OT notes · ENT

Modified radical mastoidectomy

Usual anaesthesia
General anaesthesia with controlled hypotension
Position
Supine, head turned to the opposite side, operated ear up
Setting
elective

Operative note template for modified radical (canal wall down) mastoidectomy, with a filled example for attic cholesteatoma operated by the postaural route under general anaesthesia.

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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
  • sensorineural hearing loss or dead ear
  • giddiness, labyrinthine fistula
  • altered taste from chorda tympani division
  • cerebrospinal fluid leak or dural injury
  • bleeding from sigmoid sinus or jugular bulb
  • infection, perichondritis of the pinna
  • residual or recurrent cholesteatoma needing revision
  • discharging cavity needing lifelong cleaning and water precautions
  • hearing may not improve

Pre-operative details for this operation

  1. SideRight earLeft earwrite the side in full; match with consent, CT and site mark
  2. IndicationCholesteatoma (attic / posterosuperior)Cholesteatoma with complicationFailed canal wall up surgeryOtherotoscopy / microscopy findings
  3. Pure tone audiogram both earsdate; air-bone gap; is this the only hearing ear?
  4. Fistula testNegativePositiveespecially if history of vertigo
  5. Facial nerve function before surgeryNormalWeak (grade)
  6. HRCT temporal bonedate; extent; tegmen, lateral semicircular canal, facial canal, sigmoid sinus position
  7. Pre-op topical treatment of active dischargeGivenEar dry
  8. SmokingNon-smokerSmoker: advised to stop

Anaesthesia and position

  1. AnaesthesiaGeneral with controlled hypotensionif a facial nerve monitor is used, avoid agents that block it
  2. Infiltration2% lignocaine with adrenaline 1:100,000, volume; postaural line and canal; 10 to 15 min before incision
  3. Facial nerve monitorUsedNot used
  4. PositionSupine, head turned away, operated ear up

Operative findings

  1. Cholesteatoma extentattic, antrum, mastoid, mesotympanum, sinus tympani, Eustachian tube
  2. MastoidScleroticDiploicPneumatised
  3. Ossiclesmalleus, incus (long process), stapes suprastructure: intact / eroded / absent
  4. Facial nerveCanal intactDehiscent (segment)Exposed by disease
  5. Lateral semicircular canalIntactFistula (size, matrix left or removed)
  6. Tegmen and duraIntactEroded / dura exposed (size)
  7. Sigmoid sinus and jugular bulbNot exposedExposedHigh jugular bulb

Procedure (steps)

  1. IncisionPostauralEndauralpostaural: helix to mastoid tip, about 1 cm behind the crease
  2. Graft harvestedTemporalis fasciaAreolar fasciaTragal / conchal cartilage
  3. Periosteal flapsT-shaped incision; suprameatal spine and tympanomastoid fissure exposed
  4. Mastoid cortex drilled, antrum openedalong linea temporalis; tegmen, Korner's septum, lateral semicircular canal identified; cutting then diamond burrs with irrigation
  5. Attic opened, cholesteatoma followedsac removed intact or opened and debulked
  6. Incudostapedial joint separated, incus and malleus head removedDoneAlready eroded
  7. Posterior canal wall taken down, facial ridge lowereddiamond burr, strokes parallel to the facial nerve; chorda divided or preserved
  8. Fistula check over lateral semicircular canalmatrix removed and plugged, or matrix left
  9. Mastoid tip cells exenterated, cavity smoothedno overhangs or sumps
  10. TympanoplastyGraft on stapes head (type III)Graft on footplateNot done (radical)underlay under remnant, over facial ridge; supported on gelfoam
  11. Meatoplastysize (about the surgeon's thumb); conchal cartilage excised or not
  12. Haemostasisbipolar, bone wax, gelfoam; adrenaline pledget

