OT notes · ENT

Superficial parotidectomy

Usual anaesthesia
General with endotracheal tube taped to the opposite side of the mouth
Position
Supine, head-up (reverse Trendelenburg about 45 degrees), head turned to the opposite side, shoulder roll
Setting
elective

Operative note template for superficial parotidectomy with facial nerve preservation, with a filled example for a pleomorphic adenoma of the left superficial lobe.

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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

  • temporary weakness of the face on the operated side
  • permanent facial nerve palsy (rare when the nerve is normal before surgery)
  • numbness of the ear lobe and skin over the gland (greater auricular nerve)
  • gustatory sweating (Frey's syndrome)
  • salivary collection under the flap (sialocele) or salivary fistula
  • haematoma needing return to theatre
  • skin flap necrosis, more in smokers and diabetics
  • tumour recurrence, especially if the capsule ruptures
  • further surgery (total parotidectomy, neck dissection) if frozen section or HPE shows malignancy

Pre-operative details for this operation

  1. SideRightLeftsite marked with a marker, incision line also marked
  2. Lump detailssize, duration, site (superficial lobe / tail / deep lobe on imaging), mobility, skin involvement
  3. Facial nerve function before surgeryall branches tested and recorded, House-Brackmann grade. A weak nerve before surgery suggests malignancy
  4. Imaging and cytology reviewedCT / MRI / USG report and films in OT; FNAC result if done
  5. Frozen section arrangedPathologist informedNot available
  6. Consent for extensionconsent covers total parotidectomy / neck dissection / nerve graft if frozen section shows malignancy

Anaesthesia and position

  1. AnaesthesiaGeneral, ETT taped to the opposite corner of the mouthtube position; any issue at intubation
  2. PositionSupine, head-up about 45 degrees, head turned to opposite side, shoulder roll
  3. Drapingear, lateral canthus, angle of mouth and whole neck on the operated side left visible
  4. Facial nerve monitoringAssistant watching the face for twitchingNerve monitor usedNerve stimulator usedif a monitor was used, write the make and that it was tested before incision

Operative findings

  1. Tumoursize, site in the gland, relation to the nerve (lateral / between branches / touching nerve), capsule intact or breached
  2. Facial nerve trunkfound at (landmark), diameter, normal white or thickened / dark (suspicious of infiltration)
  3. Branching patternlevel of the pes (division into temporofacial and cervicofacial), branches seen and preserved
  4. Deep lobe and neckpalpated: normal / tumour extension / enlarged nodes
  5. Frozen section resultresult and time; decision taken on it

Procedure (steps)

  1. IncisionModified Blair (preauricular, around lobule, into a neck crease 2 finger breadths below the angle)RetrotragalFacelift type (post-auricular into hairline)marked before incision; crosshatch marks if used
  2. Skin flap raisedplane: just superficial to the parotid fascia, up to the anterior border of the gland; bipolar for vessels
  3. Greater auricular nervePosterior branch preservedDividedexternal jugular vein preserved or ligated
  4. Gland separated from SCM and tragal cartilagedown to the tragal pointer; mastoid tip palpated
  5. Posterior belly of digastric identifiedlandmark for the level of the nerve trunk
  6. Facial nerve trunk identifiedlandmarks used: tragal pointer, mastoid tip, upper border of posterior belly of digastric; blunt dissection with a fine curved clamp; nothing cut until nerve seen
  7. Posterior auricular arteryLigated after the nerve was seenNot encountered
  8. Pes found and branches followedwhich division followed first (upper / lower); branches traced to the edge of the gland
  9. Posterior facial (retromandibular) veinLigated after marginal and cervical branches identifiedPreserved
  10. Superficial lobe freed from the nervecapsule intact / breached (where, spillage washed out)
  11. Parotid (Stensen's) ductchecked for adherent buccal branch, then divided and ligated (suture)
  12. Nerve checked at the endall branches in continuity; response to stimulation if a stimulator was used
  13. Irrigation and haemostasisbipolar; no cautery right next to nerve branches

