OT notes · ENT

Septorhinoplasty

Usual anaesthesia
General anaesthesia with cuffed endotracheal tube and throat pack, plus local infiltration with lignocaine and adrenaline
Position
Supine, head on a head ring, table tilted head-up about 15 degrees; tube and drapes fixed in the midline
Setting
elective

Operative note template for septorhinoplasty by open or endonasal approach, with a filled example for an open septorhinoplasty with osteotomies and spreader grafts for a post-traumatic deviated nose.

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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

  • bleeding and bruising around the eyes
  • infection
  • nasal blockage
  • septal haematoma or septal perforation
  • graft moving, showing through or absorbing
  • skin necrosis, visible or thick scar (external approach)
  • numb nasal tip for up to 6 months (external approach)
  • dissatisfaction with the shape, need for revision
  • dressings, splint for about a week, time off work

Pre-operative details for this operation

  1. Patient's concerns and the agreed planwhat the patient wants changed, what cannot be achieved; written plan signed
  2. Nasal analysisdeviation by thirds (bony / middle / lower), dorsal hump, tip projection and rotation, nasolabial angle, skin thickness, internal valve, septum on endoscopy
  3. History of trauma or previous nasal surgerydate of injury; previous operation notes
  4. Standard photographsfrontal, both laterals, both obliques, basal; displayed in OT
  5. Graft source plannedSeptal cartilageConchal cartilageCostal cartilageAlloplastic implant (type)
  6. Fitness for GA and bleeding history

Anaesthesia and position

  1. AnaesthesiaGA, cuffed oral tube, throat packGA with controlled hypotension
  2. Local infiltrationdrug, strength, adrenaline dilution, total volume; sites: septum, columella, marginal incisions, dorsum, osteotomy lines
  3. Topical vasoconstrictionpacks or paste to nasal mucosa, drug
  4. PositionSupine, head ring, 15 degrees head-up
  5. Eye protectionOintment and tapeEye pads

Operative findings

  1. Septumdeviation (side, caudal / high / bony), spurs, old fractures
  2. Bony vaultdeviation, width, hump size
  3. Middle vault and upper lateral cartilagesasymmetry, collapse, inverted V
  4. Tip and lower lateral cartilagesshape, symmetry, strength
  5. Skin thicknessThinMediumThick

Procedure (steps)

  1. Vibrissae trimmed
  2. Septoplastyincision (hemitransfixion / Killian), side; subperichondrial flap; chondrotomy; cartilage and bone removed; dorsal and caudal struts left (width in mm)
  3. Caudal septumRepositioned and fixed to nasal spineNot neededsuture used
  4. ApproachExternal: columellar (stepped / inverted V) + marginal incisionsEndonasal: intercartilaginous + transfixion
  5. Skin-soft tissue envelope elevatedplane (supraperichondrial / subperiosteal over bone), extent up to nasion; columellar arteries coagulated
  6. Upper lateral cartilages separated from dorsal septummucosa preserved if spreader grafts planned
  7. Hump reductionCartilage with blade / scissorsBony hump with osteotome / chisel / sawNot doneamount removed; rasping; debris washed out
  8. Medial osteotomiesosteotome width; not above the intercanthal line
  9. Lateral osteotomiesPercutaneous stab, 2 mm osteotomeEndonasal, curved guarded osteotomehigh-low-high; bone triangle at the pyriform aperture preserved; infracture complete
  10. GraftsSpreader graftsColumellar strutTip / shield graftAlar batten / rim graftDorsal onlaysource, size in mm, suture used to fix
  11. Tip workcephalic trim (rim left, mm), dome sutures, other
  12. Final checkprofile, symmetry from above, septum midline, airway

Closure, drains and dressing

  1. Columellar skinsuture material and size
  2. Marginal / intercartilaginous / hemitransfixion incisionssuture material and size
  3. Septal quilting / splintsQuilting sutureSilastic splintsNone
  4. Nasal packsExpandable (Merocel) packsRibbon gauzeNonenumber, what soaked in, time due out
  5. External dressingbenzoin, skin tapes, plaster of Paris or thermoplastic splint
  6. Throat pack removedYes, counted

