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A thyroglossal cyst is a benign cyst typically, that is a remnant left behind when the thyroid gland is formed in utero. It is a remnant of the descending tract that is associated with the thyroid gland as it descends in the neck to its normal position.

Typically these cysts present in the first few decades of life with an increase in size. they can become infected where they become enlarged and painful. These cysts require a careful clinical examination followed by an ultrasound related to the cyst itself but also the thyroid gland as occasionally all the thyroid tissue of the patient may be situated in this cyst.

If troublesome it is appropriate to remove the cyst, however it should b undertaken by someone who has experience in performing the operation as there is a high recurrence rate if the operation is not performed correctly. The central portion of the hyoid bone should be removed as part of the operation as during development the descending tract is intimately associated with the hyoid bone and to remove all the tract therefore, requires the removal of this portion of the hyoid bone. The operation is referred to as a Sistrunks procedure, however some people refer to it as an anterior neck dissection as this term covers a wider resection associated with a decreased incidence of recurrence.

Benign Paroxysmal Positional Vertigo, BPPV or simply positional vertigo is a troublesome complaint. Patients complain of a sudden vertigo on a specific positional movement of the head. Typically it occurs when in bed when the patient rolls over to one side.The vertigo lasts for a few seconds then settles fairly quickly but during the episode the patient can be extremely troubled by the phenomenon.

Testing in clinic can be diagnosed by using the Dix Hallpike manouvre a rapid drop of the head whilst angled to one side. Small rythmic osscilations of the eyes are seen in the eyses (nystagmus) which settles rapidly.

The description of the cause is often said to be related to debris falling into one of the semicircular canals (organ of balance). On movement the debris is said to stimulate the semicircular canal balance mechanism. A manouvre reffered to as the Epley manouvre can be undertaken to move this debris out of the semicircular canal and out of harms way. This manouvre in my hands has a success rate in excess of 80% over 2 visits. Careful advice post Epley manouvre can allow for an increased chance of success.

Wax is a normal occurence in the ear canals. It is formed by the mixture of skin cells and the secretions from the glands of the ear canal. It acts as a bacteriostatic compound as well as a waterproof for the ear canal.

Wax does become troublesome in some circumstances. If excessivie in its production or if the ear canal is narrow or if there is some obstruction or worse still pushing of the wax into the earcanal then the wax can occlude the ear canal and cause pain discomfort, hearing loss and even a swimmers ear (otitis externa).

Wax can be encouraged to extrude itself by softening with oil. It can be removed with irrigation devices in the General Practice setting and almost all practitioners have moved away from the older and more dangerous techniques of ear syringing which were high pressure systems prone to complications. With a microscope the ENT surgeon can use instruments like a Jobson Horne probe, crocodile forceps or what is often employed is a microsuction device to safely remove the wax to reveal the eardrum.

Snoring in children is not an infrequent occurence. However if significant and also mixed with obstructive symptoms this can be very disconcerting for the parent.

Obstruction of the airway causes the snoring and this is most often due to enlarged tonsils and adenoids relative to the space in the oral cavity and the back of the nose. It is for this reason that this condition can be treated by removal of the tonsils and adenoids - adenotonsillectomy a combination of both adenoidectomy and tonsillectomy.

However this operation is not to be underestimated because it is associated with risks that include bleeding, pain and infection. Careful selection of patients is therefore important and most children who have this procedure are having significant obstruction patterns with the snoring (obstructive sleep apnea), failing to thrive and are often tired and lethargic.

Children not infrequently put things in their noses. Thankfully a lot of these are sneezed out. If however, these do not self extrude they can cause local problems. These include nasal obstruction, one sided nasal discharge that can be blood stained and even a foul smell. The foreign body causes a local inflammatory response and irritation.

It is imperative that the foreign body is removed, however the first attempt is the best attempt and therefore should be undertaken by an experienced practitioner. Careful lighting and correct instrumentation are essential. In my hands if I am the first person to attempt to remove a foreign body in 80% or more of children I can remove it, this significantly reduces if an attempt has already ocurred.

A careful and quick examination under anaesthetic can and sometimes has to be employed to remove some foreign bodies. Thankfully this can be avoided by good technique, helpful parents and competency.

