Head & Neck Surgery

The following pages are provided to introduce the common disorders and surgical procedures performed by our physicians . Please consult with your physician concerning your individual condition or recommendation for procedure.

Topics Covered On This Page:

• Foreign Bodies in the Ear, Nose, and Airway
• Ventilating Ear Tubes
• Questions Most Commonly Asked
• Tympanoplasty
• Mastoidectomy
• Stapedectomy
• Tonsillectomy/Adenoidectomy
• Tongue-tie (Ankyloglossia)
• Nosebleeds
• Microlaryngoscopy & Bronchoscopy
• Treating Nasal and Sinus Polyps
• Rhinoplasty & Nasal Septal Surgery
• Nose & Facial Fractures
• Deviated Nasal Septum and Turbinate Hypertrophy
• Surgery for Nasal Obstruction: Standard and Laser Surgeries
• Thryroid Gland
• Head and Neck Cancer
• Salivary Glands
• Drainage of Neck Abscesses

The expanded Ear, Nose and Throat (ENT) services include diagnostic evaluation and treatment of patients with a wide a range of problems relating to head and neck.

When surgery is required, we offer comprehensive pre- and postoperative services.

Foreign Bodies in the Ear, Nose, and Airway

Foreign bodies in the ear, nose, and breathing tract (airway) sometimes occur in children. Foreign bodies refer to any object that is placed in the ear, nose, or mouth that is not meant to be there and could cause harm without immediate medical attention.

Foreign bodies in the ear:

Foreign bodies can either be in the ear lobe or in the ear canal. Objects usually found in the ear lobe are earrings, either stuck in the lobe from infection or placed too deep during insertion. Foreign bodies in the ear canal can be anything a child can push into his/her ear. Some of the items that are commonly found in the ear canal include the following:

• food
• insects
• toys
• buttons
• pieces of crayon
• small batteries

It is important for parents to be aware that children may cause themselves or other children great harm by placing objects in the ear. The reason children place things in their ears is usually because they are bored, curious, or copying other children. Sometimes, one child may put an object in another child's ear during play. Insects may also fly into the ear canal, causing potential harm. It has also been noted that children with chronic outer ear infections tend to place things in their ears more often.

What are the symptoms of foreign bodies in the ear?

Some objects placed in the ear may not cause symptoms, while other objects, such as food and insects, may cause pain in the ear, redness, or drainage. Hearing may be affected if the object is blocking the ear canal.

Treatment for foreign bodies in the ear:

The treatment for foreign bodies in the ear is prompt removal of the object by your child's physician. The following are some of the techniques that may be used by your child's physician to remove the object from the ear canal:

• instruments may be inserted in the ear
• magnets are sometimes used if the object is metal
• cleaning the ear canal with water
• a machine with suction to help pull the object out

After removal of the object, your child's physician will then re-examine the ear to determine if there has been any injury to the ear canal. Antibiotic drops for the ear may be prescribed to treat any possible infections.

Foreign bodies in the nose:

Objects that are put into the child's nose are usually soft things. These would include, but are not limited to, tissue, clay, and pieces of toys, or erasers. Sometimes, a foreign body may enter the nose while the child is trying to smell the object. Children often place objects in their noses because they are bored, curious, or copying other children.

What are the symptoms of foreign bodies in the nose?

The most common symptom of a foreign body in the nose is nasal drainage. The drainage appears only on the side of the nose with the object and often has a bad odor. In some cases, the child may also have a bloody nose.

Treatment for foreign bodies in the nose:

Treatment of a foreign body in the nose involves prompt removal of the object by your child's physician. Sedating the child is sometimes necessary in order to remove the object successfully. This may have to be performed in the hospital, depending on the extent of the problem and the cooperation of the child. The following are some of the techniques that may be used by your child's physician to remove the object from the nose:

• suction machines with tubes attached
• instruments such as small tweezers called forceps

After removal of the object, your child's physician may prescribe nose drops or antibiotic ointments to treat any possible infections.

Foreign bodies in the airway:

Foreign bodies in the airway constitute a medical emergency and require immediate attention. The foreign body can get stuck in many different places within the airway. Foreign bodies in the airway account for nearly 9 percent of all home accidental deaths in children under 5 years of age.

As with other foreign body problems, children tend to put things into their mouths when they are bored or curious. The child may then inhale deeply and the object may become lodged in the "airway" tube (trachea) instead of the "eating" tube (esophagus). Food may be the cause of obstruction in children who do not have a full set of teeth to chew completely, or those children who simply do not chew their food well. Children also do not have complete coordination of the mouth and tongue which may also lead to problems. Children between the ages of 7 months and 4 years are in the greatest danger of choking on small objects, including, but not limited to, the following:

• seeds
• toy parts
• grapes
• hot dogs
• pebbles
• nuts
• buttons

Children need to be watched very closely to avoid a choking emergency.

What are the symptoms of foreign bodies in the airway?

Foreign body ingestion requires immediate medical attention. The following are the most common symptoms that may indicate a child is choking. However, each child may experience symptoms differently. Symptoms may include:

• choking or gagging when the object is first inhaled
• coughing at first
• wheezing (a whistling sound, usually made when the child breathes out)

Although the initial symptoms listed above may subside, the foreign body may still be obstructing the airway. The following symptoms may indicate that the foreign body is still causing an airway obstruction:

• stridor (a high pitched sound usually heard when the child breathes)
• cough that gets worse
• child is unable to speak
• pain in the throat area or chest
• hoarse voice
• blueness around the lips
• not breathing
• the child may become unconscious

Treatment for foreign bodies in the airway:

Treatment of the problem varies with the degree of airway blockage. If the object is completely blocking the airway, the child will be unable to breath or talk and his/her lips will become blue. This is a medical emergency and you should seek emergency medical care. Sometimes, surgery is necessary to remove the object. Children that are still talking and breathing but show other symptoms also need to be evaluated by a physician immediately.

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Ventilating Ear Tubes

Tympanostomy tubes are tiny tubes that are placed in the eardrum. Also called "ear tubes", they are usually placed for these reasons:

• If your child has repeated ear infections that do not get better with antibiotics
• If your child has fluid in his or her middle ear space for 3 months or more.

The middle ear space is normally filled with air. If the middle ear is filled with fluid instead of air, hearing is muffled or garbled. This is what happens with ear infections. By draining fluid, tympanostomy tubes allow the middle ear to fill with air again and ventilate properly.

The main concern about fluid in the ear is that it makes sound garbled. This can interfere with your child's learning to speak because children imitate the sounds they hear. Hearing usually improves soon after the tubes are placed. Your doctor or an audiologist should check to make sure that your child's hearing is normal.

How are tubes placed in your child's ears?

Tubes are placed during surgery. Most children will go home the same day of the surgery. Your child is briefly put to sleep during the procedure. When you schedule the surgery, we will tell you that your child cannot ear or drink (including water) for a certain number of hours before the surgery. It is very important to have an empty stomach so that he or she doesn't vomit and inhale it in while asleep.

After you child is asleep, your doctor makes a tiny surgical opening under a microscope in your child's eardrum. Any fluid present in the middle ear is then suctioned out. Next, the tube is put in the small opening in the eardrum. Most tubes look like a small spool, generally the size of the tip of a pen.

It is normal for your child to be tired, irritable or feel sick to his or her stomach for a few hours after surgery. If your child continues to feel sick or vomits after you go home, call your doctor. There may be persistent watery ear drainage, sometimes blood-tinged, for the next 48 hours. This is normal.

When your child is ready to eat, offer clear liquids such as juice, broth, or popsicles, and if tolerated offer a light diet such as toast, crackers, or applesauce. When your child eats these foods without problems, he or she can resume a normal diet.

Activity Restrictions

Most children resume their normal routine shortly after surgery. Watch for unsteadiness during the first 24 hours after surgery. If your child does seem unsteady or dizzy, encourage quiet activities such as reading, watching TV or coloring. Traveling by airplane or to the mountains (elevation changes) will not hurt your child's ears.

More Ear Infections?

Although the risk is lowered, ear infections can still happen, usually occurring with a cold. Infections may start with drainage, but generally have little (or no) pain or fever. The drainage is usually thick and sticky with noticeable odor. Call your doctor if this happens. Most infections can be successfully treated with ear drops alone.

Water Precautions After Surgery

After tubes are placed, some children may get ear infections from water entering the ear canal and going through the tube. This seems to happen more often with older children. To protect the ears from water take a piece of cotton, place it snugly in the outer ear, then cover it generously with Vaseline to make it waterproof. Some studies have shown that water precautions are not needed for babies. Your doctor may suggest:

• Sometimes protect the ears from water. Use the cotton plugs if your child tends to submerge his or her head and ears while bathing or swimming.
• Always protect ears from water while bathing or hair washing. Follow the instructions above for using cotton plugs. Custom ear plugs are also available.

Some children are more susceptible to ear infections with even little water exposure and should always use water precautions. If incidental water enters your child's ear, use drops given to you after surgery and place 5 drops in that ear.

Follow Up

Please schedule a follow up visit for 2-3 weeks after surgery. Further follow up visits are needed for every six months thereafter. Your child's ears need to be examined regularly for the status of the tube and health of the middle ear.

The tube will work its way out of the eardrum and into the ear canal on its own. This usually happens 6-12 months after surgery. In most children the remaining hole in the ear drum will slowly close. Less than 20% of all children with tympanostomy tubes need a second set of tubes.

Call Your Doctor If...

• An ear infection develops after surgery and can not be successfully treated by your family doctor or pediatrician.
• If you have any other questions.

For more information visit www.entnet.org/kidsENT.

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Questions Most Commonly Asked

What are Tympanostomy tubes?

A Tympanostomy tube is a tiny tube that is inserted through a small hole in the eardrum to allow air to get into the middle ear. The tubes come in many different shapes and sizes and are usually made of plastic or metal.

Why does my child need tubes?

