OT notes · ENT

Excision of preauricular sinus

Usual anaesthesia
Children: general anaesthesia. Adults: local infiltration (2% lignocaine with 1:200,000 adrenaline) with sedation
Position
Supine, head on a head ring, turned to the opposite side
Setting
elective

Operative note template for excision of a preauricular sinus by simple sinectomy or the supra-auricular approach, with a filled example for a child with a recurrently infected sinus operated under general 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

  • recurrence (reported 2 to 50%), needing a second operation
  • wound infection
  • haematoma
  • bleeding from the superficial temporal artery
  • infection of the ear cartilage (perichondritis)
  • small piece of ear cartilage removed
  • visible or keloid scar
  • numbness in front of the ear

Pre-operative details for this operation

  1. SideRightLeftBilateral
  2. IndicationDischarging sinusRecurrent infection / abscessRecurrence after previous surgeryCosmetic / patient requestnumber of infections, previous incision and drainage, previous excision
  3. Current infectionQuietActive: operation deferred, antibiotics
  4. Ear examinationpinna (perichondritis), ear canal, drum
  5. Syndromic features / renal or hearing anomaly screenas indicated
  6. Hair shaved in front of the pinnaYesNot needed

Anaesthesia and position

  1. AnaesthesiaGeneralLocal with sedationif local: drug, strength, adrenaline, volume
  2. PositionSupine, head ring, turned to opposite side

Operative findings

  1. Punctumsite (anterior helix / crus), scarring from past infection
  2. Tractdirection, branches, cyst(s), depth
  3. Attachment to helix cartilagePresent: cartilage excisedAbsent
  4. Pus / granulationsNonePresent

Procedure (steps)

  1. Tract markedLacrimal probeMethylene blue injectedBothNeither
  2. Infiltrationdrug, strength, adrenaline, volume
  3. IncisionEllipse around punctum (simple sinectomy)Ellipse extended up to the supra-auricular temporal region (supra-auricular approach)Ellipse with vertical extension in front of the pinnaInverted L with skin flapellipse includes scarred skin
  4. Dissectionen bloc with skin ellipse; medial limit temporalis fascia, posterior limit helix cartilage
  5. Cartilage at attachmentSmall piece excisedNot needed
  6. Structures preservedsuperficial temporal artery, preauricular nerve; bleeding controlled by cautery or ligation
  7. Specimen checked completeblue-stained tract intact, no cut end

Closure, drains and dressing

  1. Cartilage defectClosed with fine absorbable interrupted suturesNot needed
  2. Local anaesthetic infiltrationbupivacaine 0.25%, volume
  3. Subcutaneous layerabsorbable, size
  4. SkinInterrupted non-absorbableAbsorbable subcuticularadhesive strips
  5. DrainNoneSmall drain (reason)
  6. DressingMastoid pressure dressingSimple dressing

Specimens and implants

  1. Sinus tract with skin ellipse and cysts for HPESentNot sent
  2. Pus for cultureSentNone

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. Dressingkeep pressure dressing on; check for swelling (haematoma)
  2. Analgesiadrug, dose (mg/kg for a child), frequency
  3. Antibioticsif prescribed: drug, dose, duration
  4. Oral intakewhen awake
  5. Wound check and suture removaldate; absorbable sutures need no removal
  6. Warning signsswelling, redness, discharge, fever: come back
  7. Follow HPE and reviewOPD date; watch for recurrence

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 Y.T., 8 years, 24 kg, right preauricular sinus with discharge and two infections needing antibiotics in the last year, the last one drained by needle aspiration 3 months ago; now quiet.

Case details

Date: 16/12/2026. Elective. OT 6.

Induction 09:05. Incision 09:20. Closure completed 10:05.

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

Right preauricular sinus, punctum at the root of the helix, with a small scar below it from the old aspiration. No active infection now.

Pinna, ear canal and drum normal. Hearing normal on screening. No other ear or kidney anomaly known.

Consent: general, procedure-specific and anaesthesia consent from father in Telugu. Recurrence, infection, haematoma, small cartilage removal and scar explained.

Hair in front of the right ear shaved. Side marked. WHO checklist sign in and time out done.