A grommet is a ventilation tube that is placed in the eardrum by the ENT surgeon. It can be placed under local anaesthetic but in children and not infrequently it can be placed under a general anaesthetic.

There are many reasons why grommets are inserted but usually they are to ventilate the middle ear space where the small ossicles of the ear are situated.

Indications for grommet placement include

Glue ear with a significant defecit in hearing persisting for greater than 3 months

Reccurent episodes of acute middle ear infections

Significant retraction pockets

Part of another operation to maintain ventilation of the middle ear

Grommets can be short term and long term and can last from a few months to a few years. The longer term grommets have a higher incidence of leaving a hole in the eardrum when they extrude.

A branchial cyst is a benign developmental anomaly that can form in the neck. It typically troubles patients in their first three decades of life with recurrent episodes of enlargenment. These episodes are often triggered by an upper respiratory tract infections.

Diagnosis of a branchial cyst is made on the history as above and clinical examination which usually reveals the lump in the lateral neck partly hidden under the sternocleidomastoid muscle of the neck. Occasionally with a significant infection the overlying skin can be tender and red/inflammed. Radiology in the form of an Ultrasound and aspiration cytology (cells removed from the lump) are also of real help in the diagnosis.

If symptomatic it is appropriate to remove the gland but this operation is not to be underestimated and should be undertaken by a surgeon competent and who regularly performs a neck disssection. I would always perform a selective neck dissection as it allows me to safely protect the important nerves and large blood vessels (carotid artery and jugular vein) very intimateley associated with the branchial cyst.

Swimmers ear is a common condition. It is also referred to as otitis externa. Typically it occurs because of water getting into the ear canal and starting a mild inflammatory reaction that can also become infected.

It often is chronic and recurrent in its nature and requires good ear hygeine and often ENT intervention in the form of microsuction and eardrops. Patients can make things worse by trying to clean their ears with cotton buds or their fingers which can scratch the ear canal and lead to further infection.

It is imperative to follow the instructions given by your ENT surgeon when suffering with swimmers ear:

Keep the ears dry, no swimming

Do not put anything in your ears other than drops prescribed (NO cotton buds or fingers)

Cotton wool with vaseline when having a shower

This condition is well treated but typically comes back when advice is not followed.

An endoscope is an integral piece of equipment required to look in the nose as part of a diagnostic or therapeutic procedure.

In sinus surgery also referred to as functional endoscopic sinus surgery (FESS) a ridgid endoscope is used by the surgeon in order to visualise the anatomy of the sinuses. The openings to the sinus system can then be directly visualised or indirectly visualised on a TV screen to allow the ENT surgeon to open the drainaige pathway of the sinuses or to open the sinus up itself.

The endoscope is a glass rod system developed to aid surgeons in keyhole surgery. The rod system is often called a Hopkins rod and has an attachment for a light source whilst also having a viewing end. The endoscope is placed in the nose and the eyepiece may be attached to the camera system to view where the endoscope is.

Endoscopes are now made with flexible fibres and are often used in the Outpatient setting to look in the nose and also to visualise the voice box.

Cancer of the voicebox (larynx) typically occurs in patients who are smokers. High alcohol intake can be a contributory factor too.

Patients typically present with a change in their voice or sometimes with difficulty in breathing due to a degree of airway obstruction. The voicebox is visualised using nasendoscopy, a fibreoptic telescope passed through the nose to visualise the larynx.This assesment is important as it can help stage the disease and assess options for treatment.

If it is likely that this is an laryngeal cancer investigations are undertaken in the form of a CT scan of the neck and chest and a biopsy under general anaesthetic referred to as a microlaryngoscopy and biopsy.

Once the biopsy is confirmatory then every patient should be discussed in a multidisciplinary team meeting and a decision on the best treatment options can be considered.

Broadly speaking patients fall into a number of categories

Palliative which is aimed at symptom control

Curative which is done with the intention of cure but is never a guarantee. Options in this group include radiotherapy, laser surgery and laryngectomy.

The various functions and levels of lymph nodes are summarized in a previous A & P section under the heading of lymph node biopsy . The different levels are critical to the understanding of the different types of Neck Dissection.

The lymphatics are referred to according to their position in the Head and Neck region.