Some children develop frequent middle ear infections or retain fluid in the middle ear because the Eustachian tube, a tube that connects the middle ear to the throat, isn't working well enough to allow air to pass into the middle ear. Ear infections can be very painful and fluid in the middle ear can impair hearing and speech development. Placement of a tube can help these problems by allowing air to enter and permitting fluid to drain out.

After tubes are placed, will my child still get ear infections?

Some children with tubes still get middle ear infections, but they are less common and are rarely painful. Children with tubes who get middle ear infections usually have visible pus or drainage in the ear canal. If this happens to your child, bring him/her to the doctor? The infection can be easily treated in most cases.

How long will my child need the tubes?

Usually tubes remain in place for 9 to 12 months. Generally the tubes will fall out by themselves and the holes will heal up. Most children will eventually outgrow the tendency to develop middle ear infections and will no longer need the tubes. If your child continues to have frequent middle ear infections, it is possible that your physician will recommend replacing the tubes.

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Tympanoplasty (Repair of Perforated Ear Drum)

What is a tympanoplasty?

A tympanoplasty is a surgical procedure that repairs or reconstructs the eardrum (tympanic membrane) to help restore normal hearing. This procedure may also involve repair or reconstruction of the small bones behind the tympanic membrane (ossiculoplasty) if needed. Both the eardrum and middle ear bones (ossicles) need to function well together for normal hearing to occur.

What are the indications for a tympanoplasty?

This procedure is usually not performed (or needed) in children under four years of age. A tympanoplasty is recommended when the eardrum is torn (perforated), sunken in (atelectatic), or otherwise abnormal and associated with hearing loss. Abnormalities of the ear drum and middle ear bones can occur through injury, otitis media, congenital (at birth) deformities, or chronic ear conditions such as a cholesteatoma.

How successful is tympanoplasty in restoring normal hearing?

Return to a normal range of hearing after tympanoplasty is dependent upon the extent of the abnormality. Surgeries that involve repair of the eardrum only usually have a success rate of 85-90%. A second operation may be necessary in some cases if the hearing is not restored to an acceptable level.

Are there any other options aside from tympanoplasty?

Tympanoplasty in most cases is an elective procedure, meaning that it can be scheduled whenever the patient is ready to have it done. Another option instead of this procedure includes the use of a hearing aid. When the tympanic membrane has a hole (perforation) in it, earplugs are usually recommended to protect the middle ear from infection. In a few cases, such as a significant infection or a cholesteatoma, this procedure may prevent more significant damage to the ear and the surgery may need to be performed more urgently.

What is done in preparation for a tympanoplasty?

Usually other ear, nose, and throat conditions are treated before a tympanoplasty is considered. For example, if an adenoidectomy is indicated, this surgery is usually completed before tympanoplasty.

Otitis Media of any type should not be present at the time of surgery, as infections in the ear makes the operation much more difficult and may ruin the reconstruction. If your surgeon has suggested certain medications prior to surgery, these should be done without exception to ensure a successful outcome.

A hearing test is performed to document any hearing deficiency. The more significant the hearing loss, the sooner the procedure should be performed. The eardrum will also be examined before surgery using a special operating microscope.

What is involved with a tympanoplasty?

A tympanoplasty is performed with the patient fully asleep (under general anesthesia). A surgical cut (incision) is usually made behind the ear, the ear is moved forward, and the eardrum is then carefully exposed. The eardrum is then lifted up (tympanotomy) so that the inside of the ear (middle ear) can be examined. If there is a hole in the eardrum, it is cleaned (debrided) and the abnormal area can be cut away. A piece of fascia (tissue under the skin) from the temporalis muscle (behind the ear) is then cut and placed under the hole in the ear drum to create a new intact ear drum. This tissue is called a graft. The graft allows your normal eardrum skin to grow across the hole.

If needed, reconstruction of the middle ear bones (ossiculoplasty) or cholesteatoma removal may also be performed at this time.

This surgery usually requires an overnight hospital stay. The patient has a dressing (large bandage) over the surgical site. This is removed the next morning and the patient is discharged home. Occasionally, in older children, or those undergoing a less involved procedure, same-day surgery is possible.

Eardrops may be prescribed after discharge.

The most important part of this surgery for the parent is your part in restricting activity as outlined by your surgeon. By following these instructions very closely, you can make sure the result is the best it can be. Please refer to written post-operative instructions in your surgical packet .

What are the risks and complications of a tympanoplasty?

Because this surgery takes place in and around the ear, there are special risks for this surgery in addition to the usual risks of infection and bleeding. Because each patient's situation is different, your surgeon will relate to you just how likely these complications are to occur.

HEARING LOSS - A tympanoplasty is performed to help restore normal hearing. However, some hearing loss (more common with ossiculoplasty) may still be present after the procedure. An operation is termed successful if the hearing is restored within 10-15 decibels of normal.

FACIAL NERVE INJURY AND PARALYSIS - Because the facial nerve runs close to the surgical site, injury although uncommon, can occur. This may result in temporary facial muscle weakness and/or loss of taste on one side of the tongue.

DIZZINESS - This complication after surgery is rare and is more likely to occur when mastoidectomy is performed for cholesteatoma when the cholesteatoma has eroded the balance system.

LOSS OF GRAFT - Because this operation involves grafting using your own tissue, very rarely this tissue will not survive long enough for the hole in the eardrum to heal completely. In this case, another operation may be necessary. Because the success rate of this surgery is so high, re-operation also has a very high success rate.

Your surgeon will schedule follow up visits after surgery to look at the eardrum, to check hearing and to ensure normal healing. It is important to keep these appointments, as they will help to maximize the success of the procedure.

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Mastoidectomy

What is the mastoid bone?

The mastoid bone is a bone located behind the ear (felt as a hard bump behind the ear). Inside it looks like a honeycomb, with the spaces filled with air. These air cells are connected to the middle ear through an air filled cavity called the mastoid antrum. Although the mastoid bone serves as a reserve air supply to allow normal movement of the eardrum, its connection to the middle ear may also result in the spread of middle ear infections to the mastoid bone (mastoiditis).

What is a mastoidectomy?

A mastoidectomy is a surgical procedure designed to remove infection or growths in the bone behind the ear (mastoid bone). Its purpose is to create a "safe" ear and prevent further damage to the hearing apparatus.

What are the indications for a mastoidectomy?

A mastoidectomy is indicated for mastoiditis that does not respond to antibiotics. A mastoidectomy is also helpful in preventing further complications of mastoiditis. These include meningitis (infection in the fluid surrounding the brain), brain abscess (pocket of infection in the brain), or blood clots in the veins of the brain.

Mastoidectomy is often indicated for other diseases that spread to the mastoid bone, such as cholesteatoma. This procedure allows complete removal of these benign yet destructive growths. Occasionally, a mastoidectomy may be used to help find and repair an injured facial nerve.

What is done in preparation for a mastoidectomy?

A complete physical examination of the ear area including the appearance of the outer ear, eardrum, and middle ear is performed. Facial Nerve function is also evaluated. Hearing tests and pictures (mastoid x-ray or CT scan) are also obtained prior to surgery.

What is involved with a mastoidectomy?

A mastoidectomy is performed with the patient fully asleep (under general anesthesia). A surgical cut (incision) is made behind the ear. The mastoid bone is then exposed and opened with a surgical drill. The infection or growth is then removed. The incision is closed with stitches under the skin. A drainage tube may also be placed.

Depending on the amount of infection or cholesteatoma present, various degrees of mastoidectomies can be performed.

In a simple mastoidectomy, the surgeon opens the bone and removes any infection. A tube may be placed in the eardrum to drain any pus or secretions present in the middle ear. Antibiotics are then given intravenously (through a vein) or by mouth.

A radical mastoidectomy removes the most bone and is indicated for extensive spread of a cholesteatoma. The eardrum and middle ear structures may be completely removed. Usually the stapes (the "stirrup" shaped bone) is spared if possible to help preserve some hearing.

A modified radical mastoidectomy means that some middle ear bones are left in place and the eardrum is rebuilt (tympanosplasty). Both a modified radical and a radical mastoidectomy usually result in less than normal hearing.

A hospital stay is usually required overnight for children.

What are the risks and complications of a mastoidectomy?

Bleeding and/or infection of the wound area are possible complications with any incision. Antibiotics and good surgical technique help prevent this. Some blood-tinged drainage is common in the first two days.

Other complications can include injury to the balance system, hearing loss, or facial nerve injury. Dizziness or a ringing in the ear (tinnitus) could also result.

Your doctor will discuss the possibility of these complications with you prior to your surgery.

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Stapedectomy

I. Definitions

The Stapes

The stapes is the third of the three little hearing bones in the middle ear that transmit sound vibrations from the eardrum to the inner ear fluid so that we can hear. We hear when sound vibrations set the EARDRUM in motion. The eardrum, in turn, activates the first middle ear bone, the malleus. It, in turn, sets the second middle ear bone, the incus, in motion. It, in turn, causes the third middle ear bone, the stapes, to vibrate. The stapes sets the inner ear fluids in motion which excites the hearing nerve to carry the sound on to the brain. It is by this mechanism that we hear.

Otosclerosis

Otosclerosis refers to a growth of bone in the ear that develops around the stapes, fixing it in place so that it will not vibrate properly. This fixation stops some of the sound vibrations from reaching the inner ear fluids, causing therefore hearing loss.

Stapedectomy

Stapedectomy is an operation to remove the fixed stapes and to replace it with a prosthesis. This allows sound vibrations to be transmitted properly to the inner ear fluids for hearing.

Causes of Otosclerosis

Otosclerosis is not a cancerous growth or a tumor, but, rather, a somewhat self-limited growth of bone in such an area as to cause difficulty in hearing. It only occurs in the ear. Otosclerosis is hereditary and is often seen in more than one member in a family. Its hereditary nature, however, is somewhat irregular. It is not unusual to see otosclerosis only in one member of a family.

Natural Course of Otosclerosis

Otosclerosis may affect one or both ears of an individual and gradually causes progressive hearing loss as the bony growth gets larger.

The speed at which the otosclerotic bone develops in an individual one. Though it usually takes many years for a significant hearing loss to result from otosclerosis, it may develop to a point and completely stop.