Inj cefazolin 720 mg IV (30 mg/kg) at 09:10, before incision, as the sinus had been infected before.

Anaesthesia and position

General anaesthesia. Supine, head on a ring, turned to the left. Parts painted with povidone-iodine and draped.

Procedure and findings

Lacrimal probe passed gently into the punctum: tract runs forward and down for about 1.5 cm. Methylene blue injected into the tract.

Infiltration around the sinus with 2% lignocaine with 1:200,000 adrenaline, 2 ml.

Elliptical incision around the punctum including the old scar, extended upward into the supra-auricular temporal region.

Dissection with fine curved scissors in the subcutaneous plane, keeping outside the blue-stained tract. Temporalis fascia identified as the deep limit. Tract had one branch ending in a small cyst 6 mm in front of the tragus.

Tract adherent to the helix cartilage at its root: a 3 x 3 mm piece of cartilage excised with the tract.

Superficial temporal artery seen and preserved. One small branch cauterised.

Specimen checked: skin ellipse, tract, branch and cyst in one piece, no cut blue tract.

Closure

Cartilage defect closed with fine interrupted absorbable sutures (polyglactin 910, Vicryl). Bupivacaine 0.25%, 3 ml, infiltrated into the wound. Subcutaneous layer closed with absorbable sutures. Skin closed with absorbable subcuticular suture and adhesive strips. No drain. Mastoid pressure dressing.

Specimens and implants

Sinus tract with skin ellipse, branch, cyst and cartilage piece sent in formalin for HPE.

No implant.

End of procedure

Blood loss about 10 ml.

Mop, needle and instrument count correct.

No intra-operative complications.

Extubated and shifted to recovery awake. Pulse 98/min, SpO2 99%.

Post-op orders

Keep pressure dressing on until review; check for swelling in front of the ear.

Syrup paracetamol as per weight, as charted.

Oral fluids when awake, then normal diet.

Discharge when wound is dry and child is eating. Wound check in OPD on the date given; sutures absorbable, no removal needed.

Come back for swelling, redness, discharge or fever.

Review with HPE report.

Signature

Dr A., JR-2, ENT. Reg. no. ________. 16/12/2026, 10:20.

Must document for this operation

  • How the tract was marked and whether it came out in one piece. Incomplete excision is the main cause of recurrence, and the note should show the surgeon checked the specimen.
  • Whether helix cartilage was excised at the attachment. The tract often attaches to the cartilage, and leaving it is linked to recurrence; a revision surgeon needs to know.
  • Approach used and the limits of dissection (temporalis fascia, helix cartilage). The supra-auricular approach is recorded so the next surgeon knows how wide the first dissection went.
  • Number of past infections and any past incision or drainage. Recurrence is more likely after repeated infection, and this explains a later recurrence.
  • Specimen sent for HPE. The pathologist confirms the tract and cysts, and the report is kept with the record.

Common mistakes in these notes

  • Writing 'sinus excised' with no mention of the cartilage attachment.
  • Not recording the approach (simple ellipse vs supra-auricular).
  • No note that the specimen was checked for completeness.
  • Operating on an actively infected sinus without recording why.
  • Leaving out the side in a child with bilateral pits.

Indian practice and paperwork

  • For a child, consent is from the parent or guardian, in a language they understand, and must say who will operate. (NABH 5th ed., PRE.4(c))
  • 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)
  • The prophylactic antibiotic should be given within 60 minutes before incision. (SaQushal Patient Safety Self-Assessment Tool, NHSRC 2022)

Sources

  • Hathiram BT, Khattar VS, eds. Atlas of Operative Otorhinolaryngology and Head and Neck Surgery. Jaypee Brothers, Ch 4, Preauricular sinus (Khattar VS, Hathiram BT, Devane S, Rode S), pp. 39-41.
  • Davenport M, Geiger JD, eds. Operative Pediatric Surgery (Rob & Smith's Operative Surgery). 8th ed. CRC Press; 2021, Ch 2, Head and neck surgery: preauricular sinus (Gander JW), e-book PDF pp. 97-100.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Table 1: paediatric cefazolin 30 mg/kg IV, not above the adult dose of 2 g, within 60 min before incision. 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.

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