Level I – Submental and submandibular

Level II – Upper deep cervical

Level III – Mid deep cervical

Level IV – Lower deep cervical

Level V – Posterior triangle

Level VI – Paratracheal

Level VII – Superior mediastinal

Neck Dissection

Lymph nodes in the Head and Neck region are typically the first route of spread of malignant disease in the upper aerodigestive tract. If this happens then the lymph nodes are sometimes considered for surgical removal. This is referred to as a ‘Neck Dissection’. Occasionally even if the neck has no clinically or radiologically proven neck nodes and the risk is high a Neck Dissection may be undertaken to stage the neck.

The degree and seriousness of lymph node spread in Head and Neck Squamous Cell Cancers is graded according to N staging in the TNM staging system.

N1 Single ipsilateral lymph node <3cm

N2a Single ipsilateral lymph node 3-6cm

N2b Multiple ipsilateral lymph nodes <6 cm

N2c Contralateral lymph node

N3 Lymph node >6cm

There are many types of neck dissection that are described. Simply put they can be ordered into the following list.

COMPREHENSIVE

Radical Neck Dissection Levels I-V dissected sacrificing Internal jugular vein(IJV), Accesory nerve and Sternocleidomastoid muscle (SCM)

Modified Radical Neck dissection Levels I-V dissected preserving any of the named three structures above (IJV, accessory nerve or SCM)

Extended Radical Neck Dissection Levels I-V dissected including any other lymph node levels

SELECTIVE

There are a variety of selective neck dissections depending on the site of the primary removing different lymph nodal groups that are likely to drain from the primary.

Surgery can be performed through a variety of skin incisions all of which will leave a scar. Clearly there is always a risk of bleeding and the great vessels (IJV and carotid artery) are in the territory of most neck dissections.

Very importantly there are nerves in the territory of the dissection that sometimes have to be sacrificed. These typically are:

The Accessory nerve:

If injured causes stiffness in the shoulder and some decrease in range of movement.

The Hypoglossal nerve:

If injured causes restriction of movement of that side of the tongue.

The Phrenic nerve:

This nerve supplies the diaphragm movement and is unusual to be injured.

Marginal mandibular nerve:

This is a branch of the facial nerve and is often seen and preserved in the dissection.

Rarely other channels that convey fatty acids from the gut to the venous system can be injured with a neck dissection. This is unusual but can cause problems in the postoperative period.

Most patients will have a drain placed post-operatively which is removed when it’s output decreases significantly. A patient can expect to stay in hospital from 2-5 days after the operation, however this is in the ideal case.

Lymph Node Biopsy - Anatomy & Physiology

Lymph nodes are numerous in the head and neck region. They are a filter for bacteria and viruses but occasionally can become involved either by a malignancy involving the lymphatic system ‘lymphoma’, or as a result of spread of malignancy from the head and neck region.

The lymphatics are referred to according to their position in the Head and Neck region.

Level I – Submental and submandibular

Level II – Upper deep cervical

Level III – Mid deep cervical

Level IV – Lower deep cervical

Level V – Posterior triangle

Level VI – Paratracheal

Level VII – Superior mediastinal

Lymph Node Biopsy - Lymphadenopathy

If someone has persistent lymphadenopathy a cause should be sought. Most commonly lymph nodes are reactive to a variety of infective or inflammatory conditions. It is important that if a lymph node is seen in the neck this should be investigated thoroughly by a surgeon used to the examination of the upper aerodigestive tract. A full oral examination and flexible nasendoscopy should be performed. A Fine needle aspiration should be undertaken of the lymph node to gauge if it harbours malignant cells.

If a lymph node is to be biopsied a suitable one with minimal risk to the patient should be undertaken. Again a surgeon who regularly operates in the Head and Neck will be able to explain to the patient risks associated with a lymph node biopsy. Normally a small incision is made and the lymph node or a group of lymph nodes is sampled and sent for histology.

Parotidectomy - Anatomy and Physiology

The parotid glands are paired glands that are situated in front of the ears typically but portions of them extend below the ear and occasionally behind the lower ear. They are a salivary gland and are one of three major paired salivary glands the other two being the submandibular and sublingual glands. In addition there are multiple other minor salivary glands dotted around the oral cavity that help with saliva production.