Pregnancy and birth control pills may make the growth occur more rapidly. Advancing age of the individual may cause the growth to slow down. Surgery does not stop the growth of otosclerosis, but usually results in correcting the hearing loss.

The hearing loss caused by otosclerosis is usually CONDUCTIVE. This sort of hearing loss results from a fixation of the stapes so that it cannot conduct sound vibrations properly for hearing. Conductive hearing loss is correctable by surgery.

However, otosclerosis may occasionally cause a sensorineural hearing loss. In this condition, the otosclerotic involvement of the hearing nerve cells and endings prevents hearing, rather than a defect in the small bones of the middle ear sound conduction system. Sensorineural hearing loss is NOT correctable by surgery at the present time.

These two types of hearing loss, conductive and sensorineural, may occur singly or together but are unrelated to one another as far as treatment is concerned.

Surgery for Otosclerosis

The conductive type of hearing loss caused by otosclerosis is usually correctable by surgery called stapedectomy. Such a hearing loss is possible to be overcome with a hearing aid. Most patients find that it is more convenient, more comfortable, and more satisfying, however, to hear naturally through their own ear rather than through a hearing aid.

Otosclerosis is not an emergency situation and surgery for otosclerosis need not be done immediately. The surgery is to help the patient to hear better. The timing for the surgery is strictly at the patient's discretion.

What is the surgery like?

Preoperatively

The patient will have a hearing test just prior to or during admission to the hospital.

The day of surgery

Surgery can be done under local anesthesia or general anesthesia. We prefer to use general anesthesia, i.e. the patient is asleep during the operative procedure. During the operative procedure the eardrum is gently lifted, the diseased and fixed stapes is removed. Next, a prosthesis is put in place. The eardrum is gently put back into place and held there by absorbable packing ointment. The operation usually takes one hour and a half.

Postoperatively

After awakening from anesthesia, the patient is returned to his room and is usually discharged the next morning. During this immediate post-operative period, it is important NOT to blow the nose and not to get the ear wet until the ear has completely healed.

Prognosis

In 90 of 100 patients, the operation is completely successful, in that the hearing is markedly improved. In 8 out of 100 patients, the hearing is improved, but not quite as much as hoped for. Occasionally, about 1 or 2 times in 100 operations, the hearing is actually worse. This is why the worst hearing ear is operated on first in most situations.

It is expected that the patient will be slightly dizzy for the first day or two after the operation, but this usually resolves rapidly.

Usually, the patient may return to work and normal activity one week after leaving the hospital. The patient may also fly in pressurized aircraft on the third post-operative day.

There is a small nerve running through the middle ear, the chorda tympani nerve, which supplies taste sensation to the anterior side of the tongue. Occasionally, this nerve interferes with the successful completion of the stapedectomy surgery and is removed. Other times, it may be stretched to allow good visualization to perform the surgery. This is often not noticed by the patient. However, there are instances in which the patient may notice that there is some lack of taste of that side of the tongue or that there is a strange metallic taste. This sensation of a metallic taste usually disappears.

Four uncommon problems that can occur any time an ear is operated on include: (1) complete deafness in the operated ear, (2) permanent dizziness, (3) permanent facial paralysis on the side operated, and (4) persistent ringing or noise (tinnitus) in the ear

operated. It is because of these risks that are beyond our control that we urge you to consider your surgery as seriously as we do.

PLEASE BE SURE that you discuss your ear surgery with your doctor so that he may answer, in detail, any questions you may have.

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Tonsillectomy/Adenoidectomy

The tonsils are located on each side of the back wall of the throat, just above and behind the tongue. The adenoids are found above and behind the soft palate (roof of the mouth) where the nose and mouth join. Theses tissues help defend the body against infection. When they are overcome by chronic infections, or when marked enlargement blocks breathing, tonsils and/or adenoids may need to be removed. During surgery, the tonsils and adenoids are removed from the wall of the throat. The adenoids are reached by lifting the soft palate. The operation takes about 30 minutes.

What to Expect After Surgery

After this operation, your child may lack energy for several days. Many children are restless and don't sleep through the night. This will gradually improve over 7-14 days. Constipation may also occur. This is due to less food and fluids taken and/or the use of pain medications with codeine. To avoid nausea, give your child food/drink with this type of medication.

Bleeding

No new bleeding (BRIGHT RED blood) is expected from the nose or mouth after you return home. Please check your child for bleeding during the night after the operation. If fresh bleeding occurs after you have returned home, take your child to the closest emergency room for examination. If the adenoids are removed do not allow your child to blow his or her nose for 3 days. This may cause bleeding. It is safe to sniff gently as needed. 5-10 days after the operation your child may spit up a small amount of dark, bloody material. The white membrane that formed across the back of the throat has broken away. If the bleeding does not stop within a few minutes, take your child to the closest emergency room.

Diet

Encourage your child to drink clear, cold liquids every waking hour for the first 2 days. Good choices include cold water, fruit juice, Jell-O, popsicles, slush, Gatorade, and Pedialyte. You may advance the diet to soft, the sold foods at any time after surgery. If your child is nauseated and vomits DO NOT provide any food or drink for 30-45 minutes. Then begin with clear liquids again, progressing to solid foods once your child tolerated clear liquids without vomiting.

Temperature

A slight fever is NORMAL for 24-48 hours after surgery. Giving your child plenty of fluids will help keep the fever down. If the fever rises above 101.5 F, contact your doctor.

Pain

Throat pain and/or ear pain can be severe after a tonsillectomy. Expect your child to experience pain in the ears between the 3rd and 7th day after the operation. The nerve that goes to the tonsil also goes to the ear causing pain to be felt in the ear. After the operation give pain medication 4-5 times a day. Do NOT use aspirin, medications containing aspirin, or ibuprofen (Motrin, Advil) - they increase the chance of bleeding. Acetaminophen (Tylenol, Tempra) of a prescription item advised by your physician can be used. Sometimes a short course of prescription steroids may help with pain and swelling. Other ways to decrease throat pain are:

• Give you child cold liquids. They moisten the throat and reduce the swelling.
• Cool compresses and ice collars on the neck.
• Ice chips also moisten the throat.

Bad Breath

Bad breath is common after a tonsillectomy. It is caused by the white-yellowish membrane that forms in the throat where the surgery took place. Bad breath may be improved by gargling with a mild salt-water solution. This is made by adding ½ teaspoon of table salt to 8-ounces (1 Cup) of warm tap water.

Nausea/Vomiting

Promethazine (Phenergan), or prochlorperazine (Compazine) suppositories may be used to control nausea and vomiting. The dose may be repeated after 4-6 hours. If vomiting continues after the 2nd dose, call your child's doctor or the local hospital emergency room.

Activity

Your child can be up and dressed after going home. But do NOT allow your child to resume normal activity for about one week. Your child may experience alternating "good" and "bad" days for 2 weeks after surgery. It is a good idea to keep your child away from crowds and ill people for 7 days, since the throat is highly susceptible to infections during this period.

Restrict TRAVEL to within 30 minutes of a medical center or E.R. for 2 weeks following surgery. Finally, FOLLOW your doctor's orders if they differ from these instructions.

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Tongue-tie (Ankyloglossia)

Most of us think of tongue-tie as a situation we find ourselves in when we are too excited to speak. Actually, tongue-tie is the non-medical term for a relatively common physical condition that limits the use of the tongue, ankyloglossia.

Before we are born, a strong cord of tissue that guides development of mouth structures is positioned in the center of the mouth. It is called a frenulum. After birth, the lingual frenulum continues to guide the position of incoming teeth. As we grow, it recedes and thins. This frenulum is visible and easily felt if you look in the mirror under your tongue. In some children, the frenulum is especially tight or fails to recede and may cause tongue mobility problems.

The tongue is one of the most important muscles for speech and swallowing. For this reason having tongue-tie can lead to eating or speech problems, which may be serious in some individuals.

When Is Tongue-tie a Problem That Needs Treatment?

In Infants

Feeding - A new baby with a too tight frenulum can have trouble sucking and may have poor weight gain. Such feeding problems should be discussed with your child's pediatrician who may refer you to an otolaryngologist-head and neck surgeon (ear, nose, and throat specialist) for additional treatment.

NOTE: Nursing mothers who experience significant pain while nursing or whose baby has trouble latching on should have their child evaluated for tongue tie. Although it is often overlooked, tongue tie can be an underlying cause of feeding problems that not only affect a child's weight gain, but lead many mothers to abandon breast feeding altogether.

In Toddlers and Older Children

Speech - While the tongue is remarkably able to compensate and many children have no speech impediments due to tongue-tie, others may. Around the age of three, speech problems, especially articulation of the sounds - l, r, t, d, n, th, sh, and z may be noticeable. Evaluation may be needed if more than half of a three-year-old child's speech is not understood outside of the family circle. Although, there is no obvious way to tell in infancy which children with ankyloglossia will have speech difficulties later, the following associated characteristics are common:

• V-shaped notch at the tip of the tongue
• Inability to stick out the tongue past the upper gums
• Inability to touch the roof of the mouth
• Difficulty moving the tongue from side to side

As a simple test, caregivers or parents might ask themselves if the child can lick an ice cream cone or lollipop without much difficulty. If the answer is no, they cannot, then it may be time to consult a physician.

Appearance - For older children with tongue-tie, appearance can be affected by persistent dental problems such as a gap between the bottom two front teeth. Your child's physician can guide you in the diagnosis and treatment of tongue-tie. If he/she recommends surgery, an otolaryngologist-head and neck surgeon (ear, nose, and throat specialist), can perform a surgical procedure called a frenulectomy.

Tongue-tie Surgery Considerations

Tongue-tie surgery is a simple procedure and there are normally no complications. For very young infants (less than six-weeks-old), it may be done in the office of the physician. General anesthesia may be recommended when frenulectomy is performed on older children. But in some cases, it can be done in the physician's office under local anesthesia. While frenulectomy is relatively simple, it can yield big results. Parents should consider that this surgery often yields more benefit than is obvious by restoring ease of speech and self-esteem.

