OT notes · ENT

Incision and drainage of peritonsillar abscess (quinsy)

Usual anaesthesia
Adults: topical spray with local infiltration, or no anaesthetic; children: general anaesthesia in the tonsillectomy position with suction ready
Position
Sitting upright, or head end raised to at least 60 degrees with the head supported
Setting
emergency

Operative note template for needle aspiration and incision and drainage of a peritonsillar abscess, with a filled example for an adult left-sided quinsy drained under topical and local anaesthesia in the sitting position.

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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 from the incision
  • injury to the carotid artery (rare)
  • inhaling or swallowing pus or blood
  • pain during the incision
  • no pus found, or need for a repeat aspiration or incision
  • recurrence of the abscess
  • spread to the parapharyngeal space or airway swelling
  • later tonsillectomy may be advised

Pre-operative details for this operation

  1. SideRightLeft
  2. Duration of sore throat and trismusdays; mouth opening in finger-breadths or mm
  3. Signs of pusred oedematous anterior pillar hiding the tonsil, yellow point, uvula pushed across, marked trismus
  4. Antibiotic course so fardrug, route, since when; phlegmon not settling after 48 hours
  5. Airway assessmentNo stridor, speaking in full sentencesStridor or drooling: senior and anaesthetist informed
  6. Ultrasound doneYes: collection seen, carotid position notedNot done
  7. Suction set up and working before startingYes

Anaesthesia and position

  1. AnaesthesiaTopical spray + local infiltrationTopical onlyNoneGeneral (child)drug, strength, volume infiltrated
  2. PositionSitting upright, head supportedHead end raised 60 degreesTonsillectomy position (under GA)
  3. ExposureTongue depressor and headlightLaryngoscope blade (Macintosh 3 or 4) held by patient

Operative findings

  1. Site of maximum bulge or fluctuationUpper poleMiddleLower pole
  2. Uvula and soft palateuvula deviated to which side, palatal oedema
  3. Aspiratepus yes/no, volume in ml, colour, smell; which pass (upper, middle, lower pole) gave pus
  4. Pus drained on incisionapproximate volume, loculi broken
  5. Tonsil itselfnot entered / entered (bleeding)

Procedure (steps)

  1. Topical anaesthesiaspray or gel, site
  2. Local infiltration1% lignocaine with adrenaline, 1 to 2 ml, blanching seen
  3. Palpation for fluctuationgloved finger; where the pus was felt
  4. Needle aspirationUpper pole firstThen 1 cm lower (middle)Then 1 cm lower again (lower pole)18 to 20 G needle on 10 to 20 ml syringe, needle cover cut to leave about 1 cm exposed as a depth guard; needle kept straight, not angled laterally
  5. Site of incisionPoint of aspiration / thinnest mucosaClassical site: horizontal line through the base of the uvula meets a vertical line from the junction of the anterior pillar with the base of the tongue
  6. IncisionNo. 11 or 15 blade taped so only 0.5 cm of the tip is exposed; small stab
  7. Cavity openedQuinsy forceps advanced about 13 mm and openedCurved artery (Kelly) forceps opened gentlyloculi broken
  8. Suction of puscontinuous suction so pus is not swallowed or inhaled
  9. Saline gargle and spitDoneNot possible (GA)
  10. Cavity packedNot packedthe abscess cavity is not packed
  11. Abscess tonsillectomy doneNoYes: separate consent, reason

Closure, drains and dressing

  1. IncisionLeft open to drain
  2. Bleeding at endMinimal, stoppedOozing: pressure applied
  3. Airway and swallowing at endspeaking, swallowing saliva, trismus change

Specimens and implants

  1. Pus sent for culture and sensitivityYesNo
  2. ImplantsNone

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. Observation for bleeding2 to 4 hours after the procedure before discharge or transfer
  2. Airway watchstridor, drooling, increasing neck swelling: call ENT on call at once
  3. Antibioticscontinue or restart after drainage: drug, dose, route, duration
  4. Gargleswarm saline gargles
  5. Oral intakeliquids when comfortable; admit if cannot swallow fluids or oral medicines
  6. Analgesiadrug, dose, frequency
  7. Reviewwithin 24 hours if sent home; repeat drainage if pus reaccumulates
  8. Interval tonsillectomyif planned, 4 to 9 weeks after the acute illness settles

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: Mr. S.K., 26 years, 5 days of sore throat, 2 days of trismus and muffled voice, left peritonsillar bulge not settling after 48 hours of IV antibiotics.

Case details

Date: 18/07/2026. Emergency procedure. ENT minor OT.

Start 16:40. End 16:58.

Operator: Dr A. (2nd-year resident, ENT). Assistant: Dr B. (1st-year resident). Consultant Dr C. informed and available.

Nurse: Sr E. No anaesthetist (topical and local anaesthesia by operator).