Closure, drains and dressing

  1. DrainSuction drain through a separate post-auricular stab, sutured to skinNo draintype and size of drain
  2. Deep layerdeep dermis and platysma: suture and size (e.g. interrupted poliglecaprone 25 (Monocryl) 4-0)
  3. SkinSubcuticular absorbable 5-0Interrupted non-absorbable
  4. DressingConforming / light pressure dressingAntibiotic ointment only
  5. Facial movement on wakingchecked in recovery: forehead, eye closure, smile, lower lip; House-Brackmann grade

Specimens and implants

  1. Superficial lobe with tumourSent for frozen section and HPESent for HPE onlyorientation marked; side written on requisition
  2. Nerve biopsy / nodesSent separatelyNot applicable

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. Airway and wound watchlook for swelling under the flap (haematoma); frequency of checks
  2. Drainkeep suction on; record output every shift; remove when output is low as per unit protocol
  3. Facial nerve checkrecord each branch on the evening of surgery and next morning, compare with pre-op grade
  4. Eye careif eye closure is incomplete: lubricant drops and ointment, taping at night
  5. Dietoral fluids when awake, soft diet next day
  6. Analgesiadrug, dose, frequency as charted by anaesthetist
  7. Stayovernight observation at least
  8. Sialocele adviceif fluid collects after drain removal: aspiration and pressure dressing
  9. Stitches and follow-upwound check date; HPE review in OPD

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. K.P., 42 years, painless lump in the left parotid region for 3 years, 3 x 2.5 cm, FNAC suggestive of pleomorphic adenoma, facial nerve normal, CECT showing a lesion confined to the superficial lobe.

Case details

Date: 14/04/2026. Elective. OT 3.

In OT 09:05. Induction 09:15. Incision 09:40. Specimen out 11:20. Skin closure completed 12:00.

Surgeon: Dr A. (3rd-year resident, ENT). Assistant: Dr B. (1st-year resident). Consultant: Dr C., scrubbed for nerve dissection.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Left parotid lump 3 x 2.5 cm, mobile, skin free. FNAC: pleomorphic adenoma. CECT: well-defined lesion in the left superficial lobe, deep lobe clear. Films in OT.

Facial nerve: all branches normal, House-Brackmann grade I on both sides.

Consent: general and procedure-specific consent taken in Marathi, including facial weakness, Frey's syndrome, ear lobe numbness, sialocele and possible extension if frozen section shows malignancy. Left side and incision line marked.

Pathologist informed for frozen section. WHO checklist sign in and time out done.

Anaesthesia and position

General anaesthesia, oral ETT taped to the right corner of the mouth.

Supine, head-up about 45 degrees, head turned to the right, shoulder roll. Parts painted with povidone-iodine and draped leaving the left ear, lateral canthus, angle of mouth and neck visible.

Facial nerve watched by the assistant for twitching. No nerve monitor used.

Procedure

Modified Blair incision: preauricular crease from the root of the helix, curving under the lobule and forward in a neck crease two finger breadths below the angle of the mandible.

Skin flap raised just above the parotid fascia to the anterior border of the gland. Bipolar for bleeders.

Greater auricular nerve identified over the SCM; posterior branch preserved, anterior branch divided. External jugular vein preserved.

Gland separated from the anterior border of the SCM and from the tragal cartilage down to the tragal pointer. Mastoid tip palpated. Posterior belly of digastric identified.

Facial nerve trunk found about 1 cm deep and slightly anterior-inferior to the tragal pointer, just above the upper border of the posterior belly of digastric, by blunt spreading with a fine curved clamp. Trunk white, about 2.5 mm. Nothing cut until the trunk was seen. Posterior auricular artery ligated after the trunk was seen.

Pes found about 1 cm from the trunk. Lower division followed first: cervical and marginal mandibular branches traced to the gland edge. Retromandibular vein ligated after these branches were seen. Upper division then followed: temporal, zygomatic and buccal branches.

