OT notes · ENT

Reduction of fractured nasal bones

Usual anaesthesia
General anaesthesia with endotracheal tube and throat pack; local anaesthesia with topical packs and nerve blocks is possible in adults
Position
Supine with about 15 degrees head-up tilt
Setting
urgent

Operative note template for closed (or open) reduction of fractured nasal bones with septal manipulation and splinting, with a filled example for a closed reduction under general anaesthesia 7 days after an assault.

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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

  • nose may remain crooked; later septorhinoplasty may be needed
  • nosebleed
  • septal haematoma, infection, saddle nose
  • nasal blockage from the septum
  • adhesions inside the nose
  • skin irritation from tape or plaster; plaster in the eye
  • black eyes and swelling

Pre-operative details for this operation

  1. Date and mechanism of injurydays since injury matters: closed reduction up to 14 to 21 days
  2. Deformitydeviation to which side, depressed nasal bone, flattening; patient's own view of change since injury; old photograph if available
  3. SeptumStraightDeviated / dislocatedSeptal haematoma (drain first)
  4. Associated injuries excludedCSF rhinorrhoea, eye injury, intercanthal distance (telecanthus), other facial fractures, head injury
  5. X-ray / CTdone / not done; findings (a negative X-ray does not exclude a fracture)
  6. Open wound over noseNoneLaceration: size, tetanus status
  7. Medicolegal caseYes: MLC number, police informedNo

Anaesthesia and position

  1. AnaesthesiaGA, oral tube, throat packLocal: topical packs + infiltrationdrugs and strengths
  2. Topical vasoconstrictionpacks soaked in adrenaline, time left in
  3. PositionSupine, 15 degrees head-up
  4. Eyesointment and taped before plaster

Operative findings

  1. Examination under anaesthesiafracture site, mobility of fragments, fresh or already fibrosed
  2. Nasal boneswhich side depressed, which side displaced outward, comminution
  3. Septumfracture / dislocation, side, mucosal tears, haematoma
  4. Result after reductionstraight from above, stable in slight overcorrection, septum midline

Procedure (steps)

  1. ApproachClosed manipulationOpen: intercartilaginous + transfixion incisionsThrough overlying lacerationOsteotomies (old fracture)
  2. Nasal cavity suctioned and inspected before instruments passed
  3. Nasal bones disimpacted and elevatedWalsham forceps (outer blade padded)Digital manipulation onlyBlunt elevatorforceps not placed above the fracture line; controlled force, no jerks
  4. Septum manipulatedAsch forceps: anterior then posteriorCottle elevator submucosalSeptoplasty needed
  5. Nasal pyramid mouldedpushed to slight overcorrection and stays there without support
  6. Checked from the head endlooking down the dorsum; final adjustment
  7. Anterior rhinoscopy after reductionseptum midline, airway, bleeding, mucosal tears
  8. Skin laceration (if any)explored and cleaned, foreign bodies removed, sutured

Closure, drains and dressing

  1. Nasal packingNoneLight pack for haemostasis (material)Pack to support septum / comminuted bonesside, material, when due out
  2. Septal splintsNoneSilastic splints, sutured
  3. Skin tapingbenzoin, overlapping micropore strips, lobule loop not across the nostrils
  4. External splintPlaster of Paris (layers)ThermoplasticAluminium
  5. Throat pack removedYes, countedNot used

Specimens and implants

  1. SpecimensNone
  2. Implants / wires / platesNoneType, size, batch

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. Positionhead well raised after recovery
  2. Ice packsto each eye
  3. Nasal packremoval time; antibiotic if pack stays more than 24 hours, per unit policy
  4. Bleedingwatch for nosebleed; how to respond
  5. Analgesiadrug, dose, frequency
  6. Splint carekeep dry; do not press; return if loose or skin sore
  7. Tape and splint removalskin tape at 7 days, plaster splint at 14 days
  8. Warnreturn for fever, increasing blockage, septal swelling or watery discharge from the nose

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. P.S., 19 years, punched on the nose 7 days ago; nose deviated to the right with the left nasal bone depressed; medicolegal case.

Case details

Date: 02/06/2026. Urgent (day 7 after injury). OT 2. MLC no. ________.

Induction 13:05. Start 13:25. End 13:50.

Surgeon: Dr A. (2nd-year resident, ENT). Assistant: Dr B. (1st-year resident). Consultant: Dr C., present in OT.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Assault on 26/05/2026. Nose deviated to the right, left nasal bone depressed, swelling now settled. Patient says the nose was straight before; old photograph on his phone confirms this.

Septum: deviated to the left anteriorly, no septal haematoma. No CSF rhinorrhoea. Eyes normal, intercanthal distance normal. No other facial fracture on examination.