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Nosebleeds - Prevention and Treatment

Nosebleeds (epistaxis) are a common problem. Most are merely a nuisance and are treated at home, while a small minority require prompt medical attention for repeated bleeding or life threatening episodes. The nose acts to warm, filter, and humidify the air we breathe and requires a large blood supply to do this. Nosebleeds are more common in winter because of low humidity and dry heat, but may also be year round in our dry Utah climate.

Risk Factors

Hay fever, nasal oxygen use, nose blowing, trauma (i.e. nose picking), and environmental irritants (i.e. tobacco smoke, chemicals), and cocaine abuse are common risk factors. These problems may dry the nose, cause crusting or nasal obstruction and lead to the onset of nasal bleeding. Bleeding may be more serious in the elderly, people with high blood pressure, hardening of the arteries (atherosclerosis), bleeding disorders (i.e. hemophilia), or those using blood thinners like Coumadin, Plavix, and aspirin.

Treatment

Most nosebleeds occur within the front part of the nose and can be controlled and prevented at home. If you have an active nosebleed or repeat bleeding, try this initially:

• Four sprays to both nostrils of Neo-Synephrine (phenylephrine) or Afrin (oxymetazoline) to constrict the blood vessels. These are available over the counter.
• Firmly pinch the lower base of the nose (as if plugging your nose) for 15 minutes.
• Repeat the above once again if persistent. If unsuccessful, seek medical attention while still firmly pinching the nose.

Further medical treatment may require cautery and nasal packing. Packing may require removal or may be absorbable and dissolve over time. Antibiotics are given to prevent infection from the packing. Underlying illnesses like high blood pressure or bleeding disorders may need attention. Frequently a hospital admission is needed for safe control and treatment of major nosebleeds.

Prevention

Prevention of future nosebleeds requires moisturizing the nose and controlling the underlying risk factors. The following may be recommended by your physician:

• Apply Bactroban, Vaseline, or antibiotic ointment (i.e. Neosporin) to both sides of the nose twice daily for 10 days, then as needed thereafter.
• Salt water, Alkalol or Pretz nasal sprays: 2 sprays each nostril 5-10 times daily for 10 days, then as needed thereafter. These are purchased over the counter.
• Do not blow your nose for 10 days. Gentle sniffing is allowed
• Do not strain or lift greater than 15 lbs for 2 weeks. This may increase the blood pressure in the face and nose to cause more bleeding.
• See your primary care physician if control of blood pressure, bleeding problems or blood thinners are required.
• Quit smoking.
• If you require oxygen at home, avoid the nasal route for 2 weeks. Redirect the oxygen flow to the mouth to prevent nasal dryness.

Remember to follow additional instructions given to your by your doctor and attend follow up appointments as scheduled. It is important to adhere to these guidelines and instructions to best control your nosebleeds and prevent them in the future.

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Microlaryngoscopy and Bronchoscopy (Evaluation of Airway Problems)

The airway as discussed in the above topic refers to the breathing tube starting from the lower throat (larynx) to the tubes going into the lungs (bronchi and bronchioles)

The airway can be evaluated in some cases by looking at pictures taken using x-rays (chest x-rays, or CT scans) or magnets (magnetic resonance imaging or MRI). However, sometimes this is not enough.

In these cases, the airway can be examined directly by using a tube called an endoscope. The specific endoscopes used to look at the airway are called laryngoscopes and bronchoscopes.

Laryngoscopes are used to look at the upper throat and vocal cords (voice box or larynx). Bronchoscopes are used to look at the windpipe (trachea) and the tubes that go into the lungs (bronchi and bronchioles).

What are reasons the airway may need to be looked at directly?

There are two main reasons to look at the airway directly.

The first reason is to diagnose a problem. An example of this would be stridor or noisy breathing suggesting an obstruction (blockage) in the airway. Looking at the airway directly will help make an accurate diagnosis so that the appropriate treatment can be carried out.

The second reason to directly look at the airway is to treat a problem. A good example of this is the removal of an object in the airway (foreign body). The object's location can be directly visualized, and then special tools can be accurately placed to grab the object and pull it out, effectively treating the problem with minimal complications.

Microlaryngoscopy

What is a Microlaryngoscopy?

Laryngoscopy is a procedure that allows your physician to look at your larynx (voice box) using a laryngoscope. "Micro" refers to getting a very close (magnified) view of the area to see every tiny detail. This can be done with a special telescope or operating microscope.

What are the indications for Microlaryngoscopy?

Microlaryngoscopy is especially useful for conditions in which evaluation or treatment of the vocal cords or immediate surrounding airway needs to be performed. Problems involving the vocal cords result in varying degrees of hoarseness, breathing or speech abnormalities, and laryngoscopy is commonly used to evaluate these symptoms. Microlaryngoscopy gives the surgeon the ability to view the larynx in detail. This is vitally important because minute (very small) changes can produce large changes in a person's voice.

What is involved with Microlaryngoscopy?

Microlaryngoscopy does not usually require an overnight stay in the hospital. It is generally performed under general anesthesia (the patient is asleep during the procedure) with the patient lying on the back.

With the head tilted back (to make the airway as straight as possible), a laryngoscope is placed in the mouth to look at the larynx (voice box). It also pushes the tongue out of the way. If the patient is old enough to have upper teeth, they are protected with a tooth guard. The involved area is then visualized and the view is magnified (enlarged) using an endoscope (telescope). This is usually attached to a small video camera.

Procedures that may be performed during microlaryngoscopy are numerous, and include removal of polyps or masses on or around the vocal cords or to correct deformities of the vocal cords themselves. These procedures involve the use of special tools and techniques, and may include use of the CO2 laser.

The length of surgery depends on the reason the procedure is being performed (to simply evaluate the area, or to actually remove bumps or masses). The procedure usually does not last more than an hour.

What are the risks and complications of microlaryngoscopy?

The more common risks include chipping a tooth or a temporarily numb tongue (from pressing on the tongue during the procedure). Other possible risks include excessive bleeding or breathing difficulties after the procedure.

If a laser was used during this procedure, additional risks may be present.

Bronchoscopy

What is Bronchoscopy?

Bronchoscopy is the name for the procedure using a bronchoscope (hollow metal tube) to directly look at the airway. The bronchoscope contains a telescope to better visualize all parts of the airway under magnification.

There are two types of bronchoscopes: rigid and flexible.

Rigid Bronchoscopy indicates the hollow metal bronchoscope tube used cannot bend.

Flexible bronchoscopy uses a bronchoscope tube that can bend in the front, back, and side-to-side during the procedure (in other words, is flexible).

What are the indications for rigid bronchoscopy?

Usually by the time rigid bronchoscopy is considered, other tests may have already been performed that suggest a respiratory (breathing related) problem. Other times, respiratory symptoms continue to be present, although no reason can be found. Rigid bronchoscopy is very valuable in helping to diagnose these various respiratory symptoms and problems. Examples of these include stridor (noisy breathing), chronic cough, hoarseness, asthma with unexpected symptoms (atypical asthma), and suspected foreign body evaluation. Stridor, depending on the type, is evaluated with rigid bronchoscopy to look at the anatomy, and flexible laryngoscopy to evaluate function.

The rigid bronchoscope is more effective when removing lesions, performing biopsies (getting a sample of tissue), foreign body removal, and removing thick airway secretions (fluids) than the flexible bronchoscope. CO2 laser surgery must be performed with a laryngoscope or rigid bronchoscope.

What is involved with a rigid bronchoscopy?

Rigid bronchoscopy is almost always performed with the patient under general anesthesia (fully asleep). The patient's head is tilted back to straighten the airway as much as possible. If teeth are present, a tooth guard is usually placed along the upper teeth to help prevent chipping. A laryngoscope (an instrument that holds back the tongue) is inserted that helps the surgeon visualize the voice box (larynx). A longer metal tube (the bronchoscope) in then inserted into the airway. Through the bronchoscope, the surgeon can then use telescopes, special tools, laser beams, and small cameras, among other things, depending on the reason the procedure is being performed.

The entire airway is carefully evaluated, as the telescope is moved further and further along the airway, looking for any abnormalities. Many times the size of the airway is measured to determine improvement in a condition.

What are the complications of this procedure?

With an experienced surgeon, bronchoscopy is a very safe procedure.

The most common complications are due to irritation to the airway and vocal cords from the bronchoscope itself. Other complications can include bleeding, temporary breathing problems during and after the procedure, and problems with the heart rhythm. Rarely, air can leak out around the windpipe (trachea) (called a pneumomediastinum) or the lung (called a pneumothorax).

What are the indications for flexible bronchoscopy?

Flexible bronchoscopy is more commonly used for the evaluation of wheezing or chronic cough. This is usually done by a pulmonologist (lung doctor).

It is also preferred in patients who cannot tolerate rigid bronchoscopy. Among these are patients who cannot tolerate general anesthesia (being put fully to sleep) or those with upper spine disorders (because their necks can not be positioned appropriately for rigid bronchoscopy). Other indications for this procedure include patients with a tracheotomy (breathing tube inserted through a hole in the neck), recurrent lung infections, and the evaluation of coughing up blood (hemoptysis).

What is involved with flexible bronchoscopy?

Flexible bronchoscopy does not require the use of general anesthesia. This procedure is performed by giving the patient a sedating (relaxing) medication, so that they continue to breathe on their own. This is important when evaluating conditions where the patient's natural breathing movements must be observed. In contrast to rigid bronchoscopy, the head does not need to be tilted back. Although, the flexible bronchoscope can be inserted into the mouth, it is usually inserted into the patient's nose. The nasal passages and upper throat are sprayed with a numbing spray, the bronchoscope is inserted, and the patient's nasal (nose) structures are then examined. The larynx (voice box) can then be examined fully. After this, more numbing medication can be applied to the larynx, and the bronchoscope is then advanced further down the airway, all the way to the bronchi (breathing tubes in the lungs) if required.

What are the complications of flexible bronchoscopy?

