OT notes · ENT

Tonsillectomy

Usual anaesthesia
General with endotracheal intubation
Position
Supine, head low, neck extended with mouth gag
Setting
elective

Operative note template for tonsillectomy by cold steel, bipolar or coblation dissection, with a filled example for a cold steel dissection tonsillectomy in an adult with recurrent tonsillitis.

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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 in the first 24 hours (primary) or around day 5 to 8 (secondary), which may need return to theatre
  • blood transfusion (rare)
  • throat pain and difficulty swallowing
  • dehydration from painful swallowing
  • low oxygen levels after surgery, more in sleep apnoea
  • re-admission for pain or bleeding
  • residual tonsil tissue (after intracapsular technique)

Pre-operative details for this operation

  1. IndicationRecurrent tonsillitisObstructive sleep apnoea / sleep-disordered breathingPeritonsillar abscess (quinsy): interval / hotSuspected neoplasm (asymmetry)Othernumber of episodes per year, or sleep study result
  2. Bleeding historyeasy bruising, prolonged bleeding after cuts or extractions, family history
  3. Coagulation testsAPTT, INR, platelet count and date
  4. Aspirin / NSAIDs stoppedstopped at least 7 days before; date of last dose
  5. Blood groupknown before surgery

Anaesthesia and position

  1. AnaesthesiaGeneral, nasotracheal tubeGeneral, oral tubetube size
  2. PositionSupine, head low, neck extended
  3. Mouth gagBoyle-DavisOtherblade size

Operative findings

  1. Tonsil size and appearancegrade, symmetry, crypts, pus, scarring or adhesions (after quinsy)
  2. Adenoids (if checked)size, removed or not
  3. Abnormal findingsany mass, ulcer or asymmetry that needs HPE

Procedure (steps)

  1. TechniqueCold steel (blunt) dissectionBipolar diathermy dissectionMonopolar diathermy dissectionCoblationIntracapsular (tonsillotomy)
  2. Tonsil grasped and retracted mediallytonsil holding forceps
  3. Mucosa of anterior and posterior pillars incisedinstrument used
  4. Tonsil separated from superior constrictortonsil elevator / bipolar / coblation wand; plane followed to the lower pole
  5. Lower poleTonsil loop / snareScissorsDiathermyCoblation
  6. Coblation settings (if used)wand type, ablation and coagulation settings
  7. Fossa packedswab pressure, time
  8. HaemostasisBipolar diathermySuction diathermy / monopolarCoblation coagulationTies or suture ligationsuture used for ties (e.g. polyglactin 910 4-0); number of bleeding points
  9. Both fossae and pillars inspected dryanterior and posterior pillars retracted to check
  10. Same steps on the other side
  11. Adenoidectomy (if done)see adenoidectomy note

Closure, drains and dressing

  1. Final check for bleedingboth fossae and pillars inspected before the gag is removed
  2. Oropharynx suctioned, clots removed
  3. Mouth gag removed

Specimens and implants

  1. TonsilsBoth sent for HPE, labelled right and leftNot sent (unit policy)always send if asymmetry or suspicion of neoplasm

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 primary haemorrhage (first 24 hours)pulse, BP, blood in the mouth, repeated swallowing, vomiting blood; inform surgeon at once
  2. Oxygen saturationmonitor, more closely in sleep apnoea
  3. Oral fluids and dietstart when awake; encourage fluids to avoid dehydration
  4. Analgesiadrug, dose, frequency
  5. Antibioticsnot routine after tonsillectomy
  6. Discharge advice on secondary haemorrhagereturn at once for any bleeding, especially between day 5 and 8
  7. Follow-update; HPE report

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: Ms. P.N., 22 years, 7 episodes of acute tonsillitis in the last year, each needing antibiotics. No bleeding history.

Case details

Date: 09/08/2026. Elective. ENT OT.

Induction 09:05. Start 09:20. End 09:55.

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: recurrent acute tonsillitis, 7 episodes in 12 months.

APTT, INR and platelet count normal (06/08/2026). No aspirin or NSAID in the last 2 weeks. Blood group O positive.

Consent: general, procedure-specific (including primary and secondary haemorrhage) and anaesthesia consent taken in Kannada.