Closure, drains and dressing

  1. Periosteuminterrupted polyglactin 910 3-0
  2. SkinInterrupted nylon 3-0Subcuticular polydioxanone (PDS) 4-0
  3. Cavity packBIPP ribbon gauzeRibbon gauze with antibiotic ointmentover gelfoam; length; not packed tight; removal date
  4. Mastoid pressure dressingApplied
  5. Facial nerve status at endon waking: eye closure, smile; normal or weak

Specimens and implants

  1. Cholesteatoma matrix / granulations for HPElabel with side
  2. Ossicular prosthesis (if used)type, size, make, lot number, sticker in file

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 nerve check on waking and at set intervalsif palsy on waking persists beyond 4 hours, inform consultant for exploration
  2. Weber test and nystagmuson waking and next morning
  3. Mastoid dressingremove after 24 hours
  4. Cavity packkeep dry; change outer cotton; removal in clinic at 7 to 10 days
  5. Antibioticdrug, dose, duration
  6. Analgesia and antiemeticdrug, dose, frequency
  7. Water precautionsno water in the ear
  8. Warning signsdischarge, headache, vertigo, fever, facial weakness, fall in hearing
  9. Follow-up7 to 10 days, then 3 weeks; regular cavity cleaning; HPE review

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.D., 22 years, right ear foul-smelling scanty discharge for 4 years. Right attic perforation with cholesteatoma flakes. HRCT shows soft tissue in attic, antrum and mastoid with scutum erosion.

Case details

Date: 11/06/2026. Elective. ENT OT 1.

In OT 09:00. Induction 09:10. Incision 09:35. Dressing completed 12:05.

Surgeon: Dr A. (3rd-year resident, ENT), under direct supervision of Dr C. (consultant, scrubbed). Assistant: Dr B.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Pre-op diagnosis: right chronic otitis media, squamosal, active (attic cholesteatoma).

Procedure planned and performed: right modified radical mastoidectomy with type III tympanoplasty (temporalis fascia).

PTA (02/06/2026): right air-bone gap 40 dB, left normal. Fistula test negative. Facial nerve normal both sides.

HRCT temporal bone (30/05/2026): tegmen intact, lateral semicircular canal intact, sigmoid sinus not forward.

Consent: general and procedure-specific consent in Marathi. Facial palsy, dead ear, giddiness, taste change, recurrence and need for lifelong cavity care explained.

Right ear marked. WHO checklist sign in and time out done. Inj cefazolin 2 g IV and inj metronidazole 500 mg IV at 09:15, before incision.

Anaesthesia and position

GA with oral tube and controlled hypotension. Facial nerve monitor not used.

Supine, head turned to the left, right ear up. Parts painted with povidone-iodine and draped.

2% lignocaine with adrenaline 1:100,000, 10 ml along the postaural line and canal, 10 minutes before incision.

Findings

Cholesteatoma filling attic, aditus and antrum, extending into the mastoid. Mastoid sclerotic.

Incus long process eroded. Malleus head surrounded by matrix. Stapes suprastructure intact and mobile.

Facial canal intact in tympanic and mastoid segments. Lateral semicircular canal intact, no fistula.

Tegmen intact. Sigmoid sinus not exposed. Mesotympanum and Eustachian tube free of disease.

Procedure

Right postaural incision about 1 cm behind the crease. Temporalis fascia graft harvested, thinned and kept to dry.

T-shaped periosteal incision; periosteum elevated to show suprameatal spine.

Mastoid cortex drilled along linea temporalis with cutting burrs and irrigation. Tegmen and lateral semicircular canal identified. Antrum opened.

Attic opened. Incudostapedial joint already eroded; incus removed. Malleus head removed with malleus nipper.

Posterior canal wall taken down and facial ridge lowered with diamond burr, strokes parallel to the nerve. Chorda tympani divided sharply.

Cholesteatoma removed completely with the sac. Lateral semicircular canal checked: no fistula. Tip cells exenterated. Cavity smoothed.

