OT notes · ENT

Aural polypectomy

Usual anaesthesia
Local anaesthesia in a cooperative adult; general anaesthesia in children or when done with the main ear operation
Position
Supine, head turned to the opposite side, operated ear up
Setting
elective

Operative note template for removal of an aural polyp with a cutting aural snare under the microscope, with a filled example for an adult with chronic otitis media whose polyp was removed for histopathology before planned ear surgery.

Download printable PDFFree. Just log in with your Google (Gmail) account.

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 from the ear
  • injury to the ossicles and further hearing loss
  • facial nerve weakness, if the polyp arises from or near the nerve
  • giddiness or inner ear injury
  • polyp growing back
  • need for mastoid surgery later
  • the HPE report may change the treatment plan

Pre-operative details for this operation

  1. SideRightLeft
  2. Polyp appearance on examinationPaleFleshy, pink / redBleeds on touchsize, whether it fills the canal
  3. Dischargeduration, smell; swab sent for culture
  4. Facial nerve function before surgeryNormalWeakness: grade
  5. Hearing and giddinesstuning fork tests / PTA; any vertigo or fistula sign
  6. ImagingX-ray mastoid or HRCT temporal bone if done: erosion, cholesteatoma
  7. Aural toilet before surgerysuction toilet, ear kept dry

Anaesthesia and position

  1. AnaesthesiaLocal infiltrationGeneraldrug, strength, volume
  2. PositionSupine, head turned, ear up
  3. MagnificationOperating microscopeEndoscope

Operative findings

  1. Polypsize, colour, consistency, single / multiple
  2. Site of attachment (stalk)Canal wallMiddle ear mucosa / promontoryAttic / posterosuperiorNot seena polyp may arise from promontory, ossicles or facial nerve
  3. Tympanic membrane after removalperforation type and site; attic or marginal perforation
  4. Cholesteatoma flakes / granulationsPresentAbsent
  5. Middle ear mucosa and ossicles if seen

Procedure (steps)

  1. Suction clearance of dischargefine suction; canal and polyp surface cleaned
  2. Site of attachment assessed before removalthe polyp may be attached to the ossicles, labyrinth, facial nerve or drum remnant; record what was seen
  3. Polyp removedCutting aural snare (Ballance)Cup / crocodile forceps for small piecessnare wire closed across the stalk and the polyp cut, not pulled; never avulse
  4. Residual granulationsRemoved with fine forcepsLeft (attached to ossicles / medial wall)
  5. Haemostasismethod used
  6. Ear canal at endDry mop / cotton plugMedicated wickNothing

Closure, drains and dressing

  1. Ear dressingCotton plug onlyWick and plug
  2. Facial movement at endNormalWeak: surgeon informed
  3. Nystagmus / giddiness at endNonePresent

Specimens and implants

  1. Polyp sent for HPEYes, in formalinNo
  2. Swab / tissue for culture (AFB if suspected)SentNot sent

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 movement and giddinesscheck on waking / after LA wears off; report at once
  2. Bleeding from earsmall ooze expected; change plug if soaked
  3. Ear drops / antibioticsif prescribed: drug, dose, duration
  4. Water precautionskeep ear dry
  5. Follow HPEdate to review report; plan for definitive ear surgery
  6. ReviewOPD date, suction toilet

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.D., 32 years, left ear discharge for 6 months, pale polyp filling the left ear canal; polyp removed for HPE and to see the drum before planned tympanomastoid surgery.

Case details

Date: 10/08/2026. Elective. ENT minor OT.

Start 11:20. End 11:45.

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

Nurse: Sr E. Anaesthesia: local, by surgeon.

Indication and pre-op

Left chronic otitis media with aural polyp. Pale, smooth polyp filling the outer canal, does not bleed on touch. Mucopurulent discharge, swab sent 1 week ago: Pseudomonas, sensitive to ciprofloxacin.

Facial nerve normal both sides. No giddiness, fistula test negative. Tuning forks: left conductive loss.

