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Protocol was last updated before 2010

Postoperative Care (TL and MCF)

1. Surgical Intensive Care Unit
   • Overnight Neurological monitoring for intracranial bleed.
   • No narcotics used except codeine, tylenol #3, occasional fentanyl
   • Zofran, Reglan used for nausea, avoid Phenergan
   • Control blood pressure to prevent intracranial bleed.
   • Carefully assess & document facial nerve function as soon as patient can give reliable exam.
     • Facial function may decline postoperatively secondary to swelling.
     • Good function immediately postoperatively generally implies complete return of function if the nerve does not suffer a delayed paralysis.
2. Postoperative Day 1
   • Transfer from surgical intensive care unit to general floor (3JPW)
   • Change dressing daily
     • x 5 days for BG patients,
     • qod x 4 days for MH patients.
   • Remove Foley catheter, arterial lines, supplemental oxygen, EKG leads/telemetry
   • Hemoglobin level if extensive blood loss intraoperatively
   • Up to chair, ambulate, PT
   • Clear liquids when nausea is under adequate control
     • may then advance diet as tolerated
   • Ambulate with assistance
   • Assess hearing status if MCF (tuning fork exam)
   • Daily nystagmus & facial nerve exam
   • The patient should be asked daily if he or she has a salty taste in mouth, or has noticed any dripping from nose
   • Remove abdominal Penrose drain (TL only), monitor abdominal wound (both TL & MCF)
3. Postoperative Day 2
   • Ambulate with assistance x 6 times
   • Patient receives a total of 6 doses of antibiotics (Ancef or Clindamycin) and steroids (Decadron)
     • If delayed facial paresis develops, the steroids + an antiviral are continued for 10 days
4. Postoperative Day 3
   • Reservoir test for CSF rhinorrhea x 3 minutes
5. Discharge planning may start as early as POD3
   • Criteria
     • Tolerating PO intake
     • Ambulating independently
     • Has had bowel movement (is not absolute requirement)
     • No CSF leak or fevers
6. Discharge instructions
   • No heavy lifting above 15 pounds for four weeks
   • No bending below the waist for four weeks
   • No nose blowing
   • Sneeze through open mouth
   • No strenuous activity or bearing down for four weeks
   • May wash hair after dressing is removed
     • No salon treatments until 1 month postop
   • Patient may resume driving when they feel able
   • No CPAP x4 weeks
7. If patient develops CSF leak
   • Place lumbar drain for 5 full days
     • BG: full bedrest
     • MH: may clamp x15 min for ambulation 3x daily
   • Clamp on the morning of postoperative day 6
   • Test reservoir at least 8 hours after clamping
   • If negative, remove drain and observe for 24 hours until discharge
   • If positive, revision surgery indicated to close leak
     • Approach depends on hearing status
     • After translab, do subtotal petrousectomy: obliterate mastoid and eustachian tube, close off EAC
     • If hearing present, revise MCF and place more fat, fascia, and muscle into the IAC defect; make sure no air cells are unwaxed
     • Place lumbar drain for 5 full days postoperatively
8. After discharge
   • Remove stitches (may be done locally)
     • 7-10 days for BG patients
     • 10-14 days for MH patients
     • Delay suture removal if CSF effusion is present
   • Follow-up appointment at four weeks postoperatively
     • MRI with gadolinium (consider CISS, FIESTA sequence if unable to administer contrast)
     • Test hearing if MCF approach
     • Document facial function
     • Release to return to work