OT notes · ENT

Myringotomy with grommet insertion

Usual anaesthesia
General anaesthesia in children; local or topical anaesthesia in selected cooperative adults
Position
Supine, head turned to the opposite side on a head ring, operated ear up (sitting and tilted back if done under local)
Setting
elective

Operative note template for myringotomy with grommet (ventilation tube) insertion, with a filled example for bilateral grommets in a child with persistent otitis media with effusion.

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

  • ear discharge through the tube after surgery
  • tube blocked with blood or mucus
  • fluid coming back after the tube comes out, need for repeat tubes
  • persistent hole in the eardrum after the tube comes out
  • white scarring or thinning of the eardrum
  • tube slipping into the middle ear
  • chronic infection needing tube removal
  • lasting hearing loss or ringing in the ear
  • brief giddiness or facial weakness when local anaesthetic is used

Pre-operative details for this operation

  1. SideRight earLeft earBoth earswrite in full; match with consent, audiogram and site mark; mark each ear separately when bilateral
  2. IndicationOtitis media with effusion (OME) with hearing loss after 3 months of monitoringRecurrent acute otitis mediaEustachian tube dysfunction / retracted drumOther (state)duration of effusion, dates of the two hearing assessments
  3. Otoscopy before surgeryeach ear: dull / retracted / fluid level or bubbles / blue drum; any attic retraction
  4. Tympanometryeach ear: type (A / B / C) and ear canal volume
  5. Audiogramdate; age-appropriate test; thresholds or air-bone gap each ear
  6. Adenoidectomy discussedNot indicatedDiscussed, family chose grommets alonePlanned in same sitting (separate adenoidectomy note)nasal blockage, snoring; record the shared decision
  7. Red flags excludedno pulsatile mass behind the drum (high jugular bulb, glomus, aberrant carotid); bleeding disorder asked
  8. Syndromes / cleft palate / Down syndromeNonePresent (state)narrow canals and repeat surgery are more likely

Anaesthesia and position

  1. AnaesthesiaGeneralLocal infiltrationTopical
  2. PositionSupine, head turned away on head ringSitting, tilted back, head held by assistant (local)
  3. Operating microscopeUsed
  4. Speculumlargest aural speculum that fits the canal; size

Operative findings

  1. Ear canalNormal calibreNarrowwax cleared or not
  2. Tympanic membraneretracted / dull / bulging / blue / atrophic segments / myringosclerosis; attic retraction
  3. Middle ear effusionNone (dry tap)Serous (thin, straw coloured)Mucoid (thick glue)PurulentBlood stainedrecord for each ear separately
  4. Middle ear mucosa through the incisionNormalOedematous / inflamed
  5. Bleeding from incisionMinimalBrisk (how controlled)

Procedure (steps)

  1. Speculum placed, canal cleared, drum seen in full under microscopespeculum size; wax cleared or not
  2. MyringotomyAnteroinferior quadrant, radialAnteroinferior quadrant, circumferentialPosteroinferior (anteroinferior not visible, reason written)sickle knife; make it slightly larger when a tube is planned; never posterosuperior (incus and stapes lie behind it)
  3. Effusion handledSuctionedNot aspiratedSecond incision to release thick gluesuction tip size; character of fluid
  4. Sample of effusionNot sentPus swab for culture and sensitivity
  5. Grommet insertedShort-term (e.g. Shepard, Shah)Long-term T-tubeOther (state)material (Teflon / titanium / gold), size, pull string trimmed; inserted with microforceps or applicator, inner flange under the anterior edge first, rest pushed in with a needle or pick
  6. Position and lumen checkedtube sits across the drum in the anteroinferior quadrant, lumen open, flanges on both sides
  7. Ear drops at end of procedureCiprofloxacin drops, single doseNonewrite drug and ear; avoid aminoglycoside drops when there is no active infection
  8. Repeat for other ear (if bilateral)write the findings and tube for the second ear separately
  9. Adenoidectomy (if combined)write as a separate procedure note

Closure, drains and dressing

  1. Bleeding from incision edgeNoneSettled with suctionTopical vasoconstrictor applied (drug)
  2. Final checktube in place and lumen clear in each ear at end, no tube lost in the middle ear
  3. Tube lost into middle ear (if it happened)RetrievedLeft in situ (reason)

Specimens and implants

  1. SpecimenNoneMiddle ear pus for culture (side labelled)
  2. Grommet, right eartype, material, inner diameter, make, lot/batch, sticker in file
  3. Grommet, left eartype, material, inner diameter, make, lot/batch, 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. Watch the earbleeding or discharge from the canal; note side
  2. Ear drops (if prescribed)drug, ear, number of days; quinolone drops, not aminoglycoside
  3. Ear discharge after discharge hometell parents it is the commonest problem; come back to ENT OPD; treated with ciprofloxacin drops
  4. Water precautionswrite the unit's advice; some texts advise keeping water out, others note ear protection makes little difference to discharge with bathing and swimming
  5. Analgesiadrug, dose, frequency
  6. Giddiness or facial weakness (local anaesthesia cases)usually from the local; record and inform if it persists
  7. Hearing reassessmentaudiogram / tympanometry date written on the discharge card
  8. Tube follow-uptube usually comes out on its own in about 3 to 18 months; review to check it is in place or has come out; removal under microscope if it stays too long or is chronically infected

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: Master A.K., 6 years, 18 kg. Poor hearing and school complaints for 5 months. Bilateral OME with type B tympanograms on two tests 3 months apart. No nasal blockage.

