DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Obstructive sleep apnea.
2. Hypertrophied tonsils.
3. Hypertrophied adenoids.
4. Mouth breathing.
POSTOPERATIVE DIAGNOSES:
1. Obstructive sleep apnea.
2. Hypertrophied tonsils.
3. Hypertrophied adenoids.
4. Mouth breathing.
OPERATION PERFORMED:
1. Tonsillectomy and adenoidectomy.
2. Indirect laryngoscopy.
3. Nasopharyngoscopy.
4. Therapeutic injection of Marcaine 0.5% 1:200,000 epinephrine, a total of 10 mL.
5. Therapeutic injection of Bicillin L-A 1.2 million units.
SURGEON: John Doe, MD
ANESTHESIA: General orotracheal intubation.
ESTIMATED BLOOD LOSS: Less than 25 mL.
DESCRIPTION OF OPERATION: The patient was brought to the operating room. He was draped and sterilized in the usual fashion and laid in a supine position. Once adequate anesthesia was given by the anesthesiologist, we inserted #3 McIvor in the oral cavity. We opened up the oral cavity adequately. The patient’s neck was extended. We suspended the McIvor from the Mayo stand.
At that point, we could appreciate that the tonsils were kissing, and we grabbed the superior pole of the right tonsil with the curved Allis. With the electrocautery on 15, we began dissecting from superior to inferior and from anterior to posterior, excising the tonsil in total. Minimal bleeding was encountered and was controlled with suction cautery. The exact same procedure was then performed on the left side.
Once that was completed, we used a mirror to perform indirect laryngoscopy. We could appreciate the larynx. He had a mild bit of laryngeal edema a mild bit of pachydermia, but there was no sign of traumatic intubation. The vocal cords were in the paramedian position.
We then used a mirror to perform a nasopharyngoscopy. At that point, the adenoids were 4/4 causing complete obstruction of the nasopharynx and the choana. We then placed one red rubber catheter in each nostril and lifted up the soft palate. We then used a reverse curette in a curetting fashion and excised out the majority of the adenoid tissue. Bleeding was encountered. We then used the suction cautery, which was on 25 and cauterized down the remaining portions of the adenoid bed. We then irrigated out the oral cavity with 1 liter of normal saline. We injected 0.5% Marcaine 1:200,000 epinephrine into the tonsillar fossa, a total of 5 mL was used on each side. We then injected the right and left side. We then used a 14 French catheter threaded through the oral cavity, through the esophagus, and down into the stomach. We suctioned out the stomach contents, which was 5 to 10 mL of clear fluid.
We then removed the McIvor without any difficulty. We manipulated the temporomandibular joint; it was normal. We then rolled the patient over and placed a Tylenol suppository and then we injected Bicillin L-A 1.2 million units intramuscularly into the right gluteus maximus. The patient was then awakened and transferred to the recovery room in stable satisfactory condition.
