DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right neck abscess.
POSTOPERATIVE DIAGNOSIS: Right neck abscess.
PROCEDURE PERFORMED: Incision and drainage of right neck abscess.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal anesthesia.
PROCEDURE FINDINGS: Twenty mL of purulent material expressed from right-sided neck abscess.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-month-old male who presented via his primary care physician’s office with several days of worsening right-sided submandibular mass. He was admitted and placed on IV antibiotics and enjoyed an initial improvement. When his neck mass worsened yesterday, he started to spike fevers.
A followup ultrasound and CT scan of the neck was performed. The CT scan of the neck was suggestive of right sided neck abscess.
The risks, benefits, and alternatives of incision and drainage were discussed with the patient’s parents with an emphasis on the risks of anesthesia, bleeding, and need for repeat drainage or cranial nerve injury. They verbalized understanding of these risks and consented to the procedure.
DESCRIPTION OF PROCEDURE: After obtaining informed consent, the patient was brought to the operating room and placed supine on the operating table. General anesthesia with endotracheal intubation was induced without difficulty. The eyes were protected with ointment and tape. Shoulder roll was placed. The skin of the right neck was prepped and draped in a sterile fashion.
A 1.5 cm transverse cervical incision was made in the posterior triangle over the most fluctuant area. Sharp dissection was used only to incise the skin. After the skin incision, blunt dissection was used to dissect into the center of the abscess. A large amount of purulent material was expressed and sent to microbiology.
Blunt dissection was used to spread in all directions with external pressure to break up and drain any loculation. The abscess cavity was then copiously irrigated with saline. A 1/4 inch Penrose drain was inserted into the abscess cavity.
The incision was partially closed with interrupted 4-0 chromic sutures. An anchoring stitch was placed through the drain at the posterior apex of the incision. Antibiotic ointment and Telfa gauze were applied. A bulky neck dressing was then applied to collect any drainage. The patient tolerated the procedure well without complication.
