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Postoperative Care Map for Skull Base Surgery

return to: Otology - Neurotology

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