DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Hypertrophy of lingual tonsils with asymmetry, right greater than left.
POSTOPERATIVE DIAGNOSIS: Hypertrophy of lingual tonsils with asymmetry, right greater than left.
OPERATION PERFORMED: Lingual tonsillectomy with biopsy.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal anesthesia.
ESTIMATED BLOOD LOSS: Less than 10 mL.
SPECIMENS:
1. Right lingual tonsil.
2. Left lingual tonsil.
OPERATIVE FINDINGS: The patient had hypertrophied lingual tonsils, right greater than left.
INDICATION FOR OPERATION: The patient is a (XX)-year-old female with a history of discomfort in the base of tongue and lingual tonsil, right greater than left. The lingual tonsil hypertrophy caused discomfort with swallowing. The decision was made with the patient to perform a lingual tonsillectomy with biopsy. The risks and benefits of the procedure were explained to the patient, and she agreed to go ahead with the procedure.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and was placed in the supine position on the operating room table. General face mask anesthesia was given until a deep plane of anesthesia was obtained. At that point, an endotracheal tube was placed by the anesthesiology service without difficulty. The table was then turned, and the patient was draped in routine fashion. A McIvor mouth gag was placed into the oral cavity to allow exposure of the lingual tonsils. The patient had prominent lingual tonsils bilaterally with the right being greater than the left.
At that point, approximately 9 mL of 1% lidocaine with 1:100,000 epinephrine mixed with 0.25% bupivacaine 1:1 was injected just deep to the lingual tonsils bilaterally. After allowing time for decongestion, a 15 blade was used to excise the superficial half of the lingual tonsil on the right and sent for pathology. The 15 blade was then used to excise the superficial half of the left lingual tonsil, which was sent for pathology.
A 4 mm Xomed Straightshot microdebrider was then used to shave the remaining lingual tonsils bilaterally. This was taken down to the normal surface of the base of tongue. Suction Bovie cautery was then used bilaterally for hemostasis. The oral cavity and oropharynx was serially irrigated with normal saline. There was no evidence of bleeding. At that point, the McIvor mouth gag was removed. The table was then turned back to Anesthesiology, who awoke the patient from anesthesia and extubated the patient. The patient was then sent to the postanesthesia care unit in stable condition. There were no complications during the procedure.
