OT notes · ENT

Tympanoplasty (type I, underlay temporalis fascia)

Usual anaesthesia
Local infiltration (lignocaine with adrenaline) in cooperative adults; general anaesthesia with controlled hypotension for children and anxious patients
Position
Supine, head turned to the opposite side, operated ear up
Setting
elective

Operative note template for type I tympanoplasty with an underlay temporalis fascia graft, with a filled example for a dry central perforation repaired by the postaural route under local 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

  • graft failure with a residual or recurrent perforation
  • no gain or a fall in hearing
  • sensorineural hearing loss or dead ear (rare)
  • giddiness after surgery
  • facial nerve weakness (rare)
  • altered taste from chorda tympani injury
  • wound infection or discharge
  • need for revision surgery

Pre-operative details for this operation

  1. SideRight earLeft earwrite the side in full and match it with the consent, the audiogram and the site mark
  2. Perforationsize, site (central / marginal / subtotal), relation to malleus handle, margins, middle ear mucosa
  3. Ear dry for how longweeks since last discharge; microsuction done
  4. Pure tone audiogramdate; air-bone gap in the operated ear; hearing in the other ear (is this the only hearing ear?)
  5. Tuning fork testsRinne and Weber
  6. Hidden disease ruled out on microscopyno cholesteatoma, retraction pocket or granulations
  7. Antiplatelets stoppedNot on anyStopped (date)
  8. Facial nerve function before surgeryNormalWeak (grade)

Anaesthesia and position

  1. AnaesthesiaLocal infiltrationLocal with sedationGeneral with controlled hypotension
  2. Infiltrationsolution and strength, volume; sites: postaural, canal (four quadrants), graft site; wait about 15 min before incision
  3. PositionSupine, head turned away, operated ear up
  4. Microscope usedYes

Operative findings

  1. Perforation at surgerysize, quadrants, anterior margin visible or not
  2. Middle ear mucosaHealthyOedematousPolypoidalTympanosclerotic plaques
  3. Ossicular chainmalleus, incus, stapes: intact, mobile, eroded; incudostapedial joint
  4. Eustachian tube openingPatentBlocked by mucosa / granulations
  5. Cholesteatoma or hidden retraction pocketNonePresent (site): plan changed
  6. Chorda tympaniPreservedStretchedDivided
  7. Facial nerve canalNot exposedDehiscent (site)

Procedure (steps)

  1. ApproachPostaural (Wilde)Endaural (Lempert)Permeatal / endomeatal (Rosen)for postaural, incision about 1 cm behind the postaural crease
  2. Graft harvestTemporalis fasciaAreolar fasciaTragal perichondriumFascia latasize; fat and muscle cleared; thinned; kept to dry
  3. Canal incision and tympanomeatal flapposition of incision (o'clock), flap raised to the annulus
  4. Annulus lifted and middle ear enteredentered inferiorly to protect the chorda
  5. Middle ear inspected, ossicular mobility checkedrecord what was found and any extra step taken
  6. Middle ear supportedGelfoam piecesNothing
  7. Graft placedUnderlay (medial to remnant and malleus handle)Underlay, lateral to malleus handleOverlayoverlap of at least 4 mm under the margins; no folds
  8. Tympanomeatal flap repositionedgraft and flap in contact, no wrinkles
  9. Canal packinggelfoam; ribbon gauze with antibiotic ointment or BIPP; length

Closure, drains and dressing

  1. Postaural periosteum / muscle layersuture material and size (e.g. polyglactin 910 3-0)
  2. SkinInterrupted nylon 3-0Subcuticular absorbable
  3. Mastoid dressingAppliedplanned removal time
  4. Ribbon gauze / canal pack removal datewrite the date

Specimens and implants

  1. SpecimenNoneGranulations / polyp for HPE (label side)
  2. Ossicular prosthesis (only if type changed)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 wakingeye closure and smile; inform at once if any weakness
  2. Giddiness, nystagmus and Weber testrecord on waking and next morning
  3. Mastoid dressingremove after 24 hours
  4. Canal packkeep dry; change outer cotton ball; removal date in clinic
  5. Water precautionsno water in the ear until told
  6. Analgesia and antiemeticdrug, dose, frequency
  7. Stitch care and removalday of removal if non-absorbable
  8. Warning signs to reportdischarge, headache, vertigo, fever, facial weakness, fall in hearing
  9. Follow-up7 to 10 days for pack removal; audiogram at 3 months

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. R.P., 28 years, left ear discharge on and off for 6 years, dry for 3 months. Large central perforation of the left tympanic membrane. Air-bone gap 30 dB on the left. Right ear normal.

Case details

Date: 06/05/2026. Elective. ENT OT 2.

In OT 10:00. Infiltration 10:15. Incision 10:32. Dressing completed 11:40.

