OT notes · ENT

Excision of parapharyngeal space tumour

Usual anaesthesia
General anaesthesia (nasal intubation helps; avoid muscle relaxants if nerve monitoring or stimulation is used)
Position
Supine, shoulder roll, neck extended, head turned to the opposite side
Setting
elective

Operative note template for excision of a parapharyngeal space tumour, with a filled example for transcervical excision of a prestyloid pleomorphic adenoma.

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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

  • facial nerve weakness, most often the lower lip branch (marginal mandibular)
  • weakness of cranial nerves IX to XII: swallowing difficulty, aspiration, hoarse voice, shoulder weakness, tongue weakness
  • Horner's syndrome
  • bleeding, injury to the carotid artery or jugular vein, stroke
  • airway swelling; tracheostomy may be needed
  • wound infection, haematoma, seroma
  • first bite syndrome (pain in the parotid area with the first bite of a meal)
  • tumour rupture and recurrence
  • need for a wider approach (parotidectomy or mandibulotomy)

Pre-operative details for this operation

  1. Side and compartmentPrestyloidPoststyloidon MRI / CT: size, relation to deep lobe of parotid (fat plane present / absent), carotid displaced which way
  2. Tissue diagnosisFNAC (transoral / image-guided): resultNot doneopen incisional biopsy avoided
  3. Suspected paragangliomaNoYes: catecholamine work-up, embolisation date
  4. Cranial nerve examination before surgeryVII, IX, X (vocal cord on endoscopy), XI, XII; Horner's
  5. Blood cross-matchedunits
  6. Approach plannedTranscervicalTranscervical-transparotidTransmandibularTransoral / TORS

Anaesthesia and position

  1. AnaesthesiaGA, nasal tubeGA, oral tube fixed to opposite sideno long-acting muscle relaxant if nerve monitoring used
  2. Nerve monitoringFacialVagusNot used
  3. PositionSupine, shoulder roll, head turned to opposite side, mouth closed

Operative findings

  1. Tumoursize, capsule, consistency, compartment, attachment to deep lobe of parotid
  2. Relation to great vesselsinternal carotid and jugular displaced which way
  3. Nervesmarginal mandibular, XI, X, XII (and VII trunk if transparotid): identified and preserved / sacrificed (reason)
  4. Capsule at the endIntactBreached: spill, what was done

Procedure (steps)

  1. IncisionTransverse skin-crease incision, 2 finger-breadths below the mandibleModified Blair (with parotidectomy)length
  2. Subplatysmal flapsmarginal mandibular branch identified and preserved
  3. Sternomastoid retracted back; posterior belly of digastric exposedfrom tendon to mastoid; used as guide to XI, X, XII and carotid sheath
  4. Submandibular glandMobilised and retracted forwardRemoved
  5. Facial arteryLigatedPreserved
  6. Access widenedStylomandibular ligament dividedDigastric / stylohyoid dividedStyloid process removedMandible pulled forwardNone needed
  7. Internal carotid identified and kept away from tumourvessel loops avoided on nerves if possible
  8. Tumour mobilisedgentle blunt dissection along the capsule; gauze peanuts soaked in 1:10,000 adrenaline; no vigorous finger dissection
  9. Tumour deliveredIntact, capsule not breachedPiecemeal / ruptured
  10. Parotidectomy / facial nerve dissection (if done)superficial lobe removed or pedicled; branches preserved
  11. Cavity inspected and haemostasispharyngeal mucosa intact / breached and repaired

Closure, drains and dressing

  1. DrainSuction drainNonesize, exit site
  2. Layersplatysma and skin: material, technique
  3. Tracheostomy / nasogastric tubeNeitherTracheostomyNasogastric tuberoutine after transmandibular approach
  4. Dressing

Specimens and implants

  1. Tumour sent for HPEsize, whole / fragments, capsule intact; orientation stitch if used
  2. Submandibular gland / parotid tissue sentYesNot removed
  3. Plates (mandibulotomy only)NoneType, number, batch, sticker pasted

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. Airwaystridor, oropharyngeal swelling; head up
  2. Cranial nerve check on wakingface (lower lip), voice, swallowing, tongue, shoulder
  3. Oral intakesips after swallow is checked; nasogastric feeds if unsafe
  4. Drainoutput chart; remove when output low
  5. Neck swellinghaematoma: call surgeon at once
  6. Eye careif upper facial weakness: lubricants, moisture chamber
  7. Speech and swallowing therapyif IX or X weakness
  8. Follow HPEtumour board if malignant

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: Mrs. K.D., 42 years, left oropharyngeal fullness for 1 year; MRI shows a 5 cm left prestyloid parapharyngeal mass with a fat plane between it and the deep lobe of the parotid; FNAC: pleomorphic adenoma.

Case details

Date: 20/10/2026. Elective. OT 5.

Induction 09:00. Incision 09:30. Closure completed 11:45.

Surgeon: Dr C. (consultant, ENT). Assistants: Dr A. (3rd-year resident), who did the incision, flap elevation and closure; Dr B. (1st-year resident).

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Left prestyloid parapharyngeal pleomorphic adenoma, 5 x 4 x 4 cm on MRI, left tonsil and soft palate pushed medially, internal carotid displaced backward, fat plane from deep lobe of parotid preserved. FNAC (transoral): pleomorphic adenoma.