HRCT temporal bone: soft tissue in left middle ear and antrum, ossicles present, no bony erosion.

Consent: procedure-specific consent in Hindi. Bleeding, ossicle injury, facial weakness, recurrence and HPE result explained.

WHO checklist time out done: side (left) confirmed. No antibiotic prophylaxis given.

Anaesthesia and position

Supine, head turned to the right, left ear up. Local infiltration with 2% lignocaine with adrenaline at the canal. Operating microscope.

Procedure and findings

Discharge cleared with fine suction.

Polyp about 8 x 6 mm, pale, single. Attachment seen under the microscope: it comes through a large central perforation from the middle ear mucosa over the promontory, not from the attic or posterosuperior area.

Ballance aural snare passed over the polyp, wire closed across the stalk and polyp cut cleanly. Not pulled.

After removal: large central perforation, anterior and inferior. Middle ear mucosa oedematous. Handle of malleus intact. No cholesteatoma flakes seen.

Small residual granulations on the promontory left alone.

Bleeding stopped with a dry mop and pressure. Cotton plug placed.

End of procedure

Blood loss about 2 ml.

Facial movements normal. No nystagmus, no giddiness.

Specimen: aural polyp in formalin for HPE.

No complications. Sent to ward in stable condition.

Post-op orders

Check facial movement and ask about giddiness after 2 hours and before discharge.

Change cotton plug if soaked. Keep ear dry.

Ciprofloxacin ear drops as prescribed on the drug chart.

Review in ENT OPD after 1 week with HPE report, for suction toilet and planning of surgery.

Signature

Dr A., JR-2, ENT. Reg. no. ________. 10/08/2026, 12:00.

Must document for this operation

  • Where the stalk was attached. A polyp can arise from the promontory, ossicles or facial nerve, and the site tells the next surgeon what lies under it.
  • That a cutting snare was used and the polyp was not pulled out. Avulsion can damage the ossicles, labyrinth or facial nerve, so the technique protects the surgeon if a deficit is later alleged.
  • Facial nerve function before and after removal. Without a recorded baseline, a weakness cannot be linked to or separated from the procedure.
  • Drum and middle ear findings after the polyp was removed. The type of perforation and any cholesteatoma decide the next operation.
  • Specimen sent for histopathology, with side. The report must be traced and linked to the correct ear before definitive surgery is planned.

Common mistakes in these notes

  • Writing 'polypectomy done' with no side or site of attachment.
  • No pre-operative facial nerve record.
  • Not describing the drum after the polyp was removed.
  • Not recording whether the polyp was cut or pulled.
  • Specimen not sent, or sent without the side marked.

Indian practice and paperwork

  • Tissue not sent for HPE is human anatomical waste for the yellow bag; formalin discarded from specimen jars is yellow (f) chemical waste. (Bio-Medical Waste Management Rules 2016, CPCB guidelines)
  • Consent must be in a language the patient understands and must say who will do the procedure. (NABH 5th ed., PRE.4(c))
  • The operative note, even for a short procedure in the minor OT, must be written before the patient leaves recovery. (NABH 5th ed., COP.14(e))

Sources

  • Tuli BS, Tuli IP, Singh A, Tuli NK. Textbook of Ear, Nose and Throat. 2nd ed. Jaypee Brothers; 2013, Ch 83, Ear surgery instruments: aural snare (Ballance), crocodile forceps, pp. 513-515.
  • Tuli BS, Tuli IP, Singh A, Tuli NK. Textbook of Ear, Nose and Throat. 2nd ed. Jaypee Brothers; 2013, Ch 7, Chronic suppurative otitis media: aural polyp origin and appearance; investigations, pp. 66, 70-71.
  • Hathiram BT, Khattar VS, eds. Atlas of Operative Otorhinolaryngology and Head and Neck Surgery. Jaypee Brothers, Ch 18, Endoscopic management of cholesteatoma (Patil RN): pre-operative aural toilet and removal of aural polyps, pp. 152.

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.

This page cannot be printed from the browser. Use the Download printable PDF button on the page.