Occasionally swellings occur in the parotid gland. It is important to determine if these swellings are benign or malignant. This can be done with a careful history and examination together with investigations such as fine needle aspirate cytology and further radiological imaging.

Thankfully over 90 % of swellings in the parotid are benign in their nature, however, even if benign they have a tendency to grow and it may be prudent to have them removed.

Parotidectomy

This operation requires some skill and experience as there are some definite hazards involved with doing the procedure.

Most importantly the facial nerve runs through the parotid gland and there is always a small risk of damaging it. This nerve has a number of branches that make you blink wink and smile on that side of your face. More often than not this damage is related to bruising and therefore temporary effect. The effect of this depends on the portion of the nerve that is affected. It is critical that the surgeon knows his landmarks and can identify follow and preserve the nerve and it’s branches to decrease the chances of damage.

A carefully placed incision often leaves a very difficult to spot scar, however, some people have a tendency to overscarring (hypertrophic or keloid scarring).

Incision for parotidectomy

It is not uncommon to have a numb feeling of the ear on the side that is operated on. This is related to the nerve supply to this portion of the ear that often is sacrificed in the approach. Most patients cope well with this as long as they are told in advance.

An unusual effect of the operation is that a large percentage of patients will experience sweating in and around the neck on chewing and eating. This side effect of the operation is called Frey’s syndrome or gustatory sweating as usually is not too troublesome a symptom.

The operation itself is performed under a general anaesthetic and the nerve will be stimulated or monitored through the operation.The operation may take between one to three hours on average depending on the degree of difficulty involved.

Normally patients would have a drain placed that would stay in place for a day or two and on removal usually can go home with an out-patient follow up with the results of the specimen sent for histology.

What is Thyroidectomy?

Anatomy and Physiology

The thyroid gland is a structure that sits in the midline of the neck. It comprises of two lobes (left and right) joined by an isthmus. The gland produces a hormone that is integral in maintaining the body’s metabolic status amongst other things. The gland is supplied by at least 2 major arteries on either side and approximately 3 major veins on either side. Intimate to the thyroid gland is the trachea (windpipe), oesophagus (swallowing tube) and most importantly from an operative perspective the recurrent laryngeal nerve on both sides that supply the voice box musculature and are integral to voice production. In addition there are approximately 4 parathyroid gland associated with the thyroid gland that are important with the maintenance of calcium metabolism.

Indications for thyroidectomy

There are a number of indications to consider removal of the thyroid gland:

1. Malignancy or risk of malignancy (cancer)
2. Pressure symptoms related to the thyroid gland on the airway or the oesophagus
3. Uncontrolled thyrotoxicosis (overactivity of the thyroid gland) with medical treatment.
4. Cosmesis

It is important to investigate any lump or mass in the thyroid gland that sits in the midline of the neck. This typically is undertaken using an Ultrasound scan. It is not uncommon especially if there is a solitary lump in the thyroid gland for this to be further investigated using a fine needle aspirate cytology (FNAC).This involves a needle directed into the nodule and a few cells withdrawn from it which are then looked at microscopically. This often can be helpful but is dependant upon the person undertaking the FNAC and then the person who examines the cells microscopically.

Thyroidectomy

A number of operations are mentioned in the literature and can be confusing for the patient. In the present day most people are practicing the following operations.

Total thyroidectomy - Removing all of the thyroid tissue

Hemithyroidectomy - Removing one lobe of the thyroid and the isthmus.

Isthmusectomy - Removal of the section of thyroid that joins the two lobes (uncommonly used)

Surgery is undertaken using a general anaesthetic and a low neck incision is made. The thyroid gland is mobilized and Mr Vaz is trained in traditional techniques and the use of the harmonic scalpel to do this. The upper pole of the thyroid and the major vessels are divided and the recurrent laryngeal nerve is identified followed and preserved. If only a hemithyroidectomy is performed then the free lobe is separated from the isthmus and then sent for histology (microscopic examination).

Every patient will have a scar that typically is quite well hidden in the neck given time and only occasionally does this scar become prominent.

There is a risk to the recurrent laryngeal nerve and if this is damaged on one side then the voice becomes hoarse. If damaged on both sides then the vocal cords become immobile and can pose difficulties with breathing.

