OT notes · ENT

Adenoidectomy

Usual anaesthesia
General with oral endotracheal tube (preformed / reinforced) or laryngeal mask
Position
Rose position: supine, neck extended over a shoulder roll, surgeon at the head end
Setting
elective

Operative note template for adenoidectomy by curette, suction diathermy, coblation or microdebrider, with a filled example for a curettage adenoidectomy in a child with obstructive adenoid hypertrophy.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • bleeding during or after surgery, including delayed bleeding at 5 to 10 days
  • need for a nasopharyngeal pack or return to theatre for bleeding
  • nasal (hypernasal) speech from velopharyngeal insufficiency, usually temporary
  • narrowing of the nasopharynx from scarring (rare)
  • neck stiffness or torticollis (rare)
  • scarring near the Eustachian tube opening with ear problems
  • regrowth of adenoid tissue
  • dehydration from pain

Pre-operative details for this operation

  1. IndicationObstructive symptoms (snoring, mouth breathing, sleep apnoea)Otitis media with effusion / recurrent otitis mediaRecurrent adenoiditis / sinusitisSuspected neoplasm (adult)symptoms and duration
  2. Adenoid size assessmentNasal endoscopyLateral X-ray of nasopharynxClinicalgrade / percentage of choanal obstruction
  3. Cleft palate / submucous cleft excludedbifid uvula, notch in hard palate, previous cleft repair
  4. Bleeding historyfamily history, easy bruising; coagulation tests if history positive
  5. Recent throat infectiondate of last episode
  6. Weightfor drug doses in children

Anaesthesia and position

  1. AnaesthesiaGeneral, oral preformed / reinforced tubeGeneral, laryngeal mask
  2. PositionRose position with shoulder roll
  3. Mouth gagBoyle-DavisCrowe-DavisMcGyver (McIvor)
  4. Palate retractionNelaton catheter through the noseNot usedcatheter size
  5. VisualisationLaryngeal mirror and headlightEndoscope 0 / 45 degree

Operative findings

  1. Palate on palpationIntact, no submucous cleftSubmucous cleft suspected
  2. Adenoid sizepercentage of choana blocked; relation to Eustachian tube openings
  3. Adenoid appearanceinfected, pus, bleeding tendency
  4. Choanae clear at endYesResidual tissue left (reason)

Procedure (steps)

  1. TechniqueCurettageSuction diathermyCoblationMicrodebriderPartial (upper) adenoidectomy
  2. Palate inspected and palpatedto exclude submucous cleft before removing adenoids
  3. Soft palate retractedNelaton catheter through the nose, clamped outside the mouth
  4. Nasopharynx seenmirror or endoscope; torus tubarius, fossa of Rosenmuller and vomer identified
  5. Adenoids removedcurette size and number of sweeps / diathermy power / coblation wand and settings / blade used
  6. Nasopharyngeal packtonsil sponge, time kept in
  7. Residual tissue and haemostasisBipolar diathermySuction diathermyPressure packSilver nitratepower setting; cautery kept away from Eustachian tube openings
  8. Nasopharynx irrigated and suctioned
  9. Other procedures in same sittingNoneTonsillectomyMyringotomy / grommet

Closure, drains and dressing

  1. Nasopharynx checked dry before removing the gag
  2. All sponges / packs removedcount confirmed
  3. Catheter and mouth gag removed
  4. Oral cavity and palate checked

Specimens and implants

  1. Adenoid tissueSent for HPENot sentalways send in adults (to exclude lymphoma) or if appearance is unusual

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Watch for bleedingblood from nose or mouth, repeated swallowing, rising pulse; young children may not report it
  2. Airway and oxygen saturationcloser watch if under 3 years or sleep apnoea
  3. Oral fluids and dietfluids when awake, normal diet as tolerated
  4. Analgesiadrug, dose (mg/kg), frequency
  5. Antibioticif prescribed: drug, dose, duration
  6. Discharge criteriano bleeding, taking fluids, after 2 to 4 hours of observation; overnight stay if under 3 years, sleep apnoea or medical problems
  7. Advicestay home from school 1 to 2 weeks, no swimming for 2 to 3 weeks, return at once for any bleeding
  8. Follow-update; hearing test if done for middle ear disease

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Master A.K., 6 years, 20 kg, loud snoring with pauses, mouth breathing and hyponasal speech for 1 year. Nasal endoscopy: adenoids blocking about 80% of the choanae. Tonsils small.

Case details

Date: 14/09/2026. Elective. ENT OT.

Induction 10:00. Start 10:10. End 10:30.

Surgeon: Dr A. (2nd-year resident, ENT). Assistant: Dr B. Consultant: Dr C., present. Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Indication: obstructive adenoid hypertrophy with snoring and witnessed pauses in sleep.

No cleft or bifid uvula. No family history of bleeding or easy bruising. Last sore throat 2 months ago.

Consent: general, procedure-specific (bleeding, nasal speech, regrowth) and anaesthesia consent from father, in Gujarati.

WHO checklist done. Inj cefazolin 600 mg IV and inj metronidazole 300 mg IV at 09:55.

