OT notes · ENT

Cortical (simple / canal-wall-up) mastoidectomy

Usual anaesthesia
General anaesthesia with endotracheal intubation (local anaesthesia possible in cooperative adults)
Position
Supine, head on a ring and turned fully to the opposite side
Setting
elective

Operative note template for cortical (simple) mastoidectomy, with a filled example for a child with acute coalescent mastoiditis and a subperiosteal abscess not settling on IV antibiotics.

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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

  • facial nerve weakness or paralysis
  • hearing loss, from injury to the incus or inner ear
  • giddiness from injury to the lateral semicircular canal
  • injury to the dura with CSF leak or meningitis
  • bleeding from the sigmoid (lateral) sinus
  • persistent discharge needing a second operation
  • wound infection, haematoma, scar
  • narrowing of the ear canal

Pre-operative details for this operation

  1. SideRightLeft
  2. IndicationAcute mastoiditis not settling on antibioticsSubperiosteal / postaural abscessIntracranial complicationPersistent discharge 3 to 4 weeks after onsetRefractory secretory otitis mediaApproach for another procedure
  3. Facial nerve function before surgeryNormalWeakness: describe and grademust be recorded before the operation
  4. CNS examinationneck stiffness, focal signs, if intracranial spread suspected
  5. Ear swab for cultureSentNo discharge
  6. ImagingX-ray mastoid or CT temporal bone: pneumatisation, dura and sinus position, abscess
  7. Hearing testpure tone audiogram as baseline if possible
  8. Blood countHb, total count for later comparison
  9. Antibiotics started before surgerydrug, dose, since when; CSF-penetrating agent if intracranial complication
  10. HairTaped awayShaved 2 to 3 cm behind and above the pinna

Anaesthesia and position

  1. AnaesthesiaGeneral, endotracheal tubeLocal (adult)
  2. PositionSupine, head on ring, turned to opposite side
  3. Microscope / drillmicroscope used for cells near the facial nerve; drill or gouge and hammer

Operative findings

  1. Subperiosteal abscesspresent / absent; volume of pus; bone erosion (fistula) over the mastoid
  2. Mastoid pneumatisationWell pneumatisedDiploicSclerotic
  3. Contents of cells and antrumpus, granulations (colour: pale granulations raise suspicion of TB), cholesteatoma (if found, the plan changes)
  4. Tegmen (dural plate) and sinus plateintact / eroded; dura or sinus exposed, granulations or extradural pus
  5. Adituspatent / blocked by oedema or granulations; incus seen and undisturbed
  6. Posterior canal wallIntact

Procedure (steps)

  1. Skin incisionPostaural (Wilde), 3 to 5 mm behind the postaural grooveHorizontal / upper-half incision in child under 2 yearsin infants the facial nerve is superficial at the lower end
  2. PeriosteumT-shaped incision; elevated forward to the bony canal, up to the level of the upper attachment of the pinna; temporalis preserved
  3. Self-retaining retractore.g. Mollison; bleeding points secured
  4. Landmarks identifiedMacEwen's (suprameatal) triangle: supramastoid crest above, posterosuperior meatal wall in front
  5. Cortex removed to reach the antrumDrill (burr type and size)Gouge and hammerantrum about 15 mm deep in adults, only a few mm in infants
  6. Antrum confirmedfine probe passed gently into the aditus without touching the incus
  7. Air cells exenteratedlimits reached: tegmen above, sinus plate behind, sinodural angle, tip, bony canal in front, perifacial cells under microscope
  8. Aditus widenedYes: fine curette / burrNot neededcare not to dislodge the incus
  9. Dura / sinus exposedNot exposedExposed deliberately (intracranial complication): extent
  10. Cavity irrigated and haemostasisany sinus bleeding and how controlled (e.g. gelatin sponge and pressure)

Closure, drains and dressing

  1. DrainSmall drain into antrum, out near tipNone
  2. Wound closurelayers; suture material and size; interrupted skin sutures
  3. DressingFirm mastoid pressure dressing
  4. Ear canalwick / nothing

Specimens and implants

  1. Pus / swab for culture and sensitivitySentNot sent
  2. Granulations for HPESent (reason, e.g. suspected TB)Not sent
  3. 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. Facial movementscheck as soon as awake; call surgeon at once if weak
  2. Temperature4-hourly
  3. Antibioticscontinue: drug, dose, route; review with culture
  4. Decongestantssystemic and nasal, drug and dose
  5. Drain removalwhen discharge stops, usually 48 hours to 3 days
  6. Dressingkeep mastoid dressing on; check for haematoma
  7. Giddiness, vomiting, headache, neck stiffnessreport at once
  8. Suture removalday 5 to 7
  9. Audiogramonce the ear is dry

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 V.P., 9 years, 28 kg, right acute otitis media for 10 days, now right postaural fluctuant swelling pushing the pinna forward, fever persisting after 72 hours of IV antibiotics; facial movement normal.

Case details

Date: 23/09/2026. Urgent right cortical mastoidectomy. OT 4.

Induction 09:10. Incision 09:32. Closure completed 10:40.

Surgeon: Dr C. (consultant, ENT). Assistant: Dr A. (2nd-year resident), who did the incision, periosteal elevation and closure.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Right acute coalescent mastoiditis with subperiosteal abscess. Not settling after 72 hours of IV ceftriaxone as charted.

