A nurse is caring for a client with chronic otitis media who is scheduled for a mastoidectomy. Which nursing intervention should be the priority in the immediate postoperative period?

Monitoring for facial nerve paralysis is the priority because the facial nerve runs through the mastoid bone and can be damaged during surgery, leading to permanent paralysis if not detected early. Other interventions are important but less critical immediately post-op.

Understanding the Priority After Mastoidectomy
A mastoidectomy involves the surgical removal of diseased mastoid air cells, located in the temporal bone directly behind the ear. The surgical field is in extremely close proximity to the facial nerve (Cranial Nerve VII). Even with meticulous surgical technique, the nerve can be affected by postoperative edema, hematoma formation, or direct trauma from the procedure itself. An injury to this nerve results in an inability to close the eyelid, a drooping mouth, and a loss of facial expression on the affected side, which can be devastating for the patient.

Why Monitoring for Facial Nerve Paralysis is the Priority
In the immediate postoperative period, the nurse’s primary neurological assessment must focus on the functional integrity of the facial nerve. This is a time-sensitive evaluation because any new or progressive deficit requires prompt identification and reporting to the surgical team. A key clinical implication highlighted in the literature is that complications from oncologic temporal bone surgery, which includes mastoidectomy, have not been systematically categorized until recently, underscoring the importance of vigilant, standardized postoperative monitoring for specific deficits like facial nerve palsy ^[1]. The assessment involves asking the patient to perform a series of simple movements: raise the eyebrows, squeeze the eyes shut tightly, smile, and show the teeth. The nurse observes for symmetry, noting any asymmetry or inability to move one side of the face. This is not merely a passive observation but an active, critical component of the postoperative nursing assessment that directly impacts long-term patient outcomes.

Analyzing the Incorrect Options
- Option 2: Encourage frequent coughing and deep breathing exercises. While pulmonary hygiene is a standard postoperative intervention to prevent atelectasis and pneumonia, it is not the unique, highest-priority concern for a mastoidectomy. More importantly, activities that increase intrathoracic pressure, such as vigorous coughing, can also increase venous pressure in the head and neck. This can theoretically disrupt the surgical site, increase the risk of bleeding, and place undue stress on delicate structures, including the facial nerve. The focus on preventing postoperative nausea and vomiting (PONV) is critical in otologic surgeries precisely because the act of vomiting can have similar detrimental effects on graft stability and pressure in the operative field .
- Option 3: Position the client on the affected side to promote drainage. This is contraindicated. The standard postoperative positioning for a mastoidectomy is to keep the patient flat or with the head of the bed slightly elevated, with the operative ear up. Positioning the patient on the affected side places direct pressure on the incision line and the delicate underlying surgical reconstruction, potentially compromising the blood supply to the skin flap, causing pain, and hindering healing. The goal is not to promote drainage from the ear itself but to protect the surgical site. A pressure dressing is typically in place, and the ear canal may be packed, but gravity drainage is not the objective.
- Option 4: Remove the ear packing within 24 hours to prevent infection. The internal ear packing, which often contains antibiotic ointment and supports the reconstructed structures, is typically removed by the surgeon during a follow-up visit, usually one to three weeks postoperatively, not by the nurse within the first 24 hours. Premature removal would destroy the structural support for the tympanic membrane graft or the mastoid cavity, leading to surgical failure. The external pressure dressing is also left in place for a specified time, often 24-48 hours, to prevent hematoma formation. The nurse’s role is to monitor the dressing for signs of excessive drainage or bleeding, not to remove the internal packing ^[1]. The focus on procedure-specific pain and process quality in otolaryngology surgery reinforces that postoperative care protocols, including the management of surgical dressings and packing, are highly specific to the procedure and must be followed precisely .