Surgeon: Dr A. (3rd-year resident, ENT). Assistant: Dr B. (2nd-year resident). Consultant: Dr C., present in OT.

Anaesthetist (monitoring): Dr D. Scrub nurse: Sr E.

Indication and pre-op

Pre-op diagnosis: left chronic otitis media, mucosal, inactive, large central perforation.

Procedure planned and performed: left type I tympanoplasty, postaural route, underlay temporalis fascia graft.

PTA (28/04/2026): left air-bone gap 30 dB, right normal. Rinne negative left, Weber lateralised to left.

No cholesteatoma or retraction pocket on microscopy. Facial nerve normal both sides. Not on antiplatelets.

Consent: general and procedure-specific consent taken in Hindi. Risks of graft failure, no hearing gain, dead ear, giddiness, facial weakness and taste change explained.

Left ear marked. WHO checklist sign in and time out done. No antibiotic prophylaxis (dry ear, unit protocol).

Anaesthesia and position

Local anaesthesia with monitored care. Supine, head turned to the right, left ear up.

Parts painted with povidone-iodine and draped. 2% lignocaine with adrenaline 1:100,000: about 8 ml along the postaural incision line and 2 ml in the four quadrants of the bony canal. Waited 15 minutes.

Findings

Large central perforation, about 60% of the pars tensa, anterior margin just visible.

Middle ear mucosa healthy. Malleus, incus and stapes intact and mobile. Eustachian tube opening patent.

No cholesteatoma. Chorda tympani preserved. Facial canal not exposed.

Procedure

Left postaural incision about 1 cm behind the crease, from the upper attachment of the pinna to the mastoid tip, deepened to temporalis fascia.

Temporalis fascia graft about 2 x 2 cm harvested, cleared of fat and muscle, thinned and kept to dry.

Canal incision on the posterior wall from 12 to 6 o'clock. Tympanomeatal flap elevated to the annulus.

Annulus lifted from the sulcus inferiorly first and middle ear entered. Chain checked and found mobile.

Middle ear filled with gelfoam pieces. Graft placed underlay, medial to the remnant and the malleus handle, with at least 4 mm overlap under the anterior margin.

Tympanomeatal flap replaced over the graft. No wrinkles. Canal packed with gelfoam, then ribbon gauze with antibiotic ointment.

Closure

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

Mastoid pressure dressing applied.

End of procedure

Estimated blood loss 20 ml. No specimens. No implants.

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

No intra-operative complications.

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

Shifted to ward in stable condition. Pulse 78/min, BP 122/80 mmHg.

Post-op orders

Check facial movement and giddiness at 2 hours and next morning. Inform on call ENT at once if any facial weakness.

Mastoid dressing to be removed after 24 hours. Keep canal cotton dry, change the outer cotton ball when soaked.

No water in the left ear.

Analgesic and antiemetic as per drug chart.

Stitch removal and ribbon gauze removal in ENT OPD on 14/05/2026. PTA at 3 months.

Signature

Dr A., JR-3, ENT. Reg. no. ________. 06/05/2026, 11:55.

Must document for this operation

  • The side operated, matched with the audiogram and the consent. Wrong-side ear surgery is a known never event, and the audiogram is the baseline for any claim of hearing loss.
  • Hearing in the other ear before surgery. If the operated ear is the only hearing ear, the counselling and the risk are very different, and this must be on record.
  • State of the ossicular chain and middle ear mucosa. It explains the hearing result and guides any revision or ossiculoplasty.
  • Graft material and position (underlay or overlay, relation to the malleus). The next surgeon needs this if the graft fails.
  • Facial nerve function at the end of surgery and on waking. An immediate palsy needs early exploration. Without a recorded normal baseline, the timing cannot be shown.
  • Pack type and planned removal date. Ward staff and the patient need to know when and where the pack comes out.

Common mistakes in these notes

  • Not writing the side, or writing only 'Rt' in a corner.
  • No pure tone audiogram (PTA) values quoted in the pre-op section.
  • Writing 'graft placed' without saying underlay or overlay.
  • Leaving out the ossicular chain findings.
  • Not recording facial nerve function at the end of the operation.

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))
  • 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))
  • Name every anaesthetist involved. A consumer forum held a hospital negligent when the op note left out an anaesthetist's name. (Thomas J. Indian J Urol 2009;25:384-8)

Sources

  • 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.
  • Hathiram BT, Khattar VS, eds. Atlas of Operative Otorhinolaryngology and Head and Neck Surgery. Jaypee Brothers, Ch 9, Tympanoplasty (author's technique) (Indorewala S), pp. 67-74.
  • 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): postauricular incision, temporalis fascia harvest, closure, dressing, post-op care, pp. 92-104.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Table 2, head and neck: clean procedures, no prophylaxis recommended. 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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