All operations carry the risk of bleeding and infection but thankfully this is low with thyroidectomy.

Occasionally with total thyroidectomy the calcium level may fall due to the removal of the above mentioned parathyroid glands. This may require long term replacement with Calcium.

With a total thyroidectomy the patient will be rendered hypothyroid (underfunctioning thyroid) and will require supplementation with thyroxine.

Most patients will require a drain in the neck postoperatively and this will be removed when the drainage is minimal. After this the patient may go home with some simple pain relief.

Anatomy and Physiology

The larynx and oesophagus are hidden areas to the general practitioner and therefore if someone has a complaint related to these areas it is difficult to visualize without the correct equipment.

The larynx is composed of three subsites the supraglottis (above the vocal cords) the glottis (the vocal folds) and the subglottis (below the vocal folds and is in continuity with the trachea). The larynx sits in front of the inlet of the oesophagus the so called hypopharynx (composed of the posterior pharyngeal wall, pyriform fossae and the post cricoid region).

With swallowing the larynx is protected by the epiglottis and false cords (from the supraglottis) and the closure of the vocal cords (glottis). Voice itself is created by air from the lungs being vibrated through the vocal folds and then articulated by the oral cavity, teeth and the paranasal areas.

Microlaryngoscopy and Oesophagoscopy

Occasionally it is necessary to visualize the oesophagus or the larynx to exclude or treat disease.

Oesophagoscopy is undertaken using a rigid oesophagus to carefully inspect areas of the hypopharynx and then the oesophagus lower.

Microlaryngoscopy uses a suspension frame and microscope with the benefits to the surgeon of the following

Bimanual handling of instruments

Depth of field

Magnification

Steroescopic vision

The ability to use other surgical implements such as the laser

Post-operatively the patient will have a sore throat and there is a risk of dental injury although this is small as is the risk of oesophageal perforation with an oesophagoscopy.

Snoring Surgery (Uvulopalatopharyngoplasty)

Snoring is an extremely common complaint. It’s cause may be multifactorial but it’s effects can be significant on the individuals quality of sleep and often as significant on their partners sleep pattern. Snoring can be a cause of discontent in relationships and partners often present having had to sleep apart due to the noise created.

Snoring occurs at different levels in the upper airway and can happen at more than one site. Typical palatal snoring occurs due to flutter of the palate on breathing. Pharyngeal wall collapse and tongue base collapse can also cause significant turbulence to the airway and cause noise on breathing whilst asleep.

It is important to distinguish simple snoring from ‘Apnea’ which is a cessation of breathing that has significant cardiorespiratory consequences that must be investigated further. If these symptoms are present then often a sleep study should be performed in order to investigate for obstructive sleep apnea. Any patient who suffers from snoring complaints should complete an Epworth Sleepiness Score to assess the effect of their snoring with respect to their daytime alertness / somnolence.

Sleep nasendoscopy is a technique used to artificially create sleep using anaesthetic agents and then to examine the different levels that snoring occurs at. A flexible telescope is passed through the nose as the patient drifts of to sleep and starts snoring. The various levels are inspected to see where the snoring is generated from and from this the patient may be advised sensibly with respect to appropriate treatments.

Uvulopalatopharyngoplasty (UVPPP)

When the problem is mainly palatal flutter and some lateral pharyngeal wall collapse it is possible to undertake a UVPPP. This operation stiffens the palate and lateral pharyngeal walls by removing the tonsils and the uvula. This operation is an exquisitely uncomfortable operation and requires regular pain relief post-operatively.

Mandibular advancement prosthesis

Advancement prosthesis are available to draw the mandible and the tongue forward preventing them from collapsing whilst asleep. In doing so the turbulence that is created from this obstruction may be relieved. A number of prosthetic splints are available on the market and are reasonably priced.

Epworth Sleepiness Score

Please score the questions below using the following scoring system:

0 = no chance of dozing

1 = slight chance of dozing

2 = moderate chance of dozing

3 = high chance of dozing

1. What is the chance of dozing when sitting and reading?
2. What is the chance of dozing when watching TV?
3. What is the chance of dozing when sitting inactive in a public place (e.g in a meeting)?
4. What is the chance of dozing as a passenger in a car for an hour without a break?
5. What is the chance of dozing lying down to rest in the afternoon?
6. What is the chance of dozing sitting and talking to someone?
7. What is the chance of dozing sitting quietly after a lunch without alcohol?
8. What is the chance of dozing in a car, while stopped for a few minutes in traffic?

