ABOUT: Particularly when just starting residency, dictating efficient and concise operative notes can be somewhat daunting.  We have compiled a list of common dictation examples to get you started.  Please also refer to our Surgical Video Atlas, Podcast, and 3D Temporal Bone Atlas for related content. Remember, operative notes carry significant medicolegal implications and it is your responsibility to document accurate and clear notes that reflect the specific details of your procedure. These are only examples and all dictations must be adapted to the particular encounter.

In addition to the describing the surgical narrative, most operative notes include these additional entries, but this may vary according to specific institutional preferences:

PREOPERATIVE DIAGNOSIS: ___
POSTOPERATIVE DIAGNOSIS: ___
PROCEDURE: ___
SURGEON: ___
ASSISTANT: ___
ANESTHESIA: ___ (e.g. GETA, general mask, local)
ESTIMATED BLOOD LOSS: ___
SPECIMENS: ___
INDICATION: ___
KEY FINDINGS: ___
COMPLICATIONS: ___

OTOLOGY & NEUROTOLOGY TABLE OF CONTENTS

1. PE Tubes

2. Butterfly Graft Myringoplasty

3. Transcanal Tympanoplasty with Cartilage Graft

4. Intact Canal Wall Tympanomastoidectomy for Chronic Otitis Media

5. Intact Canal Wall Tympanomastoidectomy for Cholesteatoma

6. Middle Ear Exploration with Stapedotomy

7. Unilateral Cochlear Implantation

8. Bilateral Simultaneous Cochlear Implantation

9. Linear Incision BAHA

10. Skin Punch BAHA

11. Osia Bone Conduction Implant

12. Endolymphatic Sac Decompression

13. Labyrinthectomy

14. Lateral Temporal Bone Resection for External Auditory Canal Carcinoma

15. Combined Mastoid-Middle Cranial Fossa Repair of Temporal Bone CSF Leak

16. Middle Cranial Fossa for Superior Canal Dehiscence Repair

DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. After an adequate plane of mask anesthesia was successfully obtained by the Anesthesia Service, the operating microscope was brought into the field. The right ear was examined and cleaned. The tympanic membrane was identified. A radial fashioned myringotomy was made. The middle ear was suctioned and a tympanostomy tube was placed without difficulty. Ototopical drops were instilled and a cotton ball was placed. We then turned our attention to the contralateral side. The ear was examined and cleaned. The tympanic membrane was identified. A radial fashioned myringotomy was made. The middle ear was suctioned. A tympanostomy tube was placed without difficulty. Ototopical drops were instilled and a cotton ball was placed. This marked the end of the procedure.  The patient was awakened, extubated, and transferred to the PACU in stable condition. All surgical pauses were observed.  Standard operating room protocol and universal precautions were utilized throughout the procedure.

DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. After an adequate plane of general endotracheal anesthesia was successfully obtained by the anesthesia service, the table was turned and the patient was prepped and draped in the usual sterile fashion. Bipolar orbicularis oculi and orbicularis oris facial nerve monitoring electrodes were placed for continuous intraoperative seventh nerve monitoring.  The ear canal was examined. The perforation was seen. The edges were freshened. The perforation was measured in two perpendicular diameters and 2-3 mm were added to these dimensions. Tragal cartilage was then harvested in the usual fashion and the incision was closed using single interrupted suture. The previous measurements were used to cut the tragal cartilage to an appropriate size. Then, a linear incision was made circumferentially around the rim of the tragal cartilage graft to create a groove. The perichondrium was left in place. Next, the butterfly graft was introduced into the ear canal. The medial circumferential lip of the butterfly graft was placed through the perforation and the separate lateral lip was positioned outside the perforation. This provided a stable position of the graft. A small amount of Gelfoam was placed lateral to the reconstruction and a cotton ball was placed. This marked the end of the procedure.  The patient was awakened, extubated, and transferred to the PACU in stable condition.  All surgical pauses were observed.  Standard operating room protocol and universal precautions were utilized throughout the procedure.

DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. After an adequate plane of general endotracheal anesthesia was successfully obtained by the anesthesia service, the table was turned and the patient was prepped and draped in the usual sterile fashion for transcanal tympanoplasty. Bipolar orbicularis oculi and orbicularis oris facial nerve monitoring electrodes were placed for continuous intraoperative seventh nerve monitoring.  The ear canal was examined. Canal injection using 1% lidocaine 1:100,000 with epinephrine was performed. Tragal cartilage was then harvested in the usual fashion and the tragal incision was closed using single interrupted suture. A canal incision was made, a tympanomeatal flap was elevated and the middle ear space was entered. The chorda tympani nerve was identified and preserved. The edges of the perforation were freshened. The perichondrial graft was placed in an underlay fashion and reinforced with a cartilage graft. The middle ear space was then filled with Gelfoam. The reconstructed tympanic membrane was laid flat against the posterior ear canal. Additional Gelfoam was placed lateral to the reconstruction as was Kos-House ointment. A cotton ball was then placed. A head wrap was applied. This marked the end of the procedure.  The patient was awakened, extubated, and transferred to the PACU in stable condition. All surgical pauses were observed.  Standard operating room protocol and universal precautions were utilized throughout the procedure.

DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. After an adequate plane of general endotracheal anesthesia was successfully obtained by the anesthesia service, the table was turned and the patient was prepped and draped in the usual sterile fashion for tympanomastoidectomy.  Bipolar orbicularis oculi and orbicularis oris facial nerve monitoring electrodes were placed for continuous intraoperative seventh nerve monitoring.  The ear canal was examined.  The perforation could be seen.  Canal incisions were made after a vascular strip injection was performed using ___% lidocaine with ___ epinephrine.  Next, a postauricular incision was made through skin and subcutaneous tissue and elevated forward in a loose areolar plane.  Temporalis fascia was then harvested, pressed and set aside for later use.  A musculoperiosteal incision was made to the mastoid cortex and elevated forward in a subperiosteal plane until the ear canal was encountered.  A self-retaining retractor was then placed.  The ear canal skin was then elevated so that the perforation could be seen.  The tympanomeatal flap was elevated, and the middle ear space was entered.  The chorda tympani nerve was identified and preserved.  The ossicular chain was inspected and was found to be intact.  No middle ear cholesteatoma could be seen.  Next, a cortical mastoidectomy with antrotomy was performed using a combination of cutting and diamond drill bits and continuous irrigation.  The tegmen mastoideum and the ear canal were thinned without violation.  The lateral semicircular canal and the incus were identified.  Diseased mucosa was removed from the mastoid.  Next, a tragal cartilage graft was harvested in the usual fashion and closed using single uninterrupted suture.  The cartilage graft was cut to size for later use.  A fascia graft was placed in an underlay fashion under the remnant tympanic membrane. The middle ear space was filled with Gelfoam.  Additional tragal cartilage grafts were used to reinforce the tympanoplasty repair.  The reconstructed tympanic membrane was laid flat against the posterior ear canal.  There was good overlap between the remnant tympanic membrane and the fascia graft. Additional Gelfoam was placed lateral to our reconstruction and Kos-House ointment was applied.   The vascular strip was laid flat in the ear canal.  The postauricular incision was closed in anatomical layers.  A cotton ball was placed.  A head wrap was applied.  This marked the end of the procedure.  The patient was awakened, extubated, and transferred to the PACU in stable condition. All surgical pauses were observed.  Standard operating room protocol and universal precautions were utilized throughout the procedure.

DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. After an adequate plane of general endotracheal anesthesia was successfully obtained by the anesthesia service, the table was turned and the patient was prepped and draped in the usual sterile fashion for intact canal wall tympanomastoidectomy.  Bipolar orbicularis oculi and orbicularis oris facial nerve monitoring electrodes were placed for continuous intraoperative seventh nerve monitoring.  The ear canal was examined.  An ear canal injection was performed using 1% lidocaine 1:100,000 with epinephrine.  A canal incision was performed.  Next, a postauricular incision was made through skin and subcutaneous tissue and elevated forward in a loose areolar plane.  Temporalis fascia was then harvested, pressed and set aside for later use.  A musculoperiosteal incision was made to the mastoid cortex and elevated forward in a subperiosteal plane until the ear canal was encountered.  A self-retaining retractor was then placed.  The ear canal skin was elevated.  This granted good exposure of the tympanic membrane.  The tympanomeatal flap was elevated, and the middle ear space was entered.  The chorda tympani nerve was identified.  The ossicular chain was inspected and was found to be ***.  Cholesteatoma was seen filling the ***.  The diseased portion of the tympanic membrane was excised.  Next, a cortical mastoidectomy with antrotomy was performed using a combination of cutting and diamond drill bits and continuous irrigation.  The tegmen mastoideum and the posterior ear canal were thinned without violation.  The lateral semicircular canal and the incus were identified.  Next, cholesteatoma was systematically removed.  After all visible cholesteatoma was removed, we turned our attention towards reconstruction.  A tragal cartilage graft was harvested in the usual fashion.  Hemostasis was obtained, and the tragal incision was closed with single uninterrupted suture.  Tragal cartilage was cut to size.  The fascia graft was laid under the remnant tympanic membrane.  The middle ear space was filled with Gelfoam.  Additional tragal cartilage grafts were used to reinforce the tympanoplasty.  The reconstructed tympanic membrane was laid flat against the posterior ear canal.  There was good overlap of the remnant tympanic membrane and fascia graft. Additional Gelfoam was placed lateral to the reconstruction as was Kos-House ointment.  The vascular strip was laid flat in the ear canal.  The postauricular incision was then closed in anatomical layers.  A cotton ball was placed.  A head wrap was secured.  This marked the end of the procedure.  The patient was awakened, extubated, and transferred to the PACU in stable condition. All surgical pauses were observed.  Standard operating room protocol and universal precautions were utilized throughout the procedure.

DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. After an adequate plane of general endotracheal anesthesia was successfully obtained by the anesthesia service, the table was turned and the patient was prepped and draped in the usual sterile fashion for middle ear exploration and stapedotomy. Bipolar orbicularis oculi and orbicularis oris facial nerve monitoring electrodes were placed for continuous intraoperative seventh nerve monitoring. A limited postauricular incision was made and a small fascia graft was harvested. The incision was then closed using single interrupted suture. The ear canal was then examined and ___% lidocaine with ___ epinephrine was injected for hemostasis and anesthetic affect. A canal incision was then performed and the tympanomeatal flap was elevated. The middle ear space was entered. The chorda tympani nerve was identified and preserved. Scutal bone was curetted to improve in visualization and the long process of incus and stapes suprastructure were identified. The ossicular chain was palpated. The malleus and incus appeared mobile; however, the stapes was fixed. The incudostapedial joint was then divided. The stapedial tendon was then laser divided, as was the posterior crura of the stapes. The stapes supratructure was then down fractured, exposing the footplate.  A ___ sized ____ prosthesis was brought into the surgical field. A laser rosette stapedotomy was then performed. No perilymph was directly suctioned from the vestibule. The piston was positioned in the fenestra and the shepherd’s hook was placed on the long process of the incus and laser crimped with good coupling. Very small pieces of fascia were placed around the stapedotomy opening. The tympanomeatal flap was laid flat against the ear canal. Small pieces of gelfoam were placed along the canal incision line. Kos-House ointment was applied, a cotton ball was placed and a Band-Aid was applied. This marked the end of the procedure.  The patient was awakened, extubated, and transferred to the PACU in stable condition. All surgical pauses were observed.  Standard operating room protocol and universal precautions were utilized throughout the procedure.

DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. After an adequate plane of general endotracheal anesthesia was successfully obtained by the anesthesia service, the table was turned and the patient was prepped and draped in the usual sterile fashion for cochlear implantation. Bipolar orbicularis oculi and orbicularis oris facial nerve monitoring electrodes were placed for continuous intraoperative seventh nerve monitoring. The ear was examined and ___% lidocaine with ___ epinephrine was injected along the marked incision line.   A postauricular incision was made through skin and subcutaneous tissue and elevated forward.  A separate staggered musculoperiosteal incision was made to the mastoid cortex and elevated forward in a subperiosteal plane until the ear canal was encountered.  A self-retaining retractor was then placed.  Next, a cortical mastoidectomy with antrotomy was performed using a combination of cutting and diamond drill bits and continuous irrigation.  The ear canal was thinned. The lateral semicircular canal and incus were identified.  These served as landmarks for opening the facial recess.  The facial recess was opened and the round window niche was identified.  The round window niche overhang was removed.  Next, a tight subperiosteal pocket created. The surgical site was then copiously irrigated with antibiotic solution.  The device was then brought into the field and placed in a tight subperiosteal pocket with a good snug fit.  Next, under high magnification the round window membrane was incised.  Care was taken to avoid direct suctioning of perilymph from the cochlea.  Next, the electrode was inserted fully without any perceived resistance.  Muscle was packed around the opening.  The incision was then closed in anatomical layers.  Device integrity testing was performed. A head wrap was then applied.  This marked the end of the procedure.  The patient was awakened, extubated, and transferred to the PACU in stable condition. All surgical pauses were observed.  Standard operating room protocol and universal precautions were utilized throughout the procedure.

DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. After an adequate plane of general endotracheal anesthesia was successfully obtained by the anesthesia service, the table was turned and the patient was prepped and draped in the usual sterile fashion for bilateral cochlear implantation. Bilateral bipolar orbicularis oculi and orbicularis oris facial nerve monitoring electrodes were placed for continuous intraoperative seventh nerve monitoring. The right ear was examined and ___% lidocaine with ___ epinephrine was injected along the marked incision line.   A postauricular incision was made through skin and subcutaneous tissue and elevated forward.  A separate staggered musculoperiosteal incision was made to the mastoid cortex and elevated forward in a subperiosteal plane until the ear canal was encountered.  A self-retaining retractor was then placed.  Next, a cortical mastoidectomy with antrotomy was performed using a combination of cutting and diamond drill bits and continuous irrigation.  The ear canal was thinned. The lateral semicircular canal and incus were identified.  These served as landmarks for opening the facial recess.  The facial recess was opened and the round window niche was identified.  The round window niche overhang was removed.  Next, a tight subperiosteal pocket created. The surgical site was then copiously irrigated with antibiotic solution.  The device was then brought into the field and placed in a tight subperiosteal pocket with a good snug fit.  Next, under high magnification the round window membrane was incised.  Care was taken to avoid direct suctioning of perilymph from the cochlea.  Next, the electrode was inserted fully without any perceived resistance.  Muscle was packed around the opening.  The incision was then closed in anatomical layers.  Device integrity testing was performed.

We then turned our attention to the contralateral side and the left ear was prepped and draped in the usual fashion for cochlear implantation. The ear was examined and ___% lidocaine with ___ epinephrine was injected along the marked incision line.  A postauricular incision was made through skin and subcutaneous tissue and elevated forward.  A separate staggered musculoperiosteal incision was made to the mastoid cortex and elevated forward in a subperiosteal plane until the ear canal was encountered.  A self-retaining retractor was then placed.  Next, a cortical mastoidectomy with antrotomy was performed using a combination of cutting and diamond drill bits and continuous irrigation.  The ear canal was thinned. The lateral semicircular canal and incus were identified.  These served as landmarks for opening the facial recess.  The facial recess was opened and the round window niche was identified.  The round window niche overhang was removed.  Next, a tight subperiosteal pocket created with the goal of symmetrical device placement.  The surgical site was then copiously irrigated with antibiotic solution.  The device was then brought into the field and placed in a tight subperiosteal pocket with a good snug fit.  Next, under high magnification the round window membrane was incised.  Care was taken to avoid direct suctioning of perilymph from the cochlea.  Next, the electrode was inserted fully without any perceived resistance.  Muscle was packed around the opening.  The incision was then closed in anatomical layers.  Device integrity testing was performed. A head wrap was then applied.  This marked the end of the procedure.  The patient was awakened, extubated, and transferred to the PACU in stable condition.  All surgical pauses were observed.  Standard operating room protocol and universal precautions were utilized throughout the procedure.

DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. After an adequate plane of general endotracheal anesthesia was successfully obtained by the anesthesia service, the table was turned and the patient was prepped and draped in the usual sterile fashion. The site of osseointegrated screw placement was marked relative to the pinna and temporal line. ___% lidocaine with ___ epinephrine was injected into the skin after measuring the thickness of the skin and subcutaneous tissue. Limited hair was shaved. A vertical linear incision was made through skin and subcutaneous tissue.  Surrounding subcutaneous tissue was removed to the level of the periosteum.  Hemostasis was obtained.   Next, a cruciate incision was made in the periosteum at the site of future osseointegrated screw placement.  A 3-mm pilot drill was brought into the field with the spacer in place. The pilot hole was drilled under continuous irrigation. The depth of the hole was examined and no CSF or dura could be seen. The spacer was removed and the pilot hole was carried to the depth of 4 mm. Again, there was a clean base without air cells, dura, or CSF seen. The 4 mm countersink was brought into the field. The countersink hole was drilled perpendicular to the bone cortex at a setting of 2,000 RPM with continuous irrigation. Next, the 4 mm osseointegrated screw and abutment were brought into the field. On a setting of 40 NCm torque, at low speed, the osseointegrated screw was drilled in place. Irrigation was used after the threads of the screw engaged the cortex. Care was taken to avoid directly touching the osseointegrated screw threads during handling. Following good coupling, the screw was gently manually tightened. The incision was then closed using single interrupted suture after hemostasis was obtain.  The healing cap was applied.  Xeroform gauze was placed circumferentially around the abutment underneath the healing cap.  This marked the end of the procedure.  The patient was awakened, extubated, and transferred to the PACU in stable condition. All surgical pauses were observed.  Standard operating room protocol and universal precautions were utilized throughout the procedure.

DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. After an adequate plane of general endotracheal anesthesia was successfully obtained by the anesthesia service, the table was turned and the patient was prepped and draped in the usual sterile fashion. The site of osseointegrated screw placement was marked relative to the pinna and temporal line. ___% lidocaine with ___ epinephrine was injected into the skin after measuring the thickness of the skin and subcutaneous tissue. A size 5 skin punch was used to remove skin and subcutaneous tissue to the temporal bone cortex. Dissection was performed to remove adjacent underlying periosteum. Next, a 3-mm pilot drill was brought into the field with the spacer in place. The pilot hole was drilled under continuous irrigation. The depth of the hole was examined and no CSF or dura could be seen. The spacer was removed and the pilot hole was carried to the depth of 4 mm. Again, there was a clean base without air cells, dura, or CSF seen. The 4 mm countersink was brought into the field. The countersink hole was drilled perpendicular to the bone cortex at a setting of 2,000 RPM with continuous irrigation. Next, the 4 mm osseointegrated screw and abutment were brought into the field. On a setting of 40 NCm torque, at low speed, the osseointegrated screw was drilled in place. Irrigation was used after the threads of the screw engaged the cortex. Care was taken to avoid directly touching the osseointegrated screw threads during handling. Following good coupling, the screw was gently manually tightened. The healing cap was placed along with Xeroform gauze. This marked the end of the procedure.  The patient was awakened, extubated, and transferred to the PACU in stable condition. All surgical pauses were observed.  Standard operating room protocol and universal precautions were utilized throughout the procedure.

DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. After an adequate plane of general endotracheal anesthesia was successfully obtained by the anesthesia service, the table was turned and the patient was prepped and draped in the usual sterile fashion. The position of the OSI200 Implant was marked taking care to ensure that the sound processor will not interfere with the pinna and was at least 1 cm behind the marked postauricular incision. The soft tissue thickness of the scalp was then measured and was determined to be 9 mm or less in all three measurement points. ___ lidocaine with ____ epinephrine was injected into the skin after measuring the thickness of the skin and subcutaneous tissue. Limited hair was shaved. A final timeout was performed.

A curvilinear incision was made through skin and subcutaneous tissue in a reverse L-fashion postauricularly. Tissue dissection was performed immediately superficial to the periosteum.  Hemostasis was obtained.  Periosteum was removed over the drill site.  A 3-mm pilot drill was brought into the field with the spacer in place. The pilot hole was drilled under continuous irrigation. The depth of the hole was examined and no CSF or dura could be seen. The spacer was removed and the pilot hole was carried to the depth of 4 mm. Again, there was a clean base without air cells, dura, or CSF seen. The 4 mm countersink was brought into the field. The countersink hole was drilled perpendicular to the bone cortex at a setting of 2,000 RPM with continuous irrigation. Next, the 4 mm BI300 Implant was brought into the field. On a setting of ___ Ncm torque, at low speed, the osseointegrated screw was drilled in place. Irrigation was used after the threads of the screw engaged the cortex. Care was taken to avoid directly touching the osseointegrated screw threads during handling. Following good coupling, the screw was gently manually tightened. The bone bed indicator was then placed onto the BI300 Implant (osseointegrated screw) to make sure sufficient clearance was present for the OSI200 Implant. Excess bone and periosteum was removed until the bone bed indicator could be rotated 360 degrees without applying force. The wound bed was then copiously irrigated. Next the OSI200 Implant was brought into the field and tightened onto the BI300 Implant with the machine screwdriver at a torque of 25 Ncm.