Since the flexible bronchoscope is inserted through the nasal passages, occasionally bleeding from the nose (epistaxis) can result. Otherwise, the flexible and rigid bronchoscopes can result in similar types of complications; however, both are very safe procedures and rarely result in complications.

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Treating Nasal and Sinus Polyps

Rhinosinusitis refers to an inflammation of the tissues of the nose (rhino-) and sinuses. Polyps, tissue swellings that can form within the nose and sinuses, can be responsible for many of the symptoms described by patients with rhinosinusitis.

Polyps may simply block the nasal airway, making it difficult to breath through the nose; or they may block the proper drainage of the sinus cavities, leading to stagnant secretions that may become infected.

Polyps are generally thought to occur as a result of an ongoing inflammatory process within the nose and sinuses. Although the inflammatory process might be related to allergies, most cases of polyps occur as a result of non-allergic processes.

Whatever the cause, polyps can make patients miserable. Common symptoms in patients with nasal and sinus polyps include nasal obstruction, decreased sense of smell, recurrent sinus infections and profuse nasal drainage. Many of these patients feel as though they have a cold all of the time.

If polyps are suspected, the patient may undergo an endoscopic examination in the clinic. This procedure uses a small telescope that is placed inside of the nostril to examine the nose and sinuses. Computed tomography (often called CT or CAT scans) may help to delineate the precise location of polyps within these cavities.

After establishing the appropriate diagnosis, multiple medical treatments may be initiated. Medications include anti-inflammatory sprays, decongestants, inflammatory mediator inhibitors, and systemic steroid medications. It is important that the physician and patient recognize that medications are often needed on a long-term basis in order to reduce polyp size and prevent their re-growth.

In some cases, surgical excision of the polyps is required, using the endoscope to visualize the polyps. Following this type of surgery, it is critical to maintain medical treatment and closely observe the nose and sinus cavities to prevent recurrence of any polyps. In many cases, if a proper medical and surgical treatment plan is carefully followed, patients will not require further polyp removal surgery.

Definition:

Nasal polyps are small, sac-like growths consisting of inflamed nasal mucosa.

Causes, incidence, and risk factors:

Nasal polyps appear in a number of conditions. The polyps originate near the ethmoid sinuses (located at the top of the nose) and grow into the open areas.

Large polyps can obstruct the airway.

Children with nasal polyps sound congested and often breathe through their mouths because of chronic nasal obstruction. A runny nose or infected nose is common.

Polyps are seen with asthma, allergic rhinitis (hay fever), chronic sinus infections, and cystic fibrosis. About 1 in 4 people with cystic fibrosis have nasal polyps.

Symptoms:

• Nasal obstruction
• Mouth breathing
• Voice -- sounds as if person is congested

Having any of the following conditions indicate a susceptibility to nasal polyps:

• Asthma
• Hay Fever
• Sinus infections
• Cystic fibrosis

Signs and tests:

Nasal examination reveals a grayish grape-like mass within the nasal cavity.

Treatment:

Surgery to remove the polyps is recommended.

Expectations (prognosis):

Surgical removal usually allows easier breathing through the nose.

Complications:

• Infection
• Bleeding

Nasal polyps may recur.

Calling your health care provider:

Call for an appointment with your health care provider if you have persistent difficulty breathing through your nose.

Prevention:

There is no known prevention.

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Rhinoplasty & Nasal Septal Surgery

Nasal Anatomy and Physiology

The nose is a small self-cleaning air conditioning structure designed to filter and modify the temperature of the air for passage to the lungs, and is able to function amazingly well with proper attention. Nasal obstruction is not only bothersome, but may have a significant effect on your general health. The most common causes of obstruction are allergy, infection and anatomical deformities of the internal structure of the nose.

The purpose of nasal septal surgery is to correct the obstructing deformities inside the nose. This usually involves realigning the nasal structure and/or reducing the size of the shelves, or turbinates, so that airflow can pass evenly through each side of the nose. At times, correction of an external nasal deformity may be important in correcting nasal obstruction.

Surgery usually takes from one to two hours and may be done using local or general anesthesia. This can usually be done on an outpatient basis. If nasal packing is used, it is usually removed one day after surgery.

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Sinus Surgery

The ear, nose, and throat specialist will prescribe many medications (antibiotics, decongestants, nasal steroid sprays, antihistamines) and procedures (flushing) for treating acute sinusitis. There are occasions when physician and patient find that the infections are recurrent and/or non-responsive to the medication. When this occurs, surgery to enlarge the openings that drain the sinuses is an option.

A recommendation for sinus surgery in the early 20th century would easily alarm the patient. In that era, the surgeon would have to perform an invasive procedure, reaching the sinuses by entering through the cheek area, often resulting in scarring and possible disfigurement. Today, these concerns have been eradicated with the latest advances in medicine. A trained surgeon can now treat sinusitis with minimal discomfort, a brief convalescence, and few complications.

A clinical history of the patient will be created before any surgery is performed. A careful diagnostic workup is necessary to identify the underlying cause of acute or chronic sinusitis, which is often found in the anterior ethmoid area, where the maxillary and frontal sinuses connect with the nose. This may necessitate a sinus computed tomography (CT) scan (without contrast), nasal physiology (rhinomanometry and nasal cytology), smell testing, and selected blood tests to determine an operative strategy. Note: Sinus X-rays have limited utility in the diagnosis of acute sinusitis and are of no value in the evaluation of chronic sinusitis.

Surgical options include:

Functional endoscopic sinus surgery (FESS): Developed in the 1950s, the nasal endoscope has revolutionized sinusitis surgery. In the past, the surgical strategy was to remove all sinus mucosa from the major sinuses. The use of an endoscope is linked to the theory that the best way to obtain normal healthy sinuses is to open the natural pathways to the sinuses. Once an improved drainage system is achieved, the diseased sinus mucosa has an opportunity to return to normal.

FESS involves the insertion of the endoscope, a very thin fiber-optic tube, into the nose for a direct visual examination of the openings into the sinuses. With state of the art micro-telescopes and instruments, abnormal and obstructive tissues are then removed. In the majority of cases, the surgical procedure is performed entirely through the nostrils, leaving no external scars. There is little swelling and only mild discomfort.

The advantage of the procedure is that the surgery is less extensive, there is often less removal of normal tissues, and can frequently be performed on an outpatient basis. After the operation, the patient will sometimes have nasal packing. Ten days after the procedure, nasal irrigation may be recommended to prevent crusting.

Image guided surgery: The sinuses are physically close to the brain, the eye, and major arteries, always areas of concern when a fiber optic tube is inserted into the sinus region. The growing use of a new technology, image guided endoscopic surgery, is alleviating that concern. This type of surgery may be recommended for severe forms of chronic sinusitis, in cases when previous sinus surgery has altered anatomical landmarks, or where a patient's sinus anatomy is very unusual, making typical surgery difficult.

Image guidance is a near-three-dimensional mapping system that combines computed tomography (CT) scans and real-time information about the exact position of surgical instruments using infrared signals. In this way, surgeons can navigate their surgical instruments through complex sinus passages and provide surgical relief more precisely. Image guidance uses some of the same stealth principles used by the United States armed forces to guide bombs to their target.

Caldwell Luc operation: Another option is the Caldwell-Luc operation, which relieves chronic sinusitis by improving the drainage of the maxillary sinus, one of the cavities beneath the eye. The maxillary sinus is entered through the upper jaw above one of the second molar teeth. A "window" is created to connect the maxillary sinus with the nose, thus improving drainage. The operation is named after American physician George Caldwell and French laryngologist Henry Luc and is most often performed when a malignancy is present in the sinus cavity.

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20 Questions About Your Sinuses

Q. How common is sinusitis?

A. More than 37 million Americans suffer from at least one episode of acute sinusitis each year. The prevalence of sinusitis has soared in the last decade possibly due to increased pollution, urban sprawl, and increased resistance to antibiotics.

Q. What is sinusitis?

A. Sinusitis is an inflammation of the membrane lining of any sinus, especially one of the paranasal sinuses. Acute sinusitis is a short-term condition that responds well to antibiotics and decongestants; chronic sinusitis is characterized by at least four recurrences of acute sinusitis. Either medication or surgery is a possible treatment.

Q. What are the signs and symptoms of acute sinusitis?

A. For acute sinusitis, symptoms include facial pain/pressure, nasal obstruction, nasal discharge, diminished sense of smell, and cough not due to asthma (in children). Additionally, sufferers of this disorder could incur fever, bad breath, fatigue, dental pain, and cough.

Acute sinusitis can last four weeks or more. This condition may be present when the patient has two or more symptoms and/or the presence of thick, green or yellow nasal discharge. Acute bacterial infection might be present when symptoms worsen after five days, persist after ten days, or the severity of symptoms is out of proportion to those normally associated with a viral infection.

Q. How is acute sinusitis treated?

A. Acute sinusitis is generally treated with ten to 14 days of antibiotic care. With treatment, the symptoms disappear, and antibiotics are no longer required for that episode. Oral and topical decongestants also may be prescribed to alleviate the symptoms.

Q. What are the signs and symptoms of chronic sinusitis?

A. Victims of chronic sinusitis may have the following symptoms for 12 weeks or more: facial pain/pressure, facial congestion/fullness, nasal obstruction/blockage, thick nasal discharge/discolored post-nasal drainage, pus in the nasal cavity, and at times, fever. They may also have headache, bad breath, and fatigue.

Q. What measures can be taken at home to relieve sinus pain?

A. Warm moist air may alleviate sinus congestion. Experts recommend a vaporizer or steam from a pan of boiled water (removed from the heat). Humidifiers should be used only when a clean filter is in place to preclude spraying bacteria or fungal spores into the air. Warm compresses are useful in relieving pain in the nose and sinuses. Saline nose drops are also helpful in moisturizing nasal passages.

Q. How effective are non-prescription nose drops or sprays?

A. Use of nonprescription drops or sprays might help control symptoms. However, extended use of non-prescription decongestant nasal sprays could aggravate symptoms and should not be used beyond their label recommendation. Saline nasal sprays or drops are safe for continuous use.