What is Tonsillitis?

Tonsillitis is an infection involving inflammation of the tonsils. There are two tonsils, situated on either side of the back of the throat and they form part of the body’s immune system. Like the rest of the immune system they contain special cells to trap and kill bacteria and viruses travelling through the body. When the main site of infection is within the tonsils they swell, become red and inflamed and may show a surface coating of white spots.

Tonsillitis is extremely common in children and young people but it can occur at any age. The characteristics of the disease are pain in the throat, trouble swallowing, fever, glandular enlargenment in the neck and in severe conditions, trismus (difficulty opening the mouth).

How do we contract Tonsillitis?

Whether due to viruses or bacteria, the infection is spread from person to person by airborne droplets, hand contact or kissing hence the term “kissing disease”. It is typically seen in young people but can on occasion effect the older adult, in these cases other possible causes need to be investigated.

There are many different individual viruses and bacteria that can potentially cause tonsillitis e.g. the Epstein-Barr virus, which causes glandular fever. The streptococcus group A is the most common cause of tonsillitis and sore throats - often known as ’strep throat’. The incubation period between picking up the infection and the disease breaking out is two to four days - sometimes it can be less. Tonsillitis is usually a self-limiting condition, i.e. it gets better without treatment, and generally there are no complications.

Rarely pus can collect just deep to the tonsil itself as a result of infection. This typically produces one sided throat discomfort severe difficulty swallowing and often trismus (difficulty opening the mouth). This is referred to as a “Quinsy” and requires medical intervention.

Signs and symptoms of tonsillitis

• Sore throat.
• Pain or discomfort when swallowing.
• Inability to swallow oral secretions.
• Tonsils may be coated or have a covering of white spots on them.
• Fever.
• Trismus (difficulty opening the mouth).
• Glands in the neck and at the angle of the jaw may be swollen and painful.
• Loss or change in voice.
• In children, tonsillitis may include symptoms that appear less focused on the throat, such as poor feeding, runny nose, ear pain, and a slight fever.

Treatment

1. Visit to the general practitioner (GP) who may commence a course of appropriate antibiotics and analgesia, with advice on oral intake, hygiene and to return if condition does not improve.
2. If the condition does not improve the GP should refer the patient either to a local ear, nose and throat (ENT) referral clinic or to accident and emergency (A&E) for review and treatment by an ENT specialist.
3. If there is an inability to swallow the oral secretions the patient will need to be admitted for a minimum of 24 hours for re-hydration, pain relief and intravenous (IV) antibiotics and reviewed on a daily basis.

Inpatient monitoring

• Visual examination of the tonsils.
• Blood tests, including the mono-spot test to rule out glandular fever.
• Insertion of a venflon for administration of fluids and IV antibiotics.
• Regular temperature check
• Routine observations including oxygen saturation monitoring.
• Analgesia for pain relief both regular and as required. This is also to assist in reducing any above normal temperature. Paracetamol is the most common one given.
• Aspiration if thought to be a quinsy by a trained practitioner.
• If oral medication is not suitable then intra-muscular (IM) or per rectum (PR) should be prescribed.
• Fan therapy if necessary but taking care not to reduce the pyrexial patients temperature too suddenly.
• Documentation of fluid and oral intake.
• Ongoing reviews of care delivered and appropriate alterations, depending on patient response and results of investigations undertaken.

Within 24 hours of analgesia, IV fluids and antibiotics the patient often makes a dramatic recovery and is suitable for discharge home.

The patient is ready for discharge when;

• They are apyrexial
• Are managing adequate oral fluids and diet.
• Their pain is controlled on oral analgesia.
• Any investigations are complete and show no other underlying condition that requires immediate investigation / treatment.

What happens when discharged?

