Operative Note (Myringotomy/Tympanostomy Tube Placement)

Date: [Date]

Patient Name: [Patient full name]

DOB: [DOB]

MRN: [MRN]

Surgeon: [Surgeon name and credentials]

Assistant(s): [Assistant name(s) / None]

Preoperative Diagnosis

[Diagnosis with laterality] (e.g., chronic otitis media with effusion, recurrent acute otitis media, eustachian tube dysfunction)

Postoperative Diagnosis

[Final diagnosis with laterality] (Informed by intraoperative findings; include effusion descriptor if present, e.g., bilateral mucoid middle ear effusion)

Procedure(s) Performed

• [Myringotomy with tympanostomy tube placement, right / left / bilateral]
• [Concurrent procedure, if any] (e.g., adenoidectomy; omit line if none)

Anesthesia

[General mask anesthesia / LMA / MAC / other]

Indications

[Brief summary of clinical indication, duration/recurrence, hearing concerns if relevant, and confirmation of informed consent] (2–4 sentences focusing on why this procedure today)

Findings

Right Ear: (If unilateral procedure on opposite ear, state "Not operated" or omit)

• External auditory canal: [Normal / cerumen impaction / other]
• Tympanic membrane: [Intact / perforated]; [retracted / neutral / bulging]; [notable features if any]
• Middle ear effusion: [No effusion / serous / mucoid / purulent / sanguineous]

Left Ear: (If unilateral procedure on opposite ear, state "Not operated" or omit)

• External auditory canal: [Normal / cerumen impaction / other]
• Tympanic membrane: [Intact / perforated]; [retracted / neutral / bulging]; [notable features if any]
• Middle ear effusion: [No effusion / serous / mucoid / purulent / sanguineous]

Procedure Details

[Patient positioned supine. Operating microscope used. Standard surgical time-out performed.]

Right Ear:

[Cerumen removed if needed]. A myringotomy was made in the [anteroinferior quadrant / other location]. [Effusion type] was suctioned from the middle ear. A [tube type/brand] tube was inserted; patency was confirmed. [Otic drops] were instilled. [Cotton ball placed / No dressing].

Left Ear:

[Cerumen removed if needed]. A myringotomy was made in the [anteroinferior quadrant / other location]. [Effusion type] was suctioned from the middle ear. A [tube type/brand] tube was inserted; patency was confirmed. [Otic drops] were instilled. [Cotton ball placed / No dressing].

Implants

Right Ear: [Tube type/brand], [size], [manufacturer], [catalog/lot # if available] — [Placed and patent / None: [reason]]

Left Ear: [Tube type/brand], [size], [manufacturer], [catalog/lot # if available] — [Placed and patent / None: [reason]]

(If tube specifications or identifiers are not provided, note as "[Not documented]")

Specimens

[Right ear culture obtained / Left ear culture obtained / Bilateral cultures obtained / None]

EBL

[Minimal / Estimated blood loss in mL]

Complications

[None / Description with laterality, management, and impact on plan]

Disposition

[Stable] to [PACU / recovery] in [good / fair] condition.

Postoperative Plan

• Otic drops: [Drug name, dosing, frequency, duration, and indication / No postoperative antibiotic ear drops prescribed] (Per AAO-HNSF, routine drops not recommended; document rationale if prescribed)
• Water precautions: [No water precautions / Restrictions: [specific guidance and rationale]] (Per AAO-HNSF, routine water precautions not recommended)
• Follow-up: [Timeframe for postoperative ear examination] (Within 3 months per AAO-HNSF guideline)
• Return precautions: Persistent drainage, fever, worsening pain, hearing concerns