Q. How does a physician determine the best treatment for acute or chronic sinusitis?

A. To obtain the best treatment option, the physician needs to properly assess the patient' s history and symptoms and then progress through a structured physical examination.

Q. What should one expect during the physical examination for sinusitis?

A. At a specialist' s office, the patient will receive a thorough ear, nose, and throat examination. During that physical examination, the physician will explore the facial features where swelling and erythema (redness of the skin) over the cheekbone exist. Facial swelling and redness are generally worse in the morning; as the patient remains upright, the symptoms gradually improve. The physician may feel and press the sinuses for tenderness. Additionally, the physician may tap the teeth to help identify an inflamed paranasal sinus.

Q. What other diagnostic procedures might be taken?

A. Other diagnostic tests may include a study of a mucous culture, endoscopy, x-rays, allergy testing, or CT scan of the sinuses.

Q. What is nasal endoscopy?

A. An endoscope is a special fiber optic instrument for the examination of the interior of a canal or hollow viscus. It allows a visual examination of the nose and sinus drainage areas.

Q. Why does an ear, nose, and throat specialist perform nasal endoscopy?

A. Nasal endoscopy offers the physician specialist a reliable, visual view of all the accessible areas of the sinus drainage pathways. First, the patient' s nasal cavity is anesthetized; a rigid or flexible endoscope is then placed in a position to view the nasal cavity. The procedure is utilized to observe signs of obstruction as well as detect nasal polyps hidden from routine nasal examination. During the endoscopic examination, the physician specialist also looks for pus as well as polyp formation and structural abnormalities that may cause recurrent sinusitis.

Q. What course of treatment will the physician recommend?

A. To reduce congestion, the physician may prescribe nasal sprays, nose drops, or oral decongestants. Antibiotics will be prescribed for any bacterial infection found in the sinuses (antibiotics are not effective against a viral infection). Antihistamines may be recommended for the treatment of allergies.

Q. Will any changes in lifestyle be suggested during treatment?

A. Smoking is never condoned, but if one has the habit, it is important to refrain during treatment for sinus problems. A special diet is not required, but drinking extra fluids helps to thin mucus.

Q. When is sinus surgery necessary?

A. Mucus is developed by the body to act as a lubricant. In the sinus cavities, the lubricant is moved across mucous membrane linings toward the opening of each sinus by millions of cilia (a mobile extension of a cell). Inflammation from allergy causes membrane swelling and the sinus opening to narrow, thereby blocking mucus movement. If antibiotics are not effective, sinus surgery can correct the problem.

Q. What does the surgical procedure entail?

A. The basic endoscopic surgical procedure is performed under local or general anesthesia. The patient returns to normal activities within four days; full recovery takes about four weeks.

Q. What does sinus surgery accomplish?

A. The surgery should enlarge the natural opening to the sinuses, leaving as many cilia in place as possible. Otolaryngologist--head and neck surgeons have found endoscopic surgery to be highly effective in restoring normal function to the sinuses. The procedure removes areas of obstruction, resulting in the normal flow of mucus.

Q. What are the consequences of not treating infected sinuses?

A. Not seeking treatment for sinusitis will result in unnecessary pain and discomfort. In rare circumstances, meningitis or brain abscess and infection of the bone or bone marrow can occur.

Q. Where should sinus pain sufferers seek treatment?

A. If you suffer from severe sinus pain, you should seek treatment from an otolaryngologist--head and neck surgeon, a specialist who can treat your condition with medical and/or surgical remedies.

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Nasal Irrigation

When directed, saline nasal irrigations are recommended to reduce crusting and to keep sinus openings clear. See the following section for more complete details.

Irrigations Using A Bulb Syringe

1. Purchase an "ear syringe" (small rubber bulb syringe) from a drugstore.
2. Saline Mix Solution:
   1 teaspoon salt
   1 quart water (boiled). Store in clean bottle
3. Squeeze bulb in syringe to withdraw solution
4. Leaning over a sink, insert tip of syringe into nostril
5. Gently squeeze bulb to irrigate nose. Allow solution to drain.
6. Repeat the irrigation with second syringeful

Note: the normal saline solution can be placed in a nasal spray bottle for moisturizing the nasal mucosa.

Optional Irrigations using Water Pik

1. Mix solution as above.
2. Set irrigator to lowest pressure setting.
3. Insert irrigator tip into the nose or oral cavity.
4. Leaning over the sink, irrigate nose or sinus through oral cavity defect. Keep your mouth open as some solution will come out through the mouth.
5. Repeat the irrigation.

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Nose & Facial Fractures

Diagnosis

A fracture is caused by a blunt, hard blow to the face. It often occurs along with injuries to other parts of the nose and face.

Symptoms of a facial fracture or broken nose include:

• pain in the nose or surrounding area of the face
• swelling of the nose or surrounding area of the face
• bleeding from the nose (often heavy)
• discoloration of the nose
• black eyes
• crooked or misshapen appearance of the nose (may not appear until swelling subsides)

The doctor will ask about your symptoms, how the injury occurred, and examine your nose for:

• irregularities in the shape
• movement of the bones
• rough sensation when your nose is moved
• pain or tenderness to touch

Unless there is an obvious deformity, it is often necessary to wait several days for the swelling to subside before a fracture can be diagnosed. Tests will include an x-ray of the nose to confirm the fracture and check its location and severity.

Prevention

The following factors may increase your chance of getting a nose or facial fracture:

• previous nose fracture or nose injury
• participating in sports (especially contact sports)
• reckless behavior during recreational activities or driving
• failure to wear a seatbelt

What Treatment Is Needed for a Broken Nose?

Bruises around the eyes and/or a slightly crooked nose following injury usually indicate a fractured nose. If the bones are pushed over or out to one side, immediate medical attention is ideal. But once soft tissue swelling distorts the nose, waiting 48-72 hours for a doctor's appointment may actually help the doctor in evaluating your injury as the swelling recedes. (Apply ice while waiting to see the doctor.) What's most important is whether the nasal bones have been displaced, rather than just fractured or broken.

For markedly displaced bones, surgeons often attempt to return the nasal bones to a straighter position under local or general anesthesia. This is usually done within seven to ten days after injury, so that the bones don't heal in a displaced position. Because so many fractures are irregular and won't "pop" back into place, the procedure is successful only half the time. Displacement due to injury often results in compromised breathing so corrective nasal surgery, typically septorhinoplasty, may then be elected. This procedure is typically done on an outpatient basis, and patients usually plan to avoid appearing in public for about a week due to swelling and bruising.

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Deviated Nasal Septum and Turbinate Hypertrophy

The shape of your nasal cavity could be the cause of chronic sinusitis. The nasal septum is the wall dividing the nasal cavity into halves; it is composed of a central supporting skeleton covered on each side by mucous membrane. The front portion of this natural partition is a firm but bendable structure made mostly of cartilage and is covered by skin that has a substantial supply of blood vessels. The ideal nasal septum is exactly midline, separating the left and right sides of the nose into passageways of equal size.

Estimates are that 80 percent of all nasal septums are off-center, a condition that is generally not noticed. A "deviated septum" occurs when the septum is severely shifted away from the midline. The most common symptom from a badly deviated or crooked septum is difficulty breathing through the nose. The symptoms are usually worse on one side, and sometimes actually occur on the side opposite the bend. In some cases the crooked septum can interfere with the drainage of the sinuses, resulting in repeated sinus infections.

Septoplasty is the preferred surgical treatment to correct a deviated septum. This procedure is not generally performed on minors, because the cartilaginous septum grows until around age 18. Septal deviations commonly occur due to nasal trauma.

A deviated septum may cause one or more of the following:

• Blockage of one or both nostrils
• Nasal congestion, sometimes one-sided
• Frequent nosebleeds
• Frequent sinus infections
• At times, facial pain, headaches, postnasal drip
• Noisy breathing during sleep ( in infants and young children)

In some cases, a person with a mildly deviated septum has symptoms only when he or she has a "cold" (an upper respiratory tract infection). In these individuals, the respiratory infection triggers nasal inflammation that temporarily amplifies any mild airflow problems related to the deviated septum. Once the "cold" resolves, and the nasal inflammation subsides, symptoms of a deviated septum often resolve, too.

Over growth of the turbinates is yet another cause of stuffiness. (The turbinates are the tissues that line the inside of the nasal passages.) Sometimes the turbinates need treatment to make them smaller and expand the nasal passages.

Septoplasty is a surgical procedure performed entirely through the nostrils, accordingly, no bruising or external signs occur. The surgery might be combined with a rhinoplasty, in which case the external appearance of the nose is altered and swelling/bruising of the face is evident. Septoplasty may also be combined with sinus surgery.

The time required for the operation averages about one to one and a half hours, depending on the deviation. It can be done with a local or a general anesthesia, and is usually done on an outpatient basis.

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Surgery for Nasal Obstruction: Standard and Laser Surgeries

Standard Surgical Treatments for Nasal Obstruction

Cautery (burning) of enlarged turbinates can be done with an electrosurgical probe or a laser and is usually performed as an office procedure. Both electrocautery and laser surgery are performed on either the surface of the turbinate tissue or sub-mucosally. Surface cautery results in edema and crusting in the nose which can last three weeks or longer, while sub-mucosal cautery can cause swelling for up to 10 days.

Another method for improving nasal obstruction is outward fracture of the turbinate bone(s), which moves the turbinate away from its obstructive position in the airway. This approach, however, does not address the usual source of obstruction---enlarged sub-mucosal tissue, and the fractured turbinate often returns to its previous position. Turbinate resection (removal of the bone and/or soft tissue) and excision (removal of the soft tissue only) can be performed with surgical scissors or a laser. Physicians can reduce nasal obstruction by cutting away excess tissue from the surface of the turbinate with angled scissors. Following treatment, the nose must be packed for several days with gauze containing anantibiotic ointment.

