Tonsillectomy/Adenoidectomy Operative Note

Patient: [Patient name and identifiers]

DOB: [Date of birth]

Date of Surgery: [Date]

Facility: [Facility name and location]

Case Start Time: [Case start time] (Include only if reliably available; otherwise omit this line.)

Case End Time: [Case end time] (Include only if reliably available; otherwise omit this line.)

Preoperative Diagnosis

[Preoperative diagnosis or diagnoses] (Use explicit diagnostic terms such as obstructive sleep apnea, adenotonsillar hypertrophy, recurrent acute tonsillitis, or chronic tonsillitis. If both obstructive and infectious indications apply, list both. Do not list symptoms alone.)

Postoperative Diagnosis

[Postoperative diagnosis or diagnoses] (State surgeon's final diagnostic impression. If unchanged from preoperative, state "Same as preoperative diagnosis." If pathology is pending for a suspicious lesion, document the lesion and note tissue sent to pathology without assuming a definitive diagnosis.)

Procedure(s) Performed

[Procedure(s) with exact wording] (Examples: Bilateral tonsillectomy, Adenoidectomy, Adenotonsillectomy, Intracapsular tonsillectomy with adenoidectomy. If adenoidectomy was NOT performed, explicitly state "Adenoidectomy not performed" to avoid ambiguity.)

Surgical Team and Anesthesia

Surgeon: [Name]

Assistant(s): [Names and roles / None]

Anesthesia: [Type] by [Provider name] (Type is typically general endotracheal.)

Intraoperative dexamethasone: [yes / no] (Include only if documented.)

Perioperative antibiotic: [yes / no] (Include only if documented; if yes, include indication.)

Indications

[Narrative clinical rationale for surgery] (2-4 sentences referencing supporting details such as snoring with witnessed apneas, tonsil size, frequency of infections, and prior failed medical management. May reference the preoperative clinic note for full history. Do not infer polysomnography values or episode counts not documented in the encounter.)

Findings

• Tonsils: [Size/grade, symmetry, appearance] (Describe appearance such as cryptic, inflamed, or scarred.)
• Adenoids: [Size or percent choanal obstruction, inflammation if present] (If adenoids were not assessed, state "Not assessed.")
• Unexpected findings: [Description / None]

Description of Procedure

Patient identification and consent were verified. The patient was positioned supine [with / without] a shoulder roll. A surgical time-out was performed confirming patient, procedure, and site. Eye protection was applied. A [mouth gag / retractor type] was placed and suspended.

(Include tonsillectomy paragraph only if tonsillectomy was performed.)

Tonsillectomy was performed using a [extracapsular / intracapsular] technique with [cold steel / monopolar cautery / coblation / harmonic scalpel]. The [right / left] tonsil was addressed first. The tonsil was grasped and dissected [along the capsule / intracapsularly] to the tonsillar fossa. The contralateral tonsil was removed in similar fashion. Hemostasis in each tonsillar fossa was achieved using [suction cautery / bipolar cautery / suture ligation / topical agents]. Hemostasis was confirmed after irrigation.

(Include adenoidectomy paragraph only if adenoidectomy was performed.)

The nasopharynx was visualized with a [mirror / endoscope]. Adenoid tissue was removed using [curette / suction cautery / coblation / microdebrider] until the choanae were patent, with care to protect the eustachian tube orifices. Hemostasis was achieved using [suction cautery / topical agents / packing] and confirmed on inspection.

All instruments were removed. The oral cavity and oropharynx were inspected with no trauma to lips, teeth, or tongue. The patient was transferred to PACU in [stable / guarded] condition.

EBL, Specimens, and Complications

Estimated Blood Loss: [Numeric value] mL (Always provide an estimate even if minimal.)

Specimens: [Description of tissue sent to pathology / None] (Example: Bilateral tonsils sent to pathology, labeled right and left. If tissue was removed but not sent, document disposition.)

Drains/Packing: [None / Description if used]

Complications: [None / Description with management] (Always state explicitly; do not imply absence through omission.)

Disposition

Patient in [stable / guarded] condition, transferred to [PACU / inpatient unit for overnight observation / discharged home from ASC]. (If admitting for overnight monitoring, state rationale such as age under 3 years or severe OSA.)

Postoperative Plan

• Pain control: [Planned regimen] (For pediatric patients, explicitly note avoidance of codeine-containing medications.)
• Bleeding precautions: Seek urgent evaluation for bright red bleeding, repeated blood in saliva or vomitus, or any concern for significant hemorrhage.
• Hydration and diet: Encourage oral fluids; advance diet as tolerated.
• Activity: Avoid strenuous activity for [duration per protocol].
• Follow-up: [ENT follow-up appointment / Return PRN]