OT notes · ENT

Septoplasty

Usual anaesthesia
General with topical and local infiltration of the septum; local with sedation in some units
Position
Supine
Setting
elective

Operative note template for conventional, endoscopic or open septoplasty, with a filled example for a conventional septoplasty through a Killian incision with packs and silastic splints.

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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 (epistaxis) after surgery
  • septal haematoma or abscess
  • septal perforation
  • adhesions (synechiae) in the nose
  • persistent blockage needing further surgery
  • change in nasal shape or loss of support if too much cartilage is removed
  • numbness of upper front teeth
  • CSF leak (rare)
  • discomfort from nasal packs: facial swelling, watering eyes, dry mouth, poor sleep

Pre-operative details for this operation

  1. Symptomsnasal block (side, constant or intermittent), allergy symptoms, snoring, epistaxis
  2. Examination and endoscopyside and type of deviation (caudal, anterior, posterior, spur), turbinates, valve, polyps
  3. Previous nasal surgery or traumatransillumination for missing cartilage
  4. Bleeding or clotting problems, drugsantiplatelets, anticoagulants, decongestant spray overuse
  5. Other procedures plannedNoneTurbinate reductionFESSRhinoplasty

Anaesthesia and position

  1. AnaesthesiaGeneralLocal with sedationLocal
  2. Topical decongestionpledgets: solution (e.g. 2% lignocaine with 1:100,000 adrenaline), number, time left in
  3. Infiltrationsolution, volume in ml, sites (subperichondrial, maxillary crest, nasal spine)
  4. PositionSupine
  5. VisualisationHeadlight and speculumEndoscope (0 degree)

Operative findings

  1. Deviationside, cartilage and / or bone, caudal dislocation, horizontal or vertical deviation, spur at maxillary crest
  2. Mucosal tearsNoneUnilateral tearBilateral opposing tears (repaired)site and size
  3. Turbinatessize, compensatory hypertrophy
  4. Airway at endboth sides patent on endoscopy / inspection

Procedure (steps)

  1. ApproachConventional (headlight)EndoscopicOpen (external)
  2. IncisionKillianHemitransfixionTransfixionTranscolumellar (open)side
  3. Mucoperichondrial flap elevatedside(s); subperichondrial and subperiosteal plane; instrument
  4. Chondrotomy and opposite flapwhere the cartilage was incised
  5. Cartilage separated from maxillary crest / bony septumdisarticulation of the osteocartilaginous junction, kept 1 to 1.5 cm from the dorsum
  6. CorrectionInferior (horizontal) strip removedVertical strip removedWedge resectionScoring / cross-hatchingCaudal septum repositioned and suturedsize of cartilage removed
  7. Bone and spur removedChisel / osteotomeLuc forcepsNot neededmaxillary crest, vomer, perpendicular plate
  8. L-strut preservedat least 1 cm dorsal and 1 cm caudal
  9. Flaps replaced and tears repaired

Closure, drains and dressing

  1. Quilting (mattress) suturesabsorbable suture, number
  2. Incision closedabsorbable suture
  3. SplintsSilastic splints both sides, sutured to caudal septumNoneremoval on day 5 to 7
  4. Nasal packingNon-absorbable pack (e.g. Merocel) both sidesFibrin glue, no packNo packnumber and type of packs; removal in 1 to 2 days
  5. Nasopharynx and oropharynx suctioned, no blood trickling back

Specimens and implants

  1. Septal cartilage / bone removedDiscardedSent for HPEKept for graft
  2. Packs and splints left in the nosenumber, type, side; count recorded

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. Bleedinglook for fresh bleeding from the nose or trickling into the throat
  2. Breathing with packsmouth breathing; oxygen saturation, more closely in sleep apnoea
  3. Pack removaldate and time (non-absorbable packs in 1 to 2 days)
  4. Splint removaldate (day 5 to 7)
  5. Antibiotic while splints are indrug, dose, duration
  6. Analgesiadrug, dose, frequency
  7. Watch for complicationsseptal haematoma (swelling, blocked nose after pack removal), clear watery discharge (CSF), fever
  8. Follow-update; endoscopy for adhesions

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.R., 28 years, constant right-sided nasal block for 3 years. Endoscopy: septum deviated to the right in the posterior part with a bony spur at the maxillary crest touching the right inferior turbinate. Caudal septum straight.

Case details

Date: 25/09/2026. Elective. ENT OT.

Induction 09:00. Incision 09:20. End 10:15.

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: symptomatic right-sided deviated nasal septum with maxillary crest spur, not relieved by 3 months of nasal steroid spray.

No previous nasal surgery or trauma. No bleeding disorder, no antiplatelets.

Consent: general, procedure-specific (bleeding, haematoma, perforation, adhesions, persistent block, packs) and anaesthesia consent taken in Tamil.

WHO checklist done. Inj cefazolin 2 g IV and inj metronidazole 500 mg IV at 08:55.

Anaesthesia and position

General anaesthesia with oral endotracheal tube. Supine.

Two cotton pledgets on each side soaked in 2% lignocaine with 1:100,000 adrenaline, left for 5 minutes. Subperichondrial infiltration with the same solution, 6 ml in total (120 mg lignocaine; weight 70 kg), including the maxillary crest and nasal spine. Blanching seen.