Risks Associated with Standard Surgeries for Nasal Obstruction

Bleeding, which can usually be managed by packing the nose, is the greatest risk for patients undergoing standard turbinate resection. Over-resection of the turbinates has been reported as the cause of excessive, irreversible drying of the turbinates. Resection, excision and surface cautery can all be associated with prolonged crusting and healing, which occurs over a four- to six-week period.

Laser Surgery

Laser resection of the turbinates uses light energy that reaches temperatures of 750°C to 900°C (1,400°F to 1,700°F) to vaporize the turbinate mucosa. Safety issues related to the use of the laser require specialized training and experience in laser procedures. The crusting and bleeding rates with laser surgery are similar to cautery procedures.

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Thyroid Gland

What is Your Thyroid Gland?

Your thyroid gland is one of the endocrine glands, which make hormones to regulate physiological functions in your body. The thyroid gland manufactures thyroid hormone, which regulates the rate at which your body carries on its necessary functions. Other endocrine glands are the pancreas, the pituitary, the adrenal glands, the parathyroid glands, the testes, and the ovaries.

The thyroid gland is located in the middle of the lower neck, below the larynx (voice box) and just above your clavicles (collarbones). It is shaped like a "bow tie," having two halves (lobes): a right lobe and a left lobe joined by an "isthmus.". You can't always feel a normal thyroid gland.

When Is a Thyroid Gland Abnormal?

Diseases of the thyroid gland are very common, affecting millions of Americans. The most common diseases are an over- or under-active gland. These conditions are called hyperthyroidism (e.g., Grave's disease) and hypothyroidism. Sometimes the thyroid gland can become enlarged from over-activity (as in Grave's disease) or from under-activity (as in hypothyroidism). An enlarged thyroid gland is often called a "goiter." Sometimes an inflammation of the thyroid gland (Hashimoto's disease) will cause enlargement of the gland.

Patients may develop "lumps" or "masses" in their thyroid glands. They may appear gradually or very rapidly. Patients who had radiation therapy to the head or neck as children for acne, adenoids, or other reasons are more prone to develop thyroid malignancy. A doctor should evaluate all thyroid "lumps" (nodules).

How Does Your Doctor Make the Diagnosis?

The diagnosis of a thyroid abnormality in function or a thyroid mass is made by taking a medical history and a physical examination. Specifically, your doctor will examine your neck and ask you to lift up your chin to make your thyroid gland more prominent. You may be asked to swallow during the examination, which helps to feel the thyroid and any mass in it. Other tests your doctor may order include:

1. An ultrasound examination of your neck and thyroid
2. Blood tests of thyroid function
3. A radioactive thyroid scan
4. A fine needle aspiration biopsy
5. A chest X-ray
6. A CT or MRI scan

Fine Needle Aspiration

If a lump in your thyroid is diagnosed, your doctor may recommend a fine needle aspiration biopsy. This is a safe, relatively painless procedure. A hypodermic needle is passed into the lump, and samples of tissues are taken. Often several passes with the needle are required. There is little pain afterward and very few complications from the procedure occur. This test gives the doctor more information on the nature of the lump in your thyroid gland and specifically will help to differentiate a benign from a malignant thyroid mass.

Treatment of Thyroid Disease

Abnormalities of thyroid function (hyper or hypothyroidism) are usually treated medically. If there is insufficient production of thyroid hormone, this may be given in a form of a thyroid hormone pill taken daily. Hyperthyroidism is treated mostly by medical means, but occasionally it may require the surgical removal of the thyroid gland.

If there is a lump of the thyroid or a diffused enlargement (goiter), your doctor will propose a treatment plan based on the examination and your test results. Most thyroid "lumps" are benign. Often they may be treated with thyroid hormone, and this is called "suppression" therapy. The object of this treatment is to attempt shrinkage of the mass over time, usually three-six months. If the lump continues to grow during treatment when you are taking the medication, most doctors will recommend removal of the affected lump.

If the fine needle aspiration is reported as suspicious for or suggestive of cancer, then thyroid surgery is required.

What Is Thyroid Surgery?

Thyroid surgery is an operation to remove part or all of the thyroid gland. It is performed in the hospital, and general anesthesia is usually required. Usually the operation removes the lobe of the thyroid gland containing the lump and possibly the isthmus. A frozen section (an immediate microscopic reading) may or may not be used to determine if the rest of the thyroid gland should be removed. Sometimes, based on the result of the frozen section, the surgeon may decide to stop and remove no more thyroid tissue, or proceed to remove the entire thyroid gland, and/or other tissue in the neck. This is a decision usually made in the operating room by the surgeon, based on findings at the time of surgery. Your surgeon will discuss these options with you preoperatively.

After surgery, you may have a drain (a tiny piece of plastic tubing), which prevents fluid from building up in the wound. This is removed after the fluid accumulation is minimal. Most patients are discharged one to three days after surgery. Complications after thyroid surgery are rare. They include bleeding, a hoarse voice, difficulty swallowing, numbness of the skin on the neck, and low blood calcium. Most complications go away after a few weeks. Patients who have all of their thyroid gland removed have a higher risk of low blood calcium post-operatively.

Patients who have thyroid surgery may be required to take thyroid medication to replace thyroid hormones after surgery. Some patients may need to take calcium replacement if their blood calcium is low. This will depend on how much thyroid gland remains, and what was found during surgery. If you have any questions about thyroid surgery, ask your doctor and he or she will answer them in detail.

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Head & Neck Cancer

More than 55,000 Americans will develop cancer of the head and neck (most of which is preventable) this year; nearly 13,000 of them will die from it.

Find It Early and Be Cured

Tobacco is the most preventable cause of these deaths. In the United States, up to 200,000 people die each year from smoking-related illnesses. The good news is that this figure has decreased due to the increasing number of Americans who have quit smoking. The bad news is that some of these smokers switched to smokeless or spit tobacco, assuming it is a safe alternative. This is untrue - they are merely changing the site of the cancer risk from their lungs to their mouth. While lung cancer cases are down, cancers in the head and neck appear to be increasing. Cancer of the head and neck is curable if caught early. Fortunately, most head and neck cancers produce early symptoms. You should know the possible warning signs so you can alert your doctor to your symptoms as soon as possible. Remember - successful treatment of head and neck cancer can depend on early detection. Knowing and recognizing the signs of head and neck cancer can save your life.

Here's What You Should Watch for:

A lump in the neck...Cancers that begin in the head or neck usually spread to lymph nodes in the neck before they spread elsewhere. A lump in the neck that lasts more than two weeks should be seen by a physician as soon as possible. Of course, not all lumps are cancer. But a lump (or lumps) in the neck can be the first sign of cancer of the mouth, throat, voicebox (larynx), thyroid gland, or of certain lymphomas or blood cancers. Such lumps are generally painless and continue to enlarge steadily.

Change in the voice...Most cancers in the larynx cause some change in voice. Any hoarseness or other voice change lasting more than two weeks should alert you to see your physician. An otolaryngologist is a head and neck specialist who can examine your vocal cords easily and painlessly. While most voice changes are not caused by cancer, you shouldn't take chances. If you are hoarse more than two weeks, make sure you don't have cancer of the larynx. See your doctor.

A growth in the mouth...Most cancers of the mouth or tongue cause a sore or swelling that doesn't go away. These sores and swellings may be painless unless they become infected. Bleeding may occur, but often not until late in the disease. If an ulcer or swelling is accompanied by lumps in the neck, be very concerned. Your dentist or doctor can determine if a biopsy (tissue sample test) is needed and can refer you to a head and neck surgeon to perform this procedure.

Bringing up blood...This is often caused by something other than cancer. However, tumors in the nose, mouth, throat or lungs can cause bleeding. If blood appears in your saliva or phlegm for more than a few days, you should see your physician.

Swallowing problems...Cancer of the throat or esophagus (swallowing tube) may make swallowing solid foods difficult. Sometimes liquids can also be troublesome. The food may "stick" at a certain point and then either go through to the stomach or come back up. If you have trouble almost every time you try to swallow something, you should be examined by a physician. Usually a barium swallow x-ray or an esophagoscopy (direct examination of the swallowing tube with a telescope) will be performed to find the cause.

Changes in the skin...The most common head and neck cancer is basal cell cancer of the skin. Fortunately, this is rarely a major problem if treated early. Basal cell cancers appear most often on sun-exposed areas like the forehead, face, and ears, although they can occur almost anywhere on the skin. Basal cell cancer often begins as a small, pale patch that enlarges slowly, producing a central "dimple" and eventually an ulcer. Parts of the ulcer may heal, but the major portion remains ulcerated. Some basal cell cancers show color changes. Other kinds of cancer, including squamous cell cancer and malignant melanoma, also occur on the skin of the head and neck. Most squamous cell cancers occur on the lower lip and ear. They may look like basal cell cancers and, if caught early and properly treated, usually are not much more dangerous. If there is a sore on the lip, lower face, or ear that does not heal, consult a physician. Malignant melanoma classically produces dense blue-black or black discolorations of the skin. However, any mole that changes size, color, or begins to bleed may be trouble. A black or blue-black spot on the face or neck, particularly if it changes size or shape, should be seen as soon as possible by a dermatologist or other physician.

Persistent Earache...Constant pain in or around the ear when you swallow can be a sign of infection or tumor growth in the throat. This is particularly serious if it is associated with difficulty in swallowing, hoarseness or a lump in the neck. These symptoms are best evaluated by an otolaryngologist.

Identifying High Risk of Head and Neck Cancer

As many as 90 percent of head and neck cancers arise after prolonged exposure to specific factors. Use of tobacco (cigarettes, cigars, chewing tobacco or snuff) and alcoholic beverages are closely linked with cancers of the mouth, throat, voice box and tongue. (In adults who neither smoke nor drink, cancer of the mouth and throat are nearly nonexistent.) Prolonged exposure to sunlight is linked with cancer of the lip and is also an established major cause of skin cancer.

What You Should Do...All of the symptoms and signs described here can occur with no cancer present. In fact, many times complaints of this type will be due to some other condition. But you can't tell without an examination. So, if they do occur, see your doctor-and be sure.