Indication and pre-op

Left peritonsillar abscess. Left anterior pillar red and oedematous, tonsil hidden, uvula pushed to the right, soft yellow point above the upper pole. Mouth opening 2 finger-breadths.

On IV amoxicillin-clavulanate for 48 hours as charted, no improvement.

No stridor, speaking in sentences, SpO2 98% on air.

Consent: written consent for aspiration and incision taken in Marathi after explaining bleeding, rare carotid injury, recurrence and possible later tonsillectomy.

WHO checklist time out done: patient, side (left) and procedure confirmed. Suction checked and working.

Anaesthesia and position

Sitting upright on the procedure chair, head supported against the head rest.

Topical lignocaine spray to the left soft palate. 1% lignocaine with adrenaline 1.5 ml infiltrated over the bulge with a 27 G needle. Blanching seen.

Procedure

Tongue held down with a tongue depressor, headlight used. Fluctuation felt at the upper pole.

Needle aspiration with 18 G needle on a 20 ml syringe, needle cover cut to leave about 1 cm of needle exposed. Needle passed straight back at the upper pole, not angled laterally: 4 ml of thick yellow foul-smelling pus aspirated.

Stab incision at the point of aspiration with a No. 11 blade taped to leave 0.5 cm of the tip exposed.

Cavity opened with curved artery forceps and loculi broken gently. About 5 ml more pus drained and sucked out. Tonsil not entered.

Patient gargled with warm saline and spat. Cavity not packed.

End of procedure

Incision left open. Minimal bleeding, stopped by itself. Blood loss about 5 ml.

Sharps count: needles and blade accounted for.

Pus sent for culture and sensitivity. No other specimen.

No complications. Patient says swallowing is easier; mouth opening improved to 3 finger-breadths.

Shifted to ENT ward in stable condition. Pulse 92/min, BP 124/78 mmHg.

Post-op orders

Observe for bleeding and airway for 4 hours. Call ENT resident on call for fresh bleeding, stridor or neck swelling.

Continue IV amoxicillin-clavulanate as charted; review with culture report.

Warm saline gargles 4 to 6 times a day. Liquids when comfortable, then soft diet.

Analgesia as per drug chart.

Review in the morning round. Repeat aspiration if the bulge returns.

Discuss interval tonsillectomy at follow-up, 4 to 9 weeks after recovery.

Signature

Dr A., JR-2, ENT. Reg. no. ________. 18/07/2026, 17:10.

Must document for this operation

  • Side, and the signs that pointed to pus rather than a phlegmon. A phlegmon is treated with antibiotics alone, so the note must show why drainage was needed.
  • Which pass gave pus (upper, middle or lower pole) and the volume. A 'dry tap' changes the next step, and the volume tells the next doctor whether it was adequately drained.
  • The depth guard on the needle or blade, and that the needle was not angled laterally. The carotid artery lies about 2.5 cm posterolateral to the tonsil, so this is the main safety step if a vascular injury is later alleged.
  • Airway status before and after the procedure. Airway swelling is the danger in quinsy, and a recorded baseline lets the ward staff see deterioration.
  • Whether the cavity was packed and whether the tonsil was entered. Packing is not advised, and entering the tonsil explains any later bleeding.
  • Pus sent for culture and the antibiotic plan after drainage. Antibiotics are continued or restarted after drainage, and the culture guides a change if fever persists.

Common mistakes in these notes

  • Writing 'I&D done' with no side, site or volume of pus.
  • Not recording the airway before and after drainage.
  • Leaving out the needle or blade guard, which is the step that protects the carotid.
  • No record of culture sent or of the antibiotic plan after drainage.
  • Not noting the advice about interval tonsillectomy, so the patient is lost to follow-up.

Indian practice and paperwork

  • NABH requires written consent before any invasive procedure, in a language the patient understands, so a bedside quinsy drainage still needs a signed consent in the case sheet. (NABH 5th ed., PRE.2(g) and PRE.4(c))
  • Soiled swabs and tissue go by the Bio-Medical Waste rules; human tissue not sent for testing is yellow category (a) waste. (Bio-Medical Waste Management Rules 2016, CPCB guidelines)
  • An abscess tonsillectomy added at the same sitting needs its own consent. An extra procedure without consent is defensible only when it was needed to save life or health (Samira Kohli v. Dr Prabha Manchanda, Supreme Court, 2008). ((2008) 2 SCC 1)

Sources

  • Ballantyne JC, Harrison DFN, eds. Rob & Smith's Operative Surgery: Nose and Throat. 4th ed. Butterworths; 1986, Surgery of quinsy (peritonsillar abscess) (Ballantyne J), pp. 201-202.
  • Ganti L, ed. Atlas of Emergency Medicine Procedures. 2nd ed. Springer Nature; 2022, Ch 66, Incision and drainage of peritonsillar abscess (Fernandez MW, Desai BK), pp. 329-332.

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.

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