Procedure

Conventional septoplasty with headlight and Killian speculum.

Left Killian incision about 1.5 cm behind the caudal end of the septum. Left mucoperichondrial flap elevated in the subperichondrial plane with a Freer elevator, continued as a mucoperiosteal flap over the bony septum.

Cartilage incised, right flap elevated. Osteocartilaginous junction disarticulated, staying more than 1.5 cm below the dorsum. Cartilage freed from the maxillary crest through an inferior tunnel.

Inferior horizontal strip of cartilage 2.5 cm x 4 mm removed. Deviated vomer and maxillary crest spur removed with a chisel. Deviated perpendicular plate fragments removed with Luc forceps.

L-strut of about 1.5 cm dorsal and 1.5 cm caudal preserved.

Findings: posterior cartilaginous and bony deviation to the right with a 1 cm maxillary crest spur. Small tear of the right flap posteriorly, no opposite tear. Inferior turbinates normal.

Closure

Flaps replaced. Septum midline, both airways patent.

Quilting mattress sutures with absorbable polyglactin 910 (Vicryl) 4-0, three passes. Killian incision closed with the same suture.

Silastic splints placed on both sides and sutured to the caudal septum.

Merocel pack in each nasal cavity (2 packs). Nasopharynx and oropharynx suctioned, no blood trickling back.

End of procedure

Estimated blood loss 60 ml. No transfusion.

Mop, needle and instrument count correct. Left in the nose: 2 Merocel packs and 2 silastic splints.

No intra-operative complications apart from the small unilateral flap tear.

Specimen: septal cartilage and bone discarded, not sent for HPE.

Extubated awake. Pulse 82/min, BP 128/80 mmHg, SpO2 98% on room air.

Post-op orders

Watch for fresh bleeding through the packs or into the throat. Inform ENT resident if bleeding continues.

Mouth breathing expected; SpO2 monitoring overnight.

Remove both Merocel packs on 26/09/2026 morning (POD 1). Check the septum for haematoma after pack removal.

Silastic splints to be removed in OPD on 02/10/2026 (day 7).

Oral antibiotic cover while splints are in, drug and dose as per drug chart. Analgesia as per drug chart.

Report clear watery nasal discharge, increasing pain or fever. ENT OPD review on day 7 for splint removal and endoscopy.

Signature

Dr A., JR-2, ENT. Reg. no. ________. 25/09/2026, 10:30.

Must document for this operation

  • Number, type and side of packs and splints left in the nose, and when each comes out. A forgotten pack or splint causes infection and adhesions, and the ward and OPD teams need the removal dates.
  • Size of the L-strut preserved. Loss of nasal support is a known complaint after septoplasty, and this line shows support was kept.
  • Any mucosal tear, its side, and whether opposing tears were repaired. Opposing tears are the usual cause of perforation, which may be alleged as negligence later.
  • What cartilage and bone were removed. A revision or rhinoplasty surgeon needs to know what septal cartilage is left for grafts.
  • Local anaesthetic and adrenaline solution, volume and dose. Needed to check the total dose if the patient has a cardiac or toxic reaction.
  • Incision used and approach (conventional, endoscopic or open). The incision type affects tip support and access in any later nasal surgery.

Common mistakes in these notes

  • Writing 'nasal packing done' without the number and type of packs.
  • No date for splint removal, so splints stay in too long.
  • Not recording the L-strut or what was removed.
  • Not recording the volume of adrenaline solution used.
  • Missing a note of a mucosal tear seen during elevation.
  • No mention of checking for septal haematoma after the packs come out.

Indian practice and paperwork

  • 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))
  • Name every anaesthetist in the note. A hospital was held negligent when the operation notes did not name the anaesthetist though two had given anaesthesia. (Thomas J. Indian J Urol 2009;25(3):384-8, PMID 19881136)
  • Septal cartilage and bone that are discarded are human anatomical waste for the yellow bag. (Bio-Medical Waste Management Rules 2016, CPCB guidelines)

Sources

  • Hathiram BT, Khattar VS, eds. Atlas of Operative Otorhinolaryngology and Head and Neck Surgery. Vol 2: Rhinology and Anterior Skull Base. Jaypee Brothers, Ch 45, Septoplasty (Habesoglu TE, Habesoglu M), pp. 369-378.
  • Hathiram BT, Khattar VS, eds. Atlas of Operative Otorhinolaryngology and Head and Neck Surgery. Vol 2: Rhinology and Anterior Skull Base. Jaypee Brothers, Ch 46, Endoscopic Septoplasty (Hathiram BT, Khattar VS), pp. 379-384.
  • Moran B, Mittal R, Lord A, eds. Farquharson's Textbook of Operative General Surgery. 11th ed. CRC Press, Ch 4A, Surgery of the skin: local anaesthesia (lidocaine maximum dose 3 mg/kg plain, 7 mg/kg with adrenaline), pp. 43.
  • 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 through mucosa including rhinoplasty are clean-contaminated; Table 2 (other clean-contaminated procedures except tonsillectomy and FESS): cefazolin or cefuroxime plus metronidazole, or ampicillin-sulbactam. Table 1 adult doses: cefazolin 2 g, metronidazole 500 mg, within 60 min before incision. 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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