REMEMBER: When found early, most cancers in the head and neck can be cured with relatively little difficulty. Cure rates for these cancers could be greatly improved if people would seek medical advice as soon as possible. So play it safe. If you think you have one of the warning signs of head and neck cancer, see your doctor right away.

BE SAFE: See your doctor early! And practice health habits which will make these diseases unlikely to occur.

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Salivary Glands

Where Are Your Salivary Glands?

The glands are found in and around your mouth and throat. We call the major salivary glands the parotid, submandibular, and sublingual glands.

They all secrete saliva into your mouth, the parotid through tubes that drain saliva, called salivary ducts, near your upper teeth, submandibular under your tongue, and the sublingual through many ducts in the floor of your mouth.

Besides these glands, there are many tiny glands called minor salivary glands located in your lips, inner cheek area (buccal mucosa), and extensively in other linings of your mouth and throat. Salivary glands produce the saliva used to moisten your mouth, initiate digestion, and help protect your teeth from decay.

As a good health measure, it is important to drink lots of liquids daily. Dehydration is a risk factor for salivary gland disease.

What Causes Gland Problems?

Salivary gland problems that cause clinical symptoms include:

Obstruction:

Obstruction to the flow of saliva most commonly occurs in the parotid and submandibular glands, usually because stones have formed. Symptoms typically occur when eating. Saliva production starts to flow, but cannot exit the ductal system, leading to swelling of the involved gland and significant pain, sometimes with an infection. Unless stones totally obstruct saliva flow, the major glands will swell during eating and then gradually subside after eating, only to enlarge again at the next meal. Infection can develop in the pool of blocked saliva, leading to more severe pain and swelling in the glands. If untreated for a long time, the glands may become abscessed.

It is possible for the duct system of the major salivary glands that connects the glands to the mouth to be abnormal. These ducts can develop small constrictions, which decrease salivary flow, leading to infection and obstructive symptoms.

Infection:

The most common salivary gland infection in children is mumps, which involves the parotid glands. While this is most common in children who have not been immunized, it can occur in adults. However, if an adult has swelling in the area of the parotid gland only on one side, it is more likely due to an obstruction or a tumor.

Infections also occur because of ductal obstruction or sluggish flow of saliva because the mouth has abundant bacteria.

You may have a secondary infection of salivary glands from nearby lymph nodes. These lymph nodes are the structures in the upper neck that often become tender during a common sore throat. In fact, many of these lymph nodes are actually located on, within, and deep in the substance of the parotid gland or near the submandibular glands. When these lymph nodes enlarge through infection, you may have a red, painful swelling in the area of the parotid or submandibular glands. Lymph nodes also enlarge due to tumors and inflammation.

Tumors:

Primary benign and malignant salivary gland tumors usually show up as painless enlargements of these glands. Tumors rarely involve more than one gland and are detected as a growth in the parotid, submandibular area, on the palate, floor of mouth, cheeks, or lips. An otolaryngologist-head and neck surgeon should check these enlargements.

Malignant tumors of the major salivary glands can grow quickly, may be painful, and can cause loss of movement of part or all of the affected side of the face. These symptoms should be immediately investigated.

Other Disorders:

Salivary gland enlargement also occurs in autoimmune diseases such as HIV and Sjögren's syndrome where the body's immune system attacks the salivary glands causing significant inflammation. Dry mouth or dry eyes are common. This may occur with other systemic diseases such as rheumatoid arthritis. Diabetes may cause enlargement of the salivary glands, especially the parotid glands. Alcoholics may have salivary gland swelling, usually on both sides.

How Does Your Doctor Make the Diagnosis?

Diagnosis of salivary gland disease depends on the careful taking of your history, a physical examination, and laboratory tests.

If your doctor suspects an obstruction of the major salivary glands, it may be necessary to anesthetize the opening of the salivary ducts in the mouth, and probe and dilate the duct to help an obstructive stone pass. Before these procedures, dental x-rays may show where the calcified stones are located.

If a mass is found in the salivary gland, it is helpful to obtain a CT scan or a MRI (magnetic resonance imaging). Sometimes, a fine needle aspiration biopsy in the doctor's office is helpful. Rarely, dye will be injected through the parotid duct before an x-ray of the gland is taken (a sialogram).

A lip biopsy of minor salivary glands may be needed to identify certain autoimmune diseases.

How Is Salivary Gland Disease Treated?

Treatment of salivary diseases falls into two categories: medical and surgical. Selection of treatment depends on the nature of the problem. If it is due to systemic diseases (diseases that involve the whole body, not one isolated area), then the underlying problem must be treated. This may require consulting with other specialists. If the disease process relates to salivary gland obstruction and subsequent infection, your doctor will recommend increased fluid intake and may prescribe antibiotics. Sometimes an instrument will be used to open blocked ducts.

If a mass has developed within the salivary gland, removal of the mass may be recommended. Most masses in the parotid gland area are benign (noncancerous). When surgery is necessary, great care must be taken to avoid damage to the facial nerve within this gland that moves the muscles face including the mouth and eye. When malignant masses are in the parotid gland, it may be possible to surgically remove them and preserve most of the facial nerve. Radiation treatment is often recommended after surgery. This is typically administered four to six weeks after the surgical procedure to allow adequate healing before irradiation.

The same general principles apply to masses in the submandibular area or in the minor salivary glands within the mouth and upper throat. Benign diseases are best treated by conservative measures or surgery, whereas malignant diseases may require surgery and postoperative irradiation. If the lump in the vicinity of a salivary gland is a lymph node that has become enlarged due to cancer from another site, then obviously a different treatment plan will be needed. An otolaryngologist-head and neck surgeon can effectively direct treatment.

Removal of a salivary gland does not produce a dry mouth, called xerostomia. However, radiation therapy to the mouth can cause the unpleasant symptoms associated with reduced salivary flow. Your doctor can prescribe medication or other conservative treatments that may reduce the dryness in these instances.

Salivary gland diseases are due to many different causes. These diseases are treated both medically and surgically. Treatment is readily managed by an otolaryngologist-head and neck surgeon with experience in this area.

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Drainage of Neck Abscesses

Neck abscesses (collections of pus) can be located in either a superficial (just under the skin) layer of the neck or deep in the neck.

Superficial Neck Abscess

What is a superficial neck abscess?

Superficial neck abscesses are usually the result of an infection in a lymph node in the neck (lymphadenitis) turning into an abscess. The most common cause of these abscesses are Staphylococcus or Streptococcus bacteria. If the abscess will not resolve on antibiotics by mouth, the abscess may need to be drained.

What is involved with drainage of a superficial neck abscess?

Drainage of a superficial neck abscess is a relatively simple procedure. It is performed under general anesthesia using a "mask" to deliver the "sleepy air". Local anesthetic (numbing medication) is injected into the area. The physician will then feel the lump caused by the abscess to find the area most full of pus. An incision (surgical cut) is then made to drain the pus and a drain is inserted through the skin to keep the fluid from collecting again.

The pus obtained is then cultured to determine the type of organism causing the infection. A specific antibiotic can then be used to treat the infection.

What are the complications of this procedure?

Complications of this procedure can include minor bleeding. Certain abscesses should not be drained because of fistula (connection to skin) formation. These types of abscesses are treated long term with special antibiotics instead.

Deep Neck Abscesses

What is involved with drainage of a deep neck abscess?

The most important factor when draining any deep neck abscess is to make sure that the airway is not obstructed. Therefore, these procedures are always undertaken in a hospital setting where emergency airway management is available.

Deep neck abscesses can be drained through the mouth (orally) or through the neck (transcervically).

The oral (through the mouth) drainage procedure is used for peritonsillar space abscesses and for specific cases of retropharyngeal space abscesses. All other deep neck space abscesses are usually approached through a surgical cut in the neck.

Oral Approach Of Neck Abscess Drainage

What is involved with the oral (through the mouth) approach of peritonsillar abscess drainage?

As with any deep abscess drainage, an adequate airway must first be secured. Most cases of peritonsillar abscesses are identified before the airway is obstructed; therefore, breathing tubes are usually not needed.

In younger children, the oral abscess drainage procedure is performed under general anesthesia in hospital setting.

In older children and adults, an anesthetic (numbing) spray is sprayed around the affected area in the back of the throat. This is usually done in the hospital, but in some less severe cases may be done in an office setting. A local anesthetic is then injected around the area that is to be drained. A needle is then placed in the bulging area in the back of the throat, and the pus contained in the abscess is drained out. Complete drainage may require placing the needle in more than one area of the bulge or using a scalpel (knife) to open the abscess. The material drained from the abscess is usually sent for bacterial culture to make sure the correct antibiotic will be used. This procedure usually lasts about 1/2 hour.

After this procedure, the patient usually feels much better and can swallow more easily. Antibiotics are usually given for another three weeks.

Cases in which the peritonsillar abscess recurs may require, a tonsillectomy.

What are the complications of the oral drainage technique?

Local bleeding at the surgical site is the most common complication. Although pus will sometimes continue to drain down the throat, this rarely results in any other problem except nausea. Because this abscess occurs near big blood vessels, your physician will take precautions not to puncture too deeply causing damage to the blood vessels.

Surgical Cut Through The Neck (Transcervical) Approach

What is involved in the transcervical approach for deep neck abscess drainage?

The patient is placed under general anesthesia for this procedure. A surgical cut is made in the neck, and the abscess is located and drained. The drainage is then sent for a bacterial culture. A drain is usually left in the neck so the abscess does not return. The length of this procedure varies with the size and complexity of the location of the deep neck abscess.

Usually, the patient will continue on IV (in the vein) antibiotics in the hospital to ensure complete resolution of the infection. Once the drain is removed and the infection is resolving, the patient may be sent home from the hospital on antibiotics by mouth.

What are the complications of this procedure?

The most common complications are bleeding, reaccumulation of the abscess and damage to nerves. The most common nerve at risk is the marginal mandibular nerve which moves the muscles around the mouth. Special care is taken to protect this nerve during these procedures.

Injury to other vital structures in the neck is also a possibility, although uncommon with an experienced surgeon.

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