Cranial nerves normal: face symmetric, both vocal cords mobile on endoscopy, tongue central, shoulder shrug normal. No Horner's.

Blood group B positive, 2 units cross-matched.

Consent: general, procedure-specific and anaesthesia consent in Hindi. Facial (lower lip) weakness, cranial nerve IX to XII weakness, Horner's syndrome, vessel injury, first bite syndrome, tumour spill and need for a wider approach explained and written on the form.

WHO checklist sign in and time out done. No antibiotic prophylaxis (clean procedure, no mucosal entry planned).

Anaesthesia and position

General anaesthesia, nasal intubation, no long-acting muscle relaxant after intubation (nerve stimulator used).

Supine, shoulder roll, neck extended, head turned to the right, mouth closed. Neck and lower face painted with povidone-iodine and draped.

Procedure and findings

Transverse skin-crease incision 8 cm, two finger-breadths below the left mandible. Subplatysmal flaps raised. Marginal mandibular branch identified and preserved.

Sternomastoid retracted back. Posterior belly of digastric exposed from tendon to mastoid. Accessory nerve, hypoglossal nerve, vagus and carotid sheath identified.

Submandibular gland mobilised and retracted forward. Facial artery ligated. Stylomandibular ligament divided; mandible gently pulled forward for more space.

Tumour: 5 cm, smooth, encapsulated, rubbery, in the prestyloid space, medial to the medial pterygoid, not attached to the deep lobe of the parotid. Internal carotid behind it, not adherent.

Tumour freed by gentle blunt dissection along the capsule with gauze peanuts soaked in 1:10,000 adrenaline, working around it step by step. No finger dissection.

Tumour delivered intact through the neck, capsule not breached.

Cavity inspected: pharyngeal mucosa intact, no bleeding. Hypoglossal, vagus, accessory and marginal mandibular nerves intact at the end.

Closure

Suction drain placed in the tumour bed. Platysma closed with absorbable sutures. Skin closed with interrupted sutures. Dry dressing.

No tracheostomy, no nasogastric tube.

Specimens and implants

Tumour, 5 x 4 x 4 cm, whole, capsule intact, sent in formalin for HPE.

No implant.

End of procedure

Estimated blood loss 150 ml. No transfusion.

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

No intra-operative complications.

Extubated awake. Lower lip moving symmetrically, voice normal, tongue central. Shifted to recovery. Pulse 82/min, BP 126/80 mmHg.

Post-op orders

Head end raised. Watch for stridor and neck swelling; call ENT resident on call at once if present.

Check face, voice, swallowing, tongue and shoulder on waking and on the morning round.

Sips of water once swallowing has been checked and is normal, then soft diet.

Drain output charted; remove when output is low.

Analgesia as per drug chart.

Review with HPE report in OPD.

Signature

Dr A., JR-3, ENT, for Dr C. Reg. no. ________. 20/10/2026, 12:00.

Must document for this operation

  • Cranial nerve function before and after surgery (VII, IX, X, XI, XII, Horner's). Nerve deficits are the main morbidity, and the consent must have mentioned them; a recorded baseline separates new deficits from old ones.
  • Whether the capsule was intact or breached, and any spill. Capsule rupture of a pleomorphic adenoma can cause recurrence up to 20 years later, so the follow-up plan depends on it.
  • Approach used and any extra steps (stylomandibular ligament, digastric, submandibular gland, styloid). A revision surgeon needs to know which structures were already divided or removed.
  • Relation of the tumour to the internal carotid and the parotid deep lobe. It confirms the compartment and explains the choice of approach if a complication occurs.
  • Nerves seen and preserved or sacrificed, with the reason. Planned sacrifice (for example of a vagal schwannoma) must match what was consented.
  • Specimen description: whole or in pieces, size. The pathologist and the follow-up plan both depend on whether the tumour came out whole.

Common mistakes in these notes

  • No pre-operative vocal cord or cranial nerve record.
  • Writing 'tumour excised' without saying whether the capsule was intact.
  • Not naming the structures divided to gain access.
  • Consent that mentions only 'nerve injury' instead of the specific deficits (vocal cord palsy, Horner's syndrome).
  • No post-operative swallow check before oral feeds.

Indian practice and paperwork

  • Consent must explain the procedure, risks, alternatives and who will operate, in a language the patient understands. For this operation the form should name the specific nerve deficits. (NABH 5th ed., PRE.4(c))
  • If a mandibulotomy is done, the plates' batch and serial numbers must go in the record, the OT master logbook and the discharge summary. (NABH 5th ed., MOM.10(d))
  • Formalin discarded from specimen jars is yellow (f) chemical waste. (Bio-Medical Waste Management Rules 2016, CPCB guidelines)

Sources

  • Hathiram BT, Khattar VS, eds. Atlas of Operative Otorhinolaryngology and Head and Neck Surgery. Jaypee Brothers, Ch 174, Parapharyngeal space tumors (Brown R, Ducic Y); Ch 175, Parapharyngeal space tumors (Horowitz G, Fliss DM), pp. 1500-1525.
  • Simo R, et al., eds. Atlas of Head and Neck Surgery. Springer Surgery Atlas Series. Springer Nature; 2024, Ch 22, Parapharyngeal space tumour excision (Rijken JA, Palme CE, Leemans CR), pp. 207-213.
  • 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; clean-contaminated cancer surgery: cefazolin or cefuroxime plus metronidazole, or ampicillin-sulbactam. 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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