X-ray nasal bones lateral view: fracture of nasal bones with depression.

Consent: procedure-specific and anaesthesia consent in Hindi. Explained that the nose may not be fully straight and a later septorhinoplasty may be needed.

WHO checklist sign in and time out done. No antibiotic prophylaxis (closed reduction, no open wound).

Anaesthesia and position

General anaesthesia, oral cuffed tube, throat pack placed.

Supine, 15 degrees head-up. Both nasal cavities packed with ribbon gauze soaked in adrenaline (1:80,000) for 15 minutes, then removed. Face prepared with aqueous antiseptic.

Procedure and findings

Examination under anaesthesia: left nasal bone depressed, right nasal bone and frontal process pushed out. Fragments mobile, no firm fibrous union. Septum fractured and dislocated to the left anteriorly; no mucosal tear.

Nasal cavity suctioned and inspected. Right and left Walsham forceps, outer blade in rubber tubing, placed below the fracture line. Left nasal bone elevated and disimpacted with controlled force.

Asch forceps applied to the septum just behind the dorsum, forward traction to disimpact, then reapplied further back with forward and upward traction. Septum straightened.

Nasal pyramid moulded with the fingers; nose could be pushed to slight overcorrection and stayed there without support.

Checked from the head end looking down the dorsum: straight. Anterior rhinoscopy: septum midline, both airways open.

Closure

Light BIPP ribbon gauze pack in each side, excess paste squeezed out, for haemostasis.

Benzoin painted, overlapping micropore strips on the nose, lobule loop not crossing the nostrils. Eyes lubricated and covered. Plaster of Paris splint, 8 layers, soaked, excess water squeezed out, moulded over the nasal bones and fixed with tape.

Throat pack removed and counted.

End of procedure

Blood loss about 20 ml. No transfusion.

Mop and instrument count correct, including throat pack.

No intra-operative complications. No specimen, no implant.

Extubated smoothly. Shifted to recovery in stable condition. Pulse 80/min, BP 122/76 mmHg.

Post-op orders

Head end raised. Ice packs to both eyes.

Remove nasal packs tomorrow morning; observe for bleeding for 1 hour after removal.

Analgesia as per drug chart.

Keep the splint dry. Return if it becomes loose or the skin under it is sore.

Remove skin tape at 7 days and the plaster splint at 14 days in ENT OPD.

Return for fever, increasing blockage, swelling of the septum or watery discharge from the nose.

MLC papers completed and handed to the records section.

Signature

Dr A., JR-2, ENT. Reg. no. ________. 02/06/2026, 14:05.

Must document for this operation

  • Date of injury and days since injury at the time of reduction. Closed reduction works only before firm fibrous union (about 14 to 21 days), and the timing is checked in any complaint about the result.
  • Deformity before surgery and the patient's own view of the nose before the injury. Some patients want an old deformity fixed by a simple manipulation, which is not possible, and the note must show what was there before.
  • Septal findings and what was done to the septum. An untreated septal fracture pulls the bones back, and a poor result in up to 70% of such cases is linked to a missed septal injury.
  • Septal haematoma looked for and excluded or drained. An undrained haematoma leads to cartilage necrosis and a saddle nose.
  • Result at the end, checked from the head end. It records that the nose was straight when the patient left theatre, which matters when the case is medicolegal.
  • Packs and throat pack: number placed and removed. Ward staff must know what to remove, and a retained throat pack is a serious error.

Common mistakes in these notes

  • Writing 'MUA nose done' with no side of deviation or septal findings.
  • No date of injury, so the timing of reduction cannot be judged.
  • Not recording that CSF leak, eye injury and telecanthus were looked for.
  • Leaving out the medicolegal (MLC) number in an assault case.
  • No splint and tape removal plan.

Indian practice and paperwork

  • Tetanus prophylaxis should be given if indicated, for example when there is an open wound over the nose. (NQAS Assessor's Guidebook (2020), ME E15.2)
  • Records in a possible negligence or assault case should be complete, signed and never altered. Correct an error by striking through the whole line and rewriting it with date and time. (Thomas J. Indian J Urol 2009;25(3):384-8 (PMID 19881136))
  • The operative note must be written before the patient leaves recovery. (NABH 5th ed., COP.14(e))

Sources

  • Ballantyne JC, Harrison DFN, eds. Rob & Smith's Operative Surgery: Nose and Throat. 4th ed. Butterworths; 1986, Reduction of fractures of the nasal bones (Brain D), pp. 2-16.
  • Perry M, Holmes S, eds. Atlas of Operative Maxillofacial Trauma Surgery: Primary Repair of Facial Injuries. Springer London; 2014, 10.4 Management of nasal fractures; 10.5 MUA nose, pp. 446-459.

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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