The incision was then closed in layers and dermabond applied to the skin. A headwrap dressing was then placed.  This marked the end of the procedure. The patient was awakened, extubated, and transferred to the PACU in stable condition. All surgical pauses were observed.  Standard operating room protocol and universal precautions were utilized throughout the procedure.

DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. After an adequate plane of general endotracheal anesthesia was successfully obtained by the anesthesia service, the table was turned and the patient was prepped and draped in the usual sterile fashion for endolymphatic sac decompression. Bipolar orbicularis oculi and orbicularis oris facial nerve monitoring electrodes were placed for continuous intraoperative seventh nerve monitoring.  The ear was examined and ___% lidocaine with ___ epinephrine was injected along the marked post-auricular incision line.  A postauricular incision was made through skin and subcutaneous tissue and elevated forward in a loose areolar plane.  A separate staggered musculoperiosteal incision was made to the mastoid cortex and elevated forward in a subperiosteal plane until the ear canal was encountered.  A self-retaining retractor was then placed.  Next, a cortical mastoidectomy with antrotomy was performed using a combination of cutting and diamond drill bits and continuous irrigation. The anterior border of the sigmoid sinus was decompressed. The presigmoid posterior fossa dura was then identified and decompressed without durotomy. The posterior semicircular canal was identified and not entered. The endolymphatic sac was identified and completely decompressed. Steroids were instilled into the mastoid, bathing the region of the endolymphatic sac. No CSF leak was encountered. The incision was then closed in anatomical layers and a head wrap was applied. This marked the end of the procedure.  The patient was awakened, extubated, and transferred to the PACU in stable condition.  All surgical pauses were observed.  Standard operating room protocol and universal precautions were utilized throughout the procedure.

DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. After an adequate plane of general endotracheal anesthesia was successfully obtained by the anesthesia service, the table was turned and the patient was prepped and draped in the usual sterile fashion for transmastoid labyrinthectomy. Bipolar orbicularis oculi and orbicularis oris facial nerve monitoring electrodes were placed for continuous intraoperative seventh nerve monitoring.  The ear was examined and ___% lidocaine with ___ epinephrine was injected along the marked incision line.  A postauricular incision was made through skin and subcutaneous tissue and elevated forward in a loose areolar plane.   A separate staggered musculoperiosteal incision was made to the mastoid cortex and elevated forward in a subperiosteal plane until the ear canal was encountered.  A self-retaining retractor was then placed.  Next, a cortical mastoidectomy with antrotomy was performed using a combination of cutting and diamond drill bits and continuous irrigation.  The lateral semicircular canal was identified, as was the incus.  The facial nerve was identified in the descending segment and was left in a bony covering.  Next, a labyrinthectomy was performed beginning with the lateral semicircular canal, the posterior semicircular canal and finally the superior semicircular canal.  The vestibule was identified.  Vestibular neuroepithelium was identified and cleaned from the vestibule.  No CSF leak was encountered.  The incision was then closed in anatomical layers.  A head wrap was applied.  This marked the end of the procedure.  The patient was awakened, extubated, and transferred to the PACU in stable condition. All surgical pauses were observed.  Standard operating room protocol and universal precautions were utilized throughout the procedure.

DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. After an adequate plane of general endotracheal anesthesia was successfully obtained by the anesthesia service, the table was turned and the patient was prepped and draped in the usual sterile fashion. Bipolar orbicularis oculi and orbicularis oris facial nerve monitoring electrodes were placed for continuous intraoperative seventh nerve monitoring.

After the head a neck team had concluded ___, we entered the procedure. A small post auricular limb was extended to the incision and the mastoid cortex was exposed. A self-retaining retractor was then placed.  Next, a cortical mastoidectomy with antrotomy was performed using a combination of cutting and diamond drill bits and continuous irrigation. The descending segment of the facial nerve was identified and traced inferiorly. Additional drilling was performed in the root of the zygoma carrying this forward to connect with the TMJ capsule. The interior trough was also connected to the neck and parotid bed. The incudostapedial joint was divided and the stapes suprastructure was left undisturbed. The bony ear canal was fractured forward across the carotid canal and removed from the field. The surgical site was inspected to ensure no remnants of epithelium from the ear canal remained. The eustachian tube was then occluded using musculoperiosteum. The head and neck team then entered the procedure for surgical site closure. Standard procedural protocols and universal precautions were utilized throughout the entire procedure.

DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. After an adequate plane of general endotracheal anesthesia was successfully obtained by the anesthesia service, the table was turned and the patient was prepped and draped in the usual sterile fashion for combined mastoid – middle cranial fossa repair of CSF leak. Bipolar orbicularis oculi and orbicularis oris facial nerve monitoring electrodes were placed for continuous intraoperative seventh nerve monitoring. A small strip of hair was shaved along the temporal scalp. The incision was marked and infiltrated with ___% lidocaine with ___ epinephrine. A postauricular incision was made through skin and subcutaneous tissue and elevated forward in a loose areolar plane.  Temporalis fascia was then harvested, pressed and set aside for later use. A musculoperiosteal incision was made to the mastoid cortex and elevated forward in a subperiosteal plane until the ear canal was encountered.  A self-retaining retractor was then placed. A cortical mastoidectomy with antrotomy was performed using a combination of cutting and diamond drill bits and continuous irrigation. An encephalocele was identified filling the mastoid antrum and medial mastoid. The encephalocele was bipolar coagulated and reduced. The incision was then extended to include the temporal limb. An incision was made through skin and subcutaneous tissue and elevated in a loose areolar plane. Temporalis muscle was then divided to expose the squamosal portion of the temporal bone. A self-retaining cerebellar retractor was then placed. Next, the neurosurgical team entered the procedure for temporal craniotomy.

After the neurosurgical team had performed temporal craniotomy and repair of encephalocele with CSF leak, we once again entered the procedure. Bone pate and fascia were used to reinforce the repair from the mastoid side. The bone plate was replaced with mini plates and screws. Temporalis muscle was approximated, as was the musculoperiosteum over the mastoid. The incision was then closed in anatomical layers. A head wrap was applied. This marked the end of the procedure.  The patient was awakened, extubated, and transferred to the PACU in stable condition.  All surgical pauses were observed.  Standard operating room protocol and universal precautions were utilized throughout the procedure.

DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. After an adequate plane of general endotracheal anesthesia was successfully obtained by the anesthesia service, the table was turned and the patient was prepped and draped in the usual sterile fashion for subtemporal middle cranial fossa repair of superior canal dehiscence. Bipolar orbicularis oculi and orbicularis oris facial nerve monitoring electrodes were placed for continuous intraoperative seventh nerve monitoring.  A small strip of temporal scalp hair was shaved.  An incision line was marked and infiltrated with ___% lidocaine with ___ epinephrine. A temporal incision was made through skin and subcutaneous tissue and elevated anteriorly and posteriorly in a loose areolar plane.  Next, temporalis muscle was divided and retracted anteriorly and posteriorly in order to expose the squamosa of the temporal bone. The neurosurgical team then entered the procedure and performed temporal craniotomy. 

After the neurosurgical team had performed temporal craniotomy, we once again entered the procedure.  The inferior aspect of the craniotomy was lowered to the middle fossa floor.  Bone wax was used to meticulously occlude any exposed air cells of the craniotomy.  The subtemporal dura was very carefully elevated.  The medial petrous ridge was identified and dura was elevated from posterior to anterior.  The greater superficial petrosal nerve was identified.  The region of the arcuate eminence was also identified.  The superior canal dehiscence was delineated.  Great care was taken to avoid direct suctioning over the fistula.  The superior canal dehiscence was then occluded using a combination of fascia and small bone chips.  Thinned areas of tegmen were reinforced with fascia.  The craniotomy air cells were then once again carefully inspected, and any remaining open air cells were occluded with bone wax.  The bone flap was then repositioned using mini plates and screws.  The temporalis muscle was then reapproximated.  The incision was closed in anatomical layers.  A head wrap was applied.  This marked the end of the procedure.  The patient was awakened, extubated, and transferred to the PACU in stable condition.  All surgical pauses were observed.  Standard operating room protocol and universal precautions were utilized throughout the procedure.