Bechara Y. Ghorayeb, MD, PA
Otolaryngology-Head & Neck Surgery                                                              Phone: 713 464 2614
1140 Business Center Drive, Suite 560
Houston, TX 77043                  

Informed Consent for
Deep Neurovascular Neck Dissection for Deep Large Neck Masses, Neck Cysts, Cystic Hygroma, Lymphangioma, etc.
Deep neurovascular cervical dissection for excision of cystic hygroma / lymphangioma or extensive cysts of the neck is an operation designed to remove a large cystic mass from the neck. Complications of this surgery include wound infection and breakdown, bleeding, leakage of lymph fluid (chyle fistula), injury to nerves controlling the lower face, throat, vocal cords, shoulder, tongue, diaphragm, and skin sensation under ear and jaw. Except for the nerve injuries, these complications can be successfully managed. Quality of life after such a neck dissection is only minimally affected. The major permanent undesired effects are rare, but could possibly include some shoulder weakness, pain or numbness in the neck or ear, and of course, a surgical scar. Occasionally, the mass extends to the mediastinum and chest and may require a separate operation that could be done simultaneously or at a different date.

I/We have been given an opportunity to ask questions about my condition, alternative forms of treatment, risks of nontreatment, the procedures to be used, and the risks and hazards involved, and I/we have sufficient information to give this informed consent. I/We certify this form has been fully explained to me/us, and I/we understand its contents. I/We understand every effort will be made to provide a positive outcome, but there are no guarantees.

_______________________________ ____________________________________________
Patient / Legal Guardian

Date:___________________________          Time:___________________________