PREOPERATIVE DIAGNOSIS: Chronic tonsillitis.
PROCEDURES PERFORMED:
1. Tonsillectomy.
2. Nasoscopy.
ANESTHESIA: General endotracheal.
COMPLICATIONS: None.
SPECIMEN: Bilateral tonsils.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old female with a history of chronic tonsillitis who presents for removal of her tonsils.
DESCRIPTION OF PROCEDURE: The patient was brought into the operating room and appropriate plane of anesthesia was obtained via endotracheal intubation.
The head of the bed was turned 90 degrees. A Crowe-Davis mouth gag was used to suspend the oropharynx. Electrocautery was used to dissect the right tonsil free of the tonsillar fossa in the plane of the tonsillar capsule. Appropriate hemostasis was obtained.
Attention was then turned to the left side and the procedure was repeated. Hemostasis was meticulously obtained with suction electrocautery.
Next, attention was turned to the adenoid pad. It was visualized directly using a laryngeal mirror. These were deemed not to be overly obstructive and as such were not removed. Again, hemostasis was confirmed in the tonsillar fossae. The patient was handed back to Anesthesia in stable condition. The patient was transported to the PACU.
Tonsillectomy Sample Report #2
PREOPERATIVE DIAGNOSIS: Obstructive sleep apnea.
POSTOPERATIVE DIAGNOSIS: Obstructive sleep apnea.
PROCEDURES PERFORMED:
1. Bilateral tonsillectomy.
2. Uvulopalatopharyngoplasty.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old male with a history of obstructive apnea who presents for UPPP.
DETAILS OF PROCEDURE: The patient was brought into the operating room. An appropriate plane of anesthesia was obtained via endotracheal intubation.
The head of the bed was turned 90 degrees. A Crowe-Davis mouth gag was used to suspend the oropharynx. The tonsils and palate were visualized. Electrocautery was used to dissect the right tonsil out of the tonsillar fossa and the plane of the tonsillar capsule. Appropriate hemostasis was obtained.
The extent of the incision was carried along the soft palate anterior to the uvula and this was excised, taking care not to injure the posterior pharyngeal wall. The incision was then extended leftward and the left tonsil was dissected out in a similar fashion. Appropriate hemostasis was obtained.
Next, Vicryl sutures were used to oversew the tonsillar pillars on both sides as well as the palatal mucosa in the midline. This was done in an interrupted fashion without difficulty.
The patient tolerated the procedure well, was extubated without difficulty, handed to Anesthesia and transported to the PACU in stable condition.