Tumour 3 x 2.5 cm in the lower part of the superficial lobe, lateral to the lower division, capsule intact throughout, cuff of normal gland all round.

Parotid duct checked for adherent buccal branch, then divided and ligated.

All five branches seen in continuity at the end. Wound irrigated with saline. Deep lobe and upper neck palpated: no lump, no nodes.

Frozen section

Specimen sent at 11:20. Report at 11:40: benign salivary tumour, consistent with pleomorphic adenoma, margins clear. No extension needed.

Closure

Suction drain through a separate post-auricular stab, sutured to the skin.

Deep dermis and platysma closed with interrupted poliglecaprone 25 (Monocryl) 4-0. Skin closed with subcuticular absorbable 5-0.

Light conforming dressing.

Specimens

Left superficial parotid lobe with tumour, superior end marked, sent in formalin for HPE after frozen section. Requisition filled with side and frozen section result.

End of procedure

Estimated blood loss 80 ml. No transfusion.

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

No intra-operative complications. Capsule intact.

Facial movement checked after extubation: forehead, eye closure and smile normal, slight weakness of the lower lip (House-Brackmann grade II). Patient told.

Shifted to post-operative ward in stable condition. Pulse 80/min, BP 126/80 mmHg.

Post-op orders

Watch the wound hourly for swelling under the flap. Call the resident if the neck swells.

Drain on suction. Record output every 8 hours.

Record facial movement branch by branch in the evening and next morning.

Oral fluids when fully awake, soft diet from tomorrow.

Analgesics as charted by the anaesthetist.

Review of drain and wound on POD 1. HPE review in OPD.

Signature

Dr A., JR-3, ENT. Reg. no. ________. 14/04/2026, 12:10.

Must document for this operation

  • Facial nerve function before surgery and on waking, by branch and grade. A weakness found after surgery can only be judged against a written pre-operative baseline, and this is the first thing asked in any complaint.
  • The landmark used to find the facial nerve trunk and that all branches were seen in continuity at the end. It shows that the nerve was actively found and protected, and it guides the surgeon who operates on a recurrence.
  • Whether a nerve monitor or stimulator was used. Monitor use is often questioned after a palsy, and the note is the only record of it.
  • Whether the tumour capsule stayed intact or was breached, and where. Capsule rupture in pleomorphic adenoma raises the chance of recurrence, and the next surgeon and the pathologist need to know.
  • Frozen section result, time, and the decision taken on it. It justifies stopping at a superficial parotidectomy or extending to total parotidectomy or neck dissection.
  • Greater auricular nerve divided or preserved. It explains ear lobe numbness after surgery and tells a later surgeon whether the nerve is still available as a graft.
  • Drain type and route. Ward staff need it to manage the drain, and it explains a separate stab scar.

Common mistakes in these notes

  • Writing 'facial nerve preserved' without saying how it was identified or which branches were seen.
  • No pre-operative facial nerve grade, so a post-operative weakness cannot be compared.
  • Not recording whether the capsule was breached.
  • Leaving out frozen section time and result when the extent of surgery depended on it.
  • Specimen sent without orientation or side on the requisition.

Indian practice and paperwork

  • NABH expects the operative note to be written before the patient is moved out of recovery, and post-op care to follow a written plan. Write the facial nerve status in that note, not only later in the progress sheet. (NABH 5th ed., COP.14(e) and (f))
  • Formalin discarded from specimen jars is chemical waste in the yellow (f) category under the Bio-Medical Waste Management Rules. (Bio-Medical Waste Management Rules 2016, CPCB guidelines)

Sources

  • Hathiram BT, Khattar VS, eds. Atlas of Operative Otorhinolaryngology and Head and Neck Surgery. Vol 5: Head and Neck Surgery. Jaypee Brothers, Ch 161, Superficial and Total Parotidectomy (Moore EJ), pp. 1398-1409.

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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