WHO checklist done. No antibiotic prophylaxis (not recommended for tonsillectomy).

Anaesthesia and position

General anaesthesia with nasotracheal tube size 6.5.

Supine, head low with neck extended. Boyle-Davis mouth gag inserted.

Findings

Both tonsils grade 2, symmetrical, with debris in crypts. No mass or ulcer. Adenoids not examined.

Procedure

Technique: cold steel dissection, bilateral.

Right tonsil held with tonsil forceps and pulled medially. Mucosa of the anterior and posterior pillars incised with a scalpel. Tonsil separated from the superior constrictor with a tonsil elevator down to the lower pole. Lower pole cut with a tonsil loop.

Fossa packed with a swab for 3 minutes. Two bleeding points coagulated with bipolar diathermy. One bleeding vessel at the lower pole tied with polyglactin 910 (Vicryl) 4-0.

Left tonsil removed the same way. Three bleeding points coagulated with bipolar diathermy. No ties.

Both fossae and pillars inspected after retracting the pillars: dry.

Closure

Both fossae and pillars checked again: dry. Oropharynx and nasopharynx suctioned. Mouth gag removed.

End of procedure

Estimated blood loss 40 ml. No transfusion.

Mop and instrument count correct.

No intra-operative complications.

Specimen: right and left tonsils in separate labelled formalin bottles for HPE.

Extubated awake, shifted to recovery. Pulse 86/min, BP 118/74 mmHg, SpO2 98% on room air.

Post-op orders

Pulse, BP and SpO2 monitoring in recovery, then regularly on the ward for 24 hours.

Look for blood in the mouth, frequent swallowing or vomiting of blood. Inform ENT resident on call at once.

Oral fluids once fully awake, then soft diet. Encourage fluids.

Analgesia as per drug chart. No antibiotics.

Discharge next morning if no bleeding and taking orally. Advised in Kannada to return at once for any bleeding, especially between day 5 and day 8.

ENT OPD review on day 7 with HPE report.

Signature

Dr A., JR-2, ENT. Reg. no. ________. 09/08/2026, 10:10.

Must document for this operation

  • Technique used (cold steel, bipolar, monopolar, coblation, intracapsular). Secondary bleeding rates differ by technique, so audits of post-tonsillectomy haemorrhage need it.
  • How haemostasis was achieved on each side, and any ties. If the patient bleeds, the surgeon returning to theatre needs to know what was done on which side.
  • Both fossae seen dry at the end, including after releasing the gag. Primary haemorrhage is the main early risk, and this line shows the check was made.
  • Bleeding history, coagulation tests and stopping of aspirin or NSAIDs. These are the first things reviewed if the patient bleeds.
  • Specimens sent and their labelling by side. If HPE shows a tumour, the side must be known.

Common mistakes in these notes

  • Writing 'B/L tonsillectomy done, haemostasis achieved' with no technique or method of haemostasis.
  • Not recording that aspirin or NSAIDs were stopped and that coagulation tests were checked.
  • No written advice to the patient about secondary haemorrhage in the first week.
  • Sending both tonsils in one bottle with no side label when an asymmetric tonsil was the indication.
  • Not saying on which side a tie or extra bleeding point was.

Indian practice and paperwork

  • Under AB PM-JAY (HBP 2022) tonsillectomy (unilateral or bilateral) is package SL016A. The note should state the side(s) and anaesthesia so that it matches the booked package. (SACHIS (Gujarat SHA) HBP-2022 package master; NHA HBP 2.2 User Guidelines (Nov 2021))
  • NABH expects the operative note to be written before the patient leaves recovery, and post-op care to follow a written plan. (NABH 5th ed., COP.14(e) and (f))
  • Tonsils not sent for HPE are 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 5: Head and Neck Surgery. Jaypee Brothers, Ch 149, The Surgical Technique of Tonsillectomy (Zagolski O, Nyzio J), pp. 1327-1330.
  • 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 tonsillectomy and tonsillotomy, pp. 1353.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Head and neck procedures: antimicrobial prophylaxis has not been shown to benefit patients undergoing tonsillectomy (Table 2 excludes tonsillectomy from clean-contaminated prophylaxis). 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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