Temporalis fascia placed underlay under the remnant, draped over the stapes head and the facial ridge, supported on gelfoam (type III).

Meatoplasty done, opening about the size of the surgeon's thumb. Haemostasis with bipolar and bone wax.

Closure

Periosteum closed with interrupted polyglactin 910 (Vicryl) 3-0. Skin closed with interrupted nylon (Ethilon) 3-0.

Cavity packed lightly with gelfoam and 15 cm of half-inch BIPP ribbon gauze. Mastoid pressure dressing applied.

Specimens and implants

Cholesteatoma matrix sent for HPE in formalin, labelled 'right ear, cholesteatoma'. No prosthesis used.

End of procedure

Estimated blood loss 100 ml. No transfusion.

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

No intra-operative complications. Facial nerve not exposed.

On waking: full eye closure and symmetrical smile on the right. No nystagmus. Weber lateralised to right.

Shifted to recovery in stable condition. Pulse 84/min, BP 118/76 mmHg.

Post-op orders

Check facial movement 4-hourly for 24 hours. If weakness, inform consultant at once.

Weber and nystagmus check next morning.

Mastoid dressing to be removed after 24 hours. BIPP pack to stay until review.

Antibiotic, analgesic and antiemetic as per drug chart.

No water in the right ear.

Review in ENT OPD on 19/06/2026 for stitch and pack removal, then at 3 weeks.

Signature

Dr A., JR-3, ENT. Reg. no. ________. 11/06/2026, 12:20.

Must document for this operation

  • Facial nerve status: canal intact, dehiscent or exposed, and movement on waking. A palsy noticed later cannot be timed without this, and early exploration depends on it.
  • Lateral semicircular canal fistula: present or not, and whether matrix was left. Matrix left on a fistula needs a planned second look and explains giddiness or hearing loss after surgery.
  • Extent of cholesteatoma and whether removal was complete. The next surgeon plans a revision or second look from this.
  • Ossicles present and removed, and the type of tympanoplasty. It explains the hearing result and guides any later hearing reconstruction.
  • Dura, sigmoid sinus or jugular bulb exposure and how it was handled. These carry risks of meningitis or bleeding and must be known to the ward team.
  • Meatoplasty size and cavity pack with removal date. A small meatus is a common cause of a wet cavity, and the pack must not be forgotten.

Common mistakes in these notes

  • Writing 'MRM done' without the facial nerve and fistula findings.
  • Not recording facial movement on waking.
  • Leaving out whether the chorda tympani was divided.
  • Not stating whether disease clearance was complete.
  • Specimen jar with no side label.

Indian practice and paperwork

  • Consent must explain the procedure, risks, benefits, alternatives and who will operate, in a language the patient understands. (NABH 5th ed., PRE.4(c))
  • 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))
  • Tissue not sent for HPE is yellow (a) human anatomical waste. Discarded formalin is yellow (f) chemical waste. (Bio-Medical Waste Management Rules 2016, CPCB guidelines)
  • If an ossicular prosthesis is used, its batch and serial number go in the case record, the OT implant register and the discharge summary. (NABH 5th ed., MOM.10(d))

Sources

  • Hathiram BT, Khattar VS, eds. Atlas of Operative Otorhinolaryngology and Head and Neck Surgery. Jaypee Brothers, Ch 13, The surgical management of cholesteatoma (Nikolopoulos T, Gerbesiotis P), pp. 92-105.
  • Hathiram BT, Khattar VS, eds. Atlas of Operative Otorhinolaryngology and Head and Neck Surgery. Jaypee Brothers, Ch 8, Surgical approaches to the middle ear cleft and their indications (Khattar VS, Hathiram BT), pp. 62-66.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Table 1: cefazolin 2 g (3 g if 120 kg or more), metronidazole 500 mg, started within 60 min before incision. Table 2, head and neck, other clean-contaminated procedures: cefazolin or cefuroxime plus metronidazole, or ampicillin-sulbactam. 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.

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