Anaesthesia and position

General anaesthesia with oral preformed endotracheal tube.

Rose position with shoulder roll. Boyle-Davis mouth gag inserted and suspended.

Procedure

Palate inspected and palpated: intact, no submucous cleft.

10 Ch Nelaton catheter passed through the right nostril, brought out through the mouth and clamped to retract the soft palate.

Nasopharynx seen with a No. 5 laryngeal mirror and headlight. Adenoids large, filling about 80% of the choanae, reaching the torus tubarius on both sides.

Curettage adenoidectomy with a medium-size adenoid curette placed against the septum and swept down to the posterior pharyngeal wall. Two sweeps. Small lateral tags removed with a smaller curette.

Tonsil sponge packed in the nasopharynx for 5 minutes.

Pack removed, nasopharynx irrigated with normal saline and suctioned. Residual tissue and two bleeding points coagulated with bipolar diathermy at 30 W under mirror view, keeping away from the Eustachian tube openings.

Findings at end: choanae clear, nasopharynx dry.

Closure

Nasopharynx checked again: dry. Sponge count correct. Nelaton catheter and mouth gag removed. Oral cavity and palate checked.

End of procedure

Estimated blood loss 30 ml. No transfusion.

No intra-operative complications.

Specimen: adenoid tissue in formalin for HPE.

Extubated awake. Shifted to recovery. Pulse 104/min, SpO2 99% on room air.

Post-op orders

SpO2 monitoring and observation for bleeding from nose or mouth. Inform ENT resident at once if bleeding.

Oral fluids once awake, then normal diet as tolerated.

Analgesia as per drug chart (weight 20 kg).

Discharge after 4 hours if no bleeding and taking fluids.

Parents told in Gujarati: no school for 1 week, no swimming for 3 weeks, come back at once for any bleeding from nose or mouth.

ENT OPD review in 1 week with HPE report.

Signature

Dr A., JR-2, ENT. Reg. no. ________. 14/09/2026, 10:45.

Must document for this operation

  • Palate checked for a submucous cleft before removal. Adenoidectomy in a child with a submucous cleft can cause hypernasal speech, and the note must show the check was done.
  • Technique and instruments used (curette size, diathermy power, coblation, microdebrider). Bleeding, scarring and regrowth differ by technique, and a redo surgeon needs to know.
  • How haemostasis was achieved and that the nasopharynx was dry at the end. Bleeding is the main risk, and young children may swallow blood without anyone noticing.
  • That cautery was kept away from the Eustachian tube openings. Scarring there can cause Eustachian tube dysfunction, which may be blamed on the operation later.
  • All packs and sponges removed. A retained nasopharyngeal sponge can block the airway after extubation.
  • Drug doses in mg/kg with the child's weight. Paediatric doses are checked against weight in any drug audit.

Common mistakes in these notes

  • Writing 'adenoidectomy done' with no technique or instrument size.
  • No record that the palate was palpated for a submucous cleft.
  • Not recording removal of the nasopharyngeal sponge.
  • Writing antibiotic doses in the child without the weight.
  • No written advice to parents about delayed bleeding and when to return.

Indian practice and paperwork

  • NABH expects the operative note to be written before the patient leaves recovery, and post-op care to follow a written plan. Day-care adenoidectomy still needs the full note before discharge from recovery. (NABH 5th ed., COP.14(e) and (f))
  • Adenoid tissue not sent for HPE is human anatomical waste for the yellow bag. Formalin discarded from specimen jars is yellow (f) chemical waste. (Bio-Medical Waste Management Rules 2016, CPCB guidelines)

Sources

  • Hathiram BT, Khattar VS, eds. Atlas of Operative Otorhinolaryngology and Head and Neck Surgery. Vol 2: Rhinology and Anterior Skull Base. Jaypee Brothers, Ch 63, The Surgical Technique of Adenoidectomy (Lesinskas E), pp. 563-568.
  • Hathiram BT, Khattar VS, eds. Atlas of Operative Otorhinolaryngology and Head and Neck Surgery. Vol 2: Rhinology and Anterior Skull Base. Jaypee Brothers, Ch 64, Adenoidectomy (Yuksel A, Ark N), pp. 569-571.
  • Hathiram BT, Khattar VS, eds. Atlas of Operative Otorhinolaryngology and Head and Neck Surgery. Vol 5: Head and Neck Surgery. Jaypee Brothers, Ch 153, Coblation-Assisted Procedures for Snoring and Sleep Apnea (Agrawal V): coblation adenoidectomy; Boyle-Davis gag, pp. 1353-1354.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Adenoidectomy is a clean-contaminated head and neck procedure; Table 2 (other clean-contaminated procedures except tonsillectomy and FESS): cefazolin or cefuroxime plus metronidazole, or ampicillin-sulbactam. Table 1 paediatric doses: cefazolin 30 mg/kg, metronidazole 15 mg/kg, not above the adult dose; within 60 min before incision. academic.oup.com/ajhp/article/70/3/195/5112717

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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