Endoscopic Nasal & Sinus Surgery
Sinus surgery has truly evolved in the last several years. This procedure was once performed through external incisions (incisions on the face and in the mouth), required extensive nasal packing, caused significant patient discomfort, and was often followed by a lengthy recovery. With recent advances in technology, including the nasal endoscope, this procedure is now commonly performed without incisions and entirely through the nose. The nasal endoscope is a small lighted metal telescope placed into the nostril, which allows the surgeon to visualize the nose and sinuses. In current practice, endoscopic sinus surgery usually requires minimal nasal packing and is associated with relatively mild pain and short recovery times.
My Sinus Surgery Information –Video information on Endoscopic Sinus Surgery
Rhinologists perform procedures with the aid of telescopes and cameras to magnify and illuminate the nasal and sinus tissue. Surrounding the sinuses are organs that are vital to a person’s health and well being. The most important structures surrounding the sinuses are the eyes, the tear ducts, the optic nerves, the brain, and carotid arteries. While years of training, knowledge of anatomy, and skill are vital to an understanding of anatomy, a tool known as image-guidance allows surgeons to know almost precisely where any given structure is within the nose and sinuses at any given point during surgery.
An operation to repair a small perforation is called a myringoplasty. This is often done in conjunction with removing a retained ventilating tube. The benefits of closing a perforation include prevention of water entering the middle ear, which could cause ear infection. Repairing the hole means that you should get fewer ear infections. It may result in improved hearing, but repairing the eardrum alone seldom leads to great improvement in hearing. Quite often a hole in the eardrum may heal itself but the patching increases the chance of closure.
The operation is almost always done under general anaesthetic. A perforated eardrum means there is a hole in the eardrum, which may have been caused by infection or injury. Sometimes it does not cause any problems. However it may cause recurrent infections with a discharge from the ear. If you have an infection you should avoid getting water in the ear. If the hole is large then you may experience some hearing loss.
The operation can successfully close a small hole more than 90% of the time. Complications are uncommon but include infection, tinnitus and hearing loss.
Myringotomy and Tubes
Ear tubes are tiny cylinders placed through the ear drum (tympanic membrane) to allow air into the middle ear. They also may be called tympanostomy tubes, myringotomy tubes, ventilation tubes, or PE (pressure equalization) tubes. All tubes placed by Dr. Werger are made of plastic and remain in the ear for 12 months on average before falling out on their own.
Ear tubes are often recommended when a patient has repeated middle ear infection (acute otitis media) or has hearing loss caused by the persistent presence of middle ear fluid (otitis media with effusion). These conditions most commonly occur in children, but can also be present in teens and adults and can lead to speech and balance problems, hearing loss, or changes in the structure of the ear drum. In children this is done under general anaesthesia (mask only) and in adults can be done under local anaesthesia.
Tubes should reduce future ear infection, restore hearing loss caused by middle ear fluid, and improve speech problems and balance problems.
Ear tubes are inserted through an outpatient surgical procedure called a myringotomy. A myringotomy refers to an incision (small hole) in the ear drum or tympanic membrane. This is most often done under a surgical microscope. An ear tube is inserted in the hole to keep it open and allow air to reach the middle ear space (ventilation). The fluid behind the ear drum (in the middle ear space) is suctioned out. Ear drops are administered after the ear tube is placed and may be prescribed for a few days. The procedure usually lasts less than 15 minutes and patients awaken quickly. Sometimes the otolaryngologist will recommend removal of the adenoid tissue (lymph tissue located in the upper airway behind the nose) when ear tubes are placed. This is often considered when a second or third tube insertion is necessary. Current research indicates that removing adenoid tissue concurrent with placement of ear tubes can reduce the risk of recurrent ear infections and the need for repeat surgery.
After surgery, the patient is monitored in the recovery room and will usually go home within an hour or two if no complications occur. Patients usually experience little or no postoperative pain, but grogginess, irritability, and/or nausea from the anaesthesia can occur temporarily. Hearing loss caused by the presence of middle ear fluid is immediately resolved by surgery.
At the follow-up visit an audiogram should be performed. To avoid the possibility of bacteria entering the middle ear through the ventilation tube, Dr. Werger recommends keeping ears dry by using ear plugs or other water-tight devices during bathing, swimming, and water activities.
Myringotomy with insertion of ear tubes is an extremely common and safe procedure with minimal complications. When complications do occur, they may include:
- Perforation- This can happen when a tube comes out or a long-term tube is removed and the hole in the tympanic membrane (ear drum) does not close. The hole can be patched through a surgical procedure called a tympanoplasty or myringoplasty.
- Scarring- Any irritation of the ear drum (recurrent ear infections), including repeated insertion of ear tubes, can cause scarring called tympanosclerosis or myringosclerosis. In most cases, this causes no problem with hearing.
- Infection- Ear infections can still occur in the middle ear or around the ear tube. However, these infections are usually less frequent, result in less hearing loss, and are easier to treat often only with ear drops. Sometimes an oral antibiotic is still needed.
