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Uvulopalatopharyngoplasty Tonsillectomy MT Sample Report

DESCRIPTION OF PROCEDURE: Under suitable oroendotracheal anesthesia, the McIvor mouth gag was inserted into the mouth to retract the tongue inferiorly and keep the mouth open. A red rubber catheter was placed down the right nostril and brought up below the soft palate. Examination of the oropharynx shows the tongue is very broad and relatively large for the small mandibular arch. The velopharyngeal opening and oropharyngeal opening is very small because of markedly redundant soft palate with a stout uvula. The tonsils are buried, but present. Both tonsillar fossae, the lateral base of tongue and the soft palate were injected with 1% Xylocaine with 1:100,000 of epinephrine.

The right tonsil was then grasped with a curved Allis clamp. Mucosal incisions were made over the posterior, superior, anterior aspect of the tonsillar fossa. The tonsils were prominently embedded in the lateral pharyngeal wall and also crowded by the base of tongue inferiorly. A tedious dissection was carried out carefully to remove the tonsil in an extracapsular dissection using bipolar cautery and sharp and blunt dissection removing the tonsil in toto in this manner. The tonsillar fossa was rechecked for any persistent oozers and bleeding and these were carefully cauterized with the bipolar cautery.

The attention was turned to the left side and the same careful, but yet tedious dissection, was carried out to remove the prominently embedded tonsils. The palate was then evaluated. The uvula appeared to be bifid, but the hard palate was intact with no notching. A cuff of 2 cm of palate from the posterior end of the hard palate posteriorly was preserved after marking off with a ruler. An incision at the base of the uvula went through the mucosa and was carried along transversely over the anterior soft palate. The upper portion of the anterior tonsillar pillars were removed. This was largely mucosa. The muscles of the uvula were carefully transected trying to retain the posterior mucosa of the soft palate and uvula.

Bleeders were controlled with bipolar cautery. Bilateral submucosal sutures of 3-0 Vicryl were used on each side of the palate at about the apex of the tonsillar fossa in order to establish the proper orientation of the palate and symmetry. The anterior and posterior pillars of the tonsillar fossae were then approximated with interrupted sutures of 3-0 Vicryl to the muscular layer followed by the same suture in a mucosal layer along the whole palatal arch. Oropharynx was then aspirated of all clot and debris. The mouth was irrigated and cleansed with suction. The procedure was then terminated. The patient tolerated the procedure well and went to the recovery room, extubated and maintaining his own airway with no prominent airway obstruction.

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Obstructive sleep apnea.

POSTOPERATIVE DIAGNOSIS:  Obstructive sleep apnea.

PROCEDURES PERFORMED:
1.  Uvulopalatopharyngoplasty.
2.  Tonsillectomy. 

SURGEON:  John Doe, MD

INDICATIONS FOR PROCEDURE:  This is a (XX)-year-old gentleman with dramatic obstructive sleep apnea with an apnea-hypopnea index of over 90 episodes per hour. He has failed CPAP and presents to undergo uvulopalatopharyngoplasty and tonsillectomy.

DESCRIPTION OF OPERATION:  The patient was taken to the operating room and put supine on the operating table and put to sleep using an oral endotracheal tube. A drape was placed and a Crowe-Davis mouth gag was inserted and suspended from the Mayo stand. Initially, the right and then the left tonsil were sequenced for grasp with an Allis clamp and dissected from the underlying constrictor muscle of the pharynx using a coagulating Bovie current. Bleeding was controlled with suction Bovie. A conservative resection of the soft palate mucosa was accomplished. Three sections of the posterior palatal mucosa were rotated anteriorly and secured with a row of interrupted 2-0 chromic sutures. The nasopharynx was examined and the airway was wide open. A Salem sump was passed, and the patient was awakened and extubated.

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Obstructive sleep apnea.
2.  Nasopharyngeal stenosis.

POSTOPERATIVE DIAGNOSES:
1. Obstructive sleep apnea.
2. Nasopharyngeal stenosis.

PROCEDURES PERFORMED:
1.  Uvulopalatopharyngoplasty.
2.  Repair of nasopharyngeal stenosis.

SURGEON:  John Doe, MD

ESTIMATED BLOOD LOSS:  Less than 50 mL.

COMPLICATIONS:  None.

ANESTHESIA:  General anesthesia.

DESCRIPTION OF PROCEDURE:  The patient was brought to the operating room, placed in the supine position, and induced and intubated per Anesthesia. The table was turned and a Crowe-Davis mouth gag atraumatically inserted into the oropharynx. There was noted to be extensive scarring of the soft palate to the posterior pharyngeal wall, making the procedure exceedingly difficult. Lidocaine 1% with 1:100,000 epinephrine was used to inject the soft palate. The soft palate was palpated to ensure no submucous clefting and to assess the degree of tissue that could be removed, minimizing the risk of velopharyngeal insufficiency. The mucosal incision was made on the anterior surface of the soft palate with removal of submucosal fibrofatty tissue with preservation of all palatal musculature, including the uvula muscle down to the base. There was extensive fibrosis and scarring making the procedure much more difficult than usual. A #15 blade was used to release the scar band between the soft palate and posterolateral pharyngeal wall, opening up the nasopharyngeal airway. Simple interrupted deep sutures were used to pull the soft palate anteriorly to further improve the velopharyngeal airway. A simple interrupted mucosal closure was performed to minimize the risk of re-stenosis. Hemostasis was obtained. The patient was returned to anesthesia care, awakened, extubated, and taken to the recovery room in good condition.

Tonsillectomy Sample Reports