The patient was brought into the operating room and identified by name and medical record number. General endotracheal anesthesia was successfully induced by the anesthesia service. The patient was placed in the supine position and draped in the usual sterile fashion.
The (type) mouth gag was inserted into the mouth and opened exposing symmetrically enlarged (size of tonsils) tonsils. Care was taken to ensure that the lips were not pinched by the mouth gag. The uvula was midline and not bifid. The soft palate was intact without evidence of midline diastasis. The right tonsil was grasped, retracted medially, and dissected free of the tonsillar fossa in a pericapsular plane with monopolar cautery. Minimal bleeding was found and meticulously controlled using electrocautery. A similar procedure was performed on the left. Minimal bleeding was found on this side and again meticulously controlled using electrocautery.
Attention was then turned toward the adenoid pad. A rubber catheter was inserted through the nose, advanced through to the oropharynx, and pulled out the mouth effectively suspending the soft palate. A mirror was used to directly visualize a (size) adenoid pad. Using suction cautery, the adenoid tissue was ablated. Care was taken to identify and preserve the torus bilaterally as well as the vomer and the soft palate. Minimal bleeding was noted and easily controlled with suction cautery. The rubber catheter was then removed. The anterior and posterior tonsillar pillars were infiltrated with (amount of local) ccs of (type of injection) bilaterally. The patient was desuspended for 2 minutes and resuspended. No bleeding was noted. The mouth gag was removed. The stomach was suctioned. At this point the procedure was terminated. The patient was awakened, extubated, and transferred to the PACU in stable condition. There was minimal blood loss. No complications. All surgical pauses were observed. Standard operating room protocol and universal precautions were utilized throughout the procedure.