Case details

Date: 12/05/2026. Elective, day case. ENT OT 1.

In OT 09:10. Induction 09:15. First incision 09:22. End 09:38.

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

Pre-op diagnosis: bilateral otitis media with effusion with hearing loss, persisting over 3 months of active monitoring.

Procedure planned and performed: bilateral myringotomy with grommet insertion.

Otoscopy: both drums dull and retracted, amber fluid behind both. No attic retraction. No pulsatile mass.

Tympanometry (10/02/2026 and 08/05/2026): type B both ears, normal canal volume.

Play audiometry (08/05/2026): about 30 dB conductive loss both ears.

Adenoidectomy discussed with parents. No nasal symptoms. Shared decision for grommets alone. No bleeding history.

Consent: general and procedure-specific consent from father in Marathi. Risks of ear discharge, blocked tube, repeat surgery, persistent hole and scarring of drum explained.

Both ears marked. WHO checklist sign in and time out done.

Anaesthesia and position

General anaesthesia. Supine on head ring, head turned to the left for the right ear first.

Operating microscope used. Largest aural speculum that fitted each canal (4 mm).

Procedure and findings

Right ear: small wax flake removed with suction. Drum dull and retracted, seen in full.

Radial myringotomy in the anteroinferior quadrant with a sickle knife. Thick mucoid (glue) effusion, suctioned. Mucosa slightly oedematous.

Shepard grommet (Teflon) placed with microforceps, inner flange under the anterior edge first, rest pushed in with a pick. Seated well, lumen clear.

Head turned to the right. Left ear: canal clear. Anteroinferior radial myringotomy. Serous straw coloured effusion, suctioned. Same type of grommet placed. Seated well, lumen clear.

Ciprofloxacin ear drops, single dose instilled into each canal.

Closure

No bleeding from either incision. Both tubes checked again under the microscope: in place, lumens open.

Specimens and implants

No specimen.

Right: Shepard grommet, Teflon, size ______, make ______, lot ______, sticker pasted.

Left: Shepard grommet, Teflon, size ______, make ______, lot ______, sticker pasted.

End of procedure

Blood loss negligible. Instrument count correct. No intra-operative complications.

Shifted to recovery awake. Pulse 102/min, SpO2 99% on room air.

Post-op orders

Watch for bleeding or discharge from either ear.

Analgesic as per drug chart.

Discharge today if comfortable. Parents told to return if ear discharge starts.

Water advice as per unit protocol explained to parents.

ENT OPD review on 16/06/2026 (date given on discharge card) for tube check, tympanometry and audiogram.

Signature

Dr A., JR-2, ENT. Reg. no. ________. 12/05/2026, 09:50.

Must document for this operation

  • Side, and for bilateral cases, findings and tube for each ear written separately. A single line for both ears hides which ear had pus or a difficult insertion, and the next surgeon needs it per ear.
  • Site of the myringotomy (quadrant) and the reason if it was not anteroinferior. A posterior incision risks the incus and stapes, so a note of the site defends the surgeon if hearing falls.
  • Character of the effusion in each ear (serous, mucoid, purulent, none). A dry tap questions the indication, and pus explains early discharge and the culture sent.
  • Tube type, material, size, make and lot number, with sticker. Short-term and long-term tubes have different expected stay and perforation risk, and implant details are needed for recall.
  • Final check that each tube is in place and none is lost into the middle ear. A tube that slipped into the middle ear must be recorded and explained to the family on the day.
  • The decision on adenoidectomy. It shows the option was offered and the family took part in the decision.

Common mistakes in these notes

  • Writing 'B/L M and G done' with no findings per ear.
  • Not recording the quadrant of the incision.
  • Leaving out the type and size of the grommet and the implant sticker.
  • Not writing what the fluid looked like, or writing 'glue' for both ears when one was serous.
  • No mention of the drops used at surgery, so the ward repeats or omits them.
  • Not writing the hearing reassessment date.

Indian practice and paperwork

  • Consent must explain the procedure, risks, benefits, alternatives (hearing aid, waiting) and who will operate, in a language the parents understand. (NABH 5th ed., PRE.4(c))
  • If consent was for one ear, a second-ear myringotomy found necessary on the table is an extra procedure. Consent for both ears should be taken in advance when it is contemplated. (Samira Kohli v. Prabha Manchanda, (2008) 2 SCC 1)
  • A grommet is an implanted device. Its batch and serial number go in the case record, the OT implant register and the discharge summary. (NABH 5th ed., MOM.10(d))
  • NABH expects the operative note before the patient leaves recovery, which matters in a short day-case list. (NABH 5th ed., COP.14(e))
  • Paediatric records can be kept until the child attains majority, so the op note may be read many years later. (Thomas J. Indian J Urol 2009;25:384-8)

Sources

  • Donne AJ, Nixon IJ, eds. Scott-Brown's Otorhinolaryngology Head and Neck Surgery. 9th ed. CRC Press, Ch 129, Otitis media with effusion (Markey A, Sharma S): surgical management, technique, adenoidectomy, complications, pp. 1385-1390.
  • Theissing J, Rettinger G, Werner JA. ENT-Head and Neck Surgery: Essential Procedures. Thieme, Ch 16, Surgery of the bony ear canal and tympanic membrane: myringotomy and tube insertion, pp. 355-357.
  • Bull TR. Color Atlas of ENT Diagnosis. 4th ed. Thieme, The tympanic membrane and middle ear: glue ear, myringotomy, grommets, pp. 84-88.

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.