Specimens and implants

  1. Grafts usedtype, source, size; any cartilage left over
  2. Alloplastic implantNoneType, size, make, batch number, sticker pasted
  3. Tissue sent for HPENoneSent (reason)

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. Positionhead up 30 degrees
  2. Cold compressesice packs to the eyes
  3. Nasal packsremoval time (for example next morning); watch for bleeding after removal
  4. Analgesiaparacetamol and an NSAID if no contraindication: drug, dose, frequency
  5. Steroidif prescribed to reduce swelling: drug, dose, duration
  6. Antibioticsif grafts used and prescribed: drug, dose, duration
  7. Nasal caresaline drops; antibiotic ointment to nostrils; no nose blowing; sneeze with mouth open
  8. Splint and suturesremoved at 1 week
  9. Follow-up1 month and 4 months with photographs

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. N.J., 24 years, nose broken in a cricket injury 2 years ago, now a C-shaped nose deviated to the left and left nasal obstruction from a deviated septum.

Case details

Date: 14/05/2026. Elective open septorhinoplasty. OT 5.

Induction 09:00. Incision 09:35. Closure and splint completed 12:05.

Surgeon: Dr C. (consultant, ENT). Assistant: Dr A. (3rd-year resident), who did the septoplasty and closure. Second assistant: Dr B.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Post-traumatic deviated nose. Upper and middle thirds deviated to the left, small dorsal hump, tip slightly to the left. Septum deviated to the left with caudal dislocation. Left internal valve narrow. Skin medium thickness.

Patient's aims: straight nose, better breathing on the left. Explained that a small asymmetry may remain. Written plan agreed.

Standard photographs taken and displayed in OT.

Consent: general, procedure-specific and anaesthesia consent in English. Bleeding, septal haematoma and perforation, graft problems, columellar scar, numb tip, dissatisfaction and revision explained.

WHO checklist sign in and time out done. Inj cefazolin 2 g IV and inj metronidazole 500 mg IV at 09:20, before incision. Inj dexamethasone 8 mg IV given by anaesthetist at induction.

Anaesthesia and position

General anaesthesia, cuffed oral tube fixed in the midline, moist throat pack placed.

Supine on a head ring, 15 degrees head-up. Eyes lubricated and taped. Face prepared with aqueous chlorhexidine, drapes crossed in the midline.

Nose packed with ribbon gauze soaked in adrenaline (1:80,000) for 15 minutes, then removed. 2% lignocaine with 1:80,000 adrenaline, 6 ml in total, infiltrated into the septum, columella, marginal incision lines, dorsum and lateral osteotomy lines.

Procedure and findings

Vibrissae trimmed.

Septoplasty: right hemitransfixion incision with No. 15 blade. Subperichondrial flap raised on the left. Quadrilateral cartilage deviated to the left with a spur on the maxillary crest; caudal septum off the spine to the left. Chondrotomy anterior to the perpendicular plate, cartilage freed inferiorly. Deviated posterior cartilage and bony spur removed; dorsal and caudal struts preserved, each measured at 12 mm and recorded. Harvested cartilage kept in saline. Caudal septum repositioned to the midline and fixed to the nasal spine with polydioxanone (PDS) 3-0.

External approach: stepped (Gunter) columellar incision at the narrowest point, joined to bilateral marginal incisions. Columellar skin elevated without notching the medial crura. Paired columellar arteries coagulated with bipolar.

Skin-soft tissue envelope raised in the supraperichondrial plane over the lower laterals and dorsum, periosteum elevated over the nasal bones up to the nasion. Aufricht retractor placed.

Findings: left upper lateral cartilage collapsed, right one longer; dorsal septum deviated to the left; 2 mm bony-cartilaginous hump; tip cartilages symmetric.

Upper lateral cartilages separated from the dorsal septum, mucosa preserved. Cartilaginous hump lowered 2 mm with No. 15 blade. Bony hump taken with 7 mm osteotome and rasped smooth; debris washed out with saline.

Medial osteotomies with 4 mm osteotome from the septum-nasal bone junction, fading laterally, not above the intercanthal line. Lateral osteotomies through stab incisions with 2 mm osteotome, high-low-high, keeping the bone triangle at the pyriform aperture. Complete infracture, bones mobile.