- Ear tubes come out too early or stay in too long- —If an ear tube expels from the ear drum too soon (which is unpredictable), fluid may return and repeat surgery may be needed. Ear tubes that remain too long (3 years) may result in perforation or may require removal
The term “rhinoplasty” refers to plastic surgery that involves making changes to the internal and external structures of the nose. While this may be performed for purely cosmetic reasons to improve the appearance, often the primary or concomitant goal is to res tore adequate nasal breathing, and is then referred to as a “functional rhinoplasty”. This is separate from a septoplasty, which involves only repair of the internal wall that divides the nasal cavities , or from a “cosmetic rhinoplaty”, which is only concerned about the appearance. A “functional rhinoplasty” typically involves repair of the “nasal valves ”, which are the internal nostrils, and can be congenitally narrow, collapsed, or scarred from prior surgery.
Septoplasty & Turbinate Surgery
A deviated septum (crooked dividing wall in nose) is very common. This can lead to a stuffy nose (known as nasal obstruction). Patients with nasal obstruction have trouble breathing through their nose. This can force them to breathe through their mouth, leading to a sensation of a dry mouth. In many patients, these symptoms get worse at night when they are lying flat. This can cause them to have less restful sleep.
Tonsillectomy and Adenoidectomy
Tonsils and adenoids are similar to lymph nodes or glands. Tonsils are the two round balls in the back of the throat on either side. Adenoids are high in the throat behind the nose and the roof of the mouth (soft palate) and are not visible through the mouth or nose without special instruments. The adenoid is tonsil number 3 but has its own name. It often Shrinks is when one is an adult. Tonsils and adenoids are the body’s first line of defense as part of the immune system. They sample bacteria and viruses that enter the body through the mouth or nose, but they sometimes become infected. At times, they become more of a liability than an asset and may even cause airway obstruction or repeated bacterial infections. The main reasons for removal include repeated infections, enlargement causing difficulty eating or breathing (sleep apnea), asymmetry, recent tonsil abscess or suspected tumour. They may also be removed for “tonsil stones” or cryptic tonsils at the patient’s request.
The procedure will be done under general anaesthesia and will last less than 30 minutes.
When the patient arrives at the hospital, the anesthesiologist and nursing staff may meet with the patient and family to review the patient’s history. The patient will then be taken to the operating room and given an anesthetic. Intravenous fluids are usually given during and after surgery. After the operation, the patient will be taken to the recovery area. Recovery room staff will observe the patient closely until admission or transfer to the Day Surgery area.
There are several postoperative problems that may arise. These include swallowing problems, vomiting, fever, throat pain, and ear pain. Occasionally, bleeding from the mouth or nose may occur after surgery. If the patient has any bleeding, you should go to your local emergency room immediately. It is also important to drink liquids after surgery to avoid dehydration
Surgery to reconstruct the tympanic membrane (eardrum) is usually performed under general anesthesia. The operating microscope is used to enlarge the view of the ear structures. An incision is made into the ear canal and the remaining eardrum is elevated away from the bony ear canal and lifted forward. If the perforation is very large or the hole is far forward and away from the view of the surgeon, it may be necessary to perform an incision behind the ear. This elevates the entire outer ear forward, gaining access to the perforation. Once the hole is exposed fully, the perforated remnant is rotated forward, and the bones of hearing are inspected. There may be scar tissue and bands surrounding the bones of hearing. Having identified the bones of hearing, the ossicular chain is pressed to determine if the chain is mobile and functioning. If the chain is mobile, then the remaining surgery concentrates on repairing the drum defect. If the bones of hearing are eroded, then ossicular reconstruction (reconstruction of the bones of hearing) may be necessary at the time of tympanoplasty.
Tissue is taken either from the back of the ear or from the small cartilaginous lobe of skin in front the ear called the tragus. The tissues are thinned and dried. An absorbable gelatin sponge is placed under the drum to allow for support of the graft. The graft is then inserted underneath the remaining drum remnant and the drum remnant is folded back onto the perforation to provide closure. The ear canal is packed with gauze.
After about seven to ten days, the packing is removed and a good evaluation can then be obtained as to whether the graft was successful. Water is kept away from the ear and blowing of the nose is discouraged. Most individuals can return to work after a few days unless they perform heavy physical labor, in which case the patient can return after two weeks. There can be imbalance and dizziness immediately after this procedure.
In over 80 percent of cases, the tympanoplasty procedure is successful and a hearing test is performed at four to six weeks after the operation.
Failure of tympanoplasty can occur either from an immediate infection during the healing period, from water getting into the ear, or from displacement of the graft after surgery. Most patients can expect a full “take” of the grafted eardrum and improvement in hearing. After three to four months, water can be allowed to enter the ear and the patient can even return to swimming.
Complications are rare but include infection, bleeding, dizziness, tinnitus or noises in the ear, transient (rarely permanent) period of altered taste to food or hearing loss.