Facial nerve: normal movement both sides. No neck stiffness or focal signs.

CT temporal bone: right mastoid cells coalescent, cortical erosion over the mastoid with subperiosteal collection, tegmen and sinus plate intact, no intracranial collection.

Ear swab sent 3 days ago: no growth. Hb 11.2 g/dl, TLC 16,800/cu mm. Audiogram not possible (unwell child).

Consent: general, procedure-specific and anaesthesia consent from mother in Marathi. Facial palsy, hearing loss, giddiness, CSF leak, sinus bleed and need for further surgery explained.

Hair shaved 2 cm behind the right ear. Side marked. WHO checklist sign in and time out done. IV antibiotic dose due was given at induction, as charted.

Anaesthesia and position

General anaesthesia with endotracheal tube. Supine, head on a ring, turned to the left. Parts painted with povidone-iodine and draped. Operating microscope and drill ready.

Procedure and findings

Right postaural (Wilde) incision 4 mm behind the postaural groove. On deepening, 6 ml of thick pus under the periosteum; sent for culture. Small cortical fistula over MacEwen's triangle.

T-shaped periosteal incision, periosteum elevated forward to the bony canal and upward to the level of the pinna attachment. Temporalis not cut. Mollison retractor placed.

Cortex removed with a cutting burr over MacEwen's triangle. Mastoid well pneumatised; cells full of pus and oedematous red granulations. Antrum reached at about 12 mm. Fine probe passed gently into the aditus: aditus blocked by oedematous mucosa, cleared with a fine curette. Incus seen and not touched.

All cells exenterated under the microscope: tegmen above, sinus plate behind, sinodural angle cleared, tip cells cleared, bony canal in front. Tegmen and sinus plate intact, dura and sinus not exposed. Posterior canal wall intact.

Cavity irrigated with saline. Bleeding points secured. No sinus bleed.

Closure

Small drain placed into the antrum and brought out near the mastoid tip. Wound closed in layers: periosteum with absorbable sutures, skin with interrupted sutures (material and size as used).

Firm mastoid pressure dressing. Nothing in the ear canal.

End of procedure

Estimated blood loss 60 ml. No transfusion.

Mop, needle and instrument count correct, confirmed by scrub nurse.

No intra-operative complications.

Specimens: subperiosteal pus for culture and sensitivity; granulations sent for HPE.

Face moving normally on both sides after extubation. Shifted to recovery awake. Pulse 108/min, BP 102/64 mmHg.

Post-op orders

Check facial movements on waking and 4-hourly. Call ENT resident on call at once if any weakness.

Temperature 4-hourly.

Continue IV antibiotics as charted; review with culture report.

Nasal decongestant drops as charted.

Remove drain when discharge stops, usually day 2 or 3.

Report giddiness, vomiting, headache or neck stiffness.

Suture removal day 7. Audiogram when the ear is dry.

Signature

Dr A., JR-2, ENT, for Dr C. Reg. no. ________. 23/09/2026, 10:55.

Must document for this operation

  • Facial nerve function before and after the operation. A palsy present immediately after surgery but not before means the nerve was injured and the mastoid must be re-explored, so the pre-op state must be on record.
  • State of the tegmen and sinus plate, and whether dura or sinus was exposed. This guides the ward team if the child develops headache, fever or neck stiffness, and the next surgeon if a revision is needed.
  • That the posterior bony canal wall was kept intact. It separates a cortical mastoidectomy from a canal-wall-down operation, and taking it down can cause meatal stenosis.
  • Aditus findings and whether the incus was touched. Incus dislocation is the usual cause of conductive hearing loss after this operation.
  • Contents of the cells, including cholesteatoma or pale granulations. Cholesteatoma is a contraindication to this operation, and pale granulations should raise suspicion of tuberculosis, so the pathologist needs to know.
  • Drain type and where it exits. Nurses must know what to remove and when; it usually comes out after 2 to 3 days.

Common mistakes in these notes

  • No record of facial nerve function before surgery.
  • Writing 'mastoid cleared' without saying which limits were reached (tegmen, sinus plate, tip, sinodural angle).
  • Not stating whether the posterior canal wall was preserved.
  • Forgetting to record culture and HPE samples sent.
  • Not naming which parts the resident did when the consultant was the main surgeon.

Indian practice and paperwork

  • NABH expects the operative note before the patient leaves recovery and post-op care to follow a written plan. (NABH 5th ed., COP.14(e) and (f))
  • Granulation 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)
  • In a teaching hospital, write which significant steps were done by the resident (for example opening and closure), as the CMS and Joint Commission op-note standards require. (CMS State Operations Manual Appendix A, tag A-0959; TJC RC.12.01.03)

Sources

  • Ballantyne JC, Morrison A, eds. Rob & Smith's Operative Surgery: Ear. 4th ed. Butterworths; 1986, Cortical mastoidectomy (Ransome J), pp. 67-71.
  • Tuli BS, Tuli IP, Singh A, Tuli NK. Textbook of Ear, Nose and Throat. 2nd ed. Jaypee Brothers; 2013, Ch 66, Mastoidectomy, pp. 436-439.

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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