Two spreader grafts from septal cartilage, each about 25 x 3 x 2 mm, placed between the septum and upper lateral cartilages and fixed with polyglactin 910 rapid (Vicryl Rapide) 5-0 horizontal mattress sutures.

Tip not altered. Final check from above: dorsum straight, septum midline, both airways open.

Closure

Columellar skin closed with absorbable 5-0 polyglactin (Vicryl) mattress sutures. Marginal and hemitransfixion incisions closed with Vicryl Rapide 4-0.

Merocel pack in each side, coated with antibiotic ointment.

Benzoin painted, skin tapes from radix to tip, plaster of Paris splint moulded over the dorsum and osteotomy sites, fixed with tape. Bolster under the nose.

Throat pack removed and counted.

End of procedure

Estimated blood loss 200 ml. No transfusion.

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

No intra-operative complications. No alloplastic implant used. No specimen sent for HPE; excess cartilage discarded.

Extubated smoothly. Shifted to recovery in stable condition. Pulse 84/min, BP 118/74 mmHg.

Post-op orders

Nurse 30 degrees head-up. Ice packs to both eyes for the first day.

Remove Merocel packs tomorrow morning; watch for bleeding for 30 minutes after removal.

Tab paracetamol and an NSAID as per drug chart.

Tab dexamethasone 2 mg four times a day for 5 days.

Saline nasal drops and antibiotic ointment to nostrils. No nose blowing; sneeze with the mouth open.

Discharge after pack removal if no bleeding. Splint and skin sutures off at 1 week. Review at 1 month and 4 months with photographs.

Signature

Dr A., JR-3, ENT, for Dr C. Reg. no. ________. 14/05/2026, 12:20.

Must document for this operation

  • The patient's stated aims and the written plan agreed before surgery. Dissatisfaction is the main complaint after rhinoplasty, and a documented plan protects the surgeon if the patient later disputes what was promised.
  • Width of dorsal and caudal septal struts left. The struts are the support left for the nose, and a revision surgeon needs to know what septal cartilage remains.
  • Every graft: source, size, position and fixation. Grafts can move or absorb, and a revision surgeon needs to know what was placed and where.
  • Osteotomies done, their type and whether the infracture was complete. Incomplete osteotomies explain early relapse, and the type affects the airway at the pyriform aperture.
  • Any alloplastic implant with its batch number and sticker. NABH requires implant batch and serial numbers in the record for recall.
  • Packs and throat pack: number placed and removed. A retained throat pack is a serious never event, and ward staff must know how many nasal packs to remove.

Common mistakes in these notes

  • Writing 'SRP done' with no approach, osteotomies or grafts.
  • Not recording the strut width left after septoplasty.
  • No note of throat pack removal and count.
  • Pre-operative photographs taken but not mentioned or stored with the record.
  • Not naming which parts the resident did.

Indian practice and paperwork

  • If an alloplastic implant (silicone, polyethylene or similar) is used, its batch and serial number must be recorded in the patient record, the OT master logbook and the discharge summary. (NABH 5th ed., MOM.10(d))
  • Consent must be in a language the patient understands and must say who will do the operation. For a cosmetic operation, record the patient's expectations as part of the consent discussion. (NABH 5th ed., PRE.4(c))
  • Excess cartilage or bone not sent for HPE is human anatomical waste for the yellow bag. (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 97, A colour atlas of septorhinoplasty (Ifeacho S, Dasgupta R, Kenyon G), pp. 887-915.
  • Ballantyne JC, Harrison DFN, eds. Rob & Smith's Operative Surgery: Nose and Throat. 4th ed. Butterworths; 1986, Rhinoplasty (Bull TR, Mackay IS), pp. 66-79.
  • Ballantyne JC, Harrison DFN, eds. Rob & Smith's Operative Surgery: Nose and Throat. 4th ed. Butterworths; 1986, Reduction of fractures of the nasal bones (Brain D): pre-operative adrenaline packs, post-operative ice packs, pp. 5, 16.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Rhinoplasty is listed as a clean-contaminated head and neck procedure; Table 2 (other clean-contaminated procedures except tonsillectomy and FESS): cefazolin or cefuroxime plus metronidazole, or ampicillin-sulbactam. Table 1: cefazolin 2 g (3 g if 120 kg or more), metronidazole 500 mg, 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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