specimen has a tan-red beefy unremarkable appearance. Within the same specimen container there is a *** cm fragment of tan-yellow and lobulated adipose tissue designated as “central neck dissection”. Sectioning reveals *** possible lymph nodes. The cut surfaces of the lymph nodes are tan-grey and unremarkable.  Specimen photographs are obtained and representative sections are submitted in *** cassettes:

***= full face of the nodule

***= Sections directly adjacent to the nodule

***= representative section of right lobe

***= representative section of isthmus

***= representative section of left lobe

***= Lymph node candidates [1 bisected node per cassette]

Received [fresh / in formalin] labeled with the patient’s name and medical record number, and designated as “***” is a *** gram portion of thyroid gland which is [received without orientation / oriented as follows “___”]. The specimen measures *** cm SI x *** cm ML x *** cm AP. The specimen is [intact / disrupted – describe any disruptions]. The outer surface is smooth to shaggy. There [are / are not] attached parathyroid glands [if present, describe the glands; for example – A small (___ x___ x___ cm) soft tan/brown ovoid nodule is adherent to the ___ surface of the lobe and is grossly consistent with a parathyroid gland.] The thyroid surface is inked as follows: anterior – blue, posterior – black, lateral – green, isthmus [or other medial margin] margin – red.
The [portion of thyroid tissue / lobe] is serially sectioned from superior to inferior into *** slices. The cut surfaces are
[beefy and red brown – indicating normal, which, if accompanied by general enlargement coincides with Grave’s disease] and / or
[focally pale and somewhat fleshy – indicating Hashimoto’s or lymphocytic thyroiditis] and / or
[diffusely nodular, and the nodules are heterogeneous. The largest nodule measures [___] cm and is located at the superior / mid / inferior aspect. The nodules have [well demarcated / encapsulated] borders and are [soft and pink red to dark red / show focal calcifications / are focally hemorrhagic / are focally cystic / show focal areas of scarring / etc – indicating nodular hyperplasia / multinodular goiter].

Gross photographs [are / are not] taken.
Representative sections are submitted as follows [any nodule with infiltrative border should be submitted one section per cm or entirely]:
***