• The patient will continue on a course of oral antibiotics, which must be completed otherwise the infection may return.
• A seven-day supply of appropriate analgesia will be prescribed.
• Verbal and written advice on areas such as dietary advice, when to return to work & refraining or cessation of smoking and oral hygiene should be given to the patient or carer once discharged.
• If the patient suffers from tonsillitis i.e. 3-4 episodes annually and it affects work/ school attendance, they should be offered a tonsillectomy and if agreed, added to the ENT waiting list.
• A copy of their discharge letter will be given to the patient and one posted to their GP.
• They should be advised if their symptoms return they should see their GP and if appropriate the GP will refer them back to the hospital.

Tonsillectomy

What is a Tonsillectomy?

Recurrent tonsillitis, quinsy, obstructive sleep patterns in children are all indications to remove the tonsils in the form of a tonsillectomy.
This procedure is performed under general anaesthetic. Post-operatively patients require regular analgesia and strongly encouraged to continue eating and drinking to speed up their post-operative recovery.
Having a tonsillectomy generally requires an overnight stay in hospital.

Gastro-oesophageal and Pharyngeal Reflux

The stomach produces acid that is corrosive and irritant. It is possible in some situations that the acid can reflux up into the oesophagus and even into the pharynx causing irritant symptoms of indigestion, burning, sore throat, hoarseness, coughing fits or a lump sensation in the throat.

There are things one can do to prevent the production and the reflux of the acid and thereby decrease the symptoms incurred by the patient. It is important to adhere to the advice given to decrease the reflux and its effect.

Medications

Over the counter antacids such as Rennies or gelusil or gaviscon a liquid preparation that prevents the acid irritation are available without prescription and can be of help. It is useful to take them before going to sleep but if symptoms are sever then it is useful to take them 30-45 mins before eating meals.
Proton pump inhibitors (PPI’s) are often prescribed in this situation by your GP or ENT surgeon. These should be taken as instructed by your doctor and instructions should be meticulously adhered to. PPI’s decrease the production of acid from the stomach and therefore decrease the effects of the acid when it refluxes.
Beware that some medications increase acid production such as anticholinergics, beta blockers, aspirin, theophylline and non steroidal anti-inflammatory drugs.
Also smoking increases acid production and it’s cessation is beneficial to the treatment reflux.

Weight

An increased Body mass index (BMI) above the normal level increases the chances of reflux. In this situation it is beneficial to try to lose weight to reach your target weight for height (BMI).

Posture

Acid reflux is not an uncommon symptom at night and is related to the fact that lying down allows for the easier refluxing of acidic contents. Elevating the head end of the bed between 4-10 inches will decrease the chances of reflux whilst not being too high so as to feel like you are sliding off the bed.

Diet

Smaller frequent meals are more conducive to avoiding reflux. The avoidance of irritating foods and drinks such as caffeine, chocolate, alcohol should be avoided. Also any specific foods that cause an individual heartburn should be avoided.

Vocal Hygiene Advice

Ensure adequate fluid intake of water / squashes (NOT coffee or tea which contain caffeine and will dry the throat). Approximately 8-10 drinks per day is appropriate.

Steam inhalations to be undertaken carefully if possible twice a day. This may include the steam in a shower. Also ensure humidification of your bedroom / living room (a bowl of water near the radiators).

Avoid smoky noisy environments where you will strain your voice whilst irritating it.

Eat regular balanced meals avoiding late night eating which is associated with indigestion.

Get adequate amounts of sleep as the larynx is a complex muscular organ that will under perform if you are tired.

Chewing gum or sucking ordinary pastilles can keep the mouth moist. Try to avoid medicated lozenges as they may numb the throat or the menthol can dry it.

Avoid aspirin gargles especially if having an acute infection.

Ear Care Advice

• The ear canal is self-cleaning. Do not insert any implements such as cotton buds into the ear. They will damage the delicate skin lining the ear and increase the chance of you developing an ear infection, itchy ears or a problem with wax.
• To dry/ clean the outside of the ear use a dry tissue or alcohol free baby wipes around and behind the ear after showering or bathing.
• If you suffer from excessive wax; insertion of 1 to 2 drops of olive oil on a regular basis may help the ear clean itself.
• If the entrance to the ear canal is dry and/ or itchy, you may find it of benefit to insert one drop of olive oil into the ear canal as instructed by your practitioner. Keep the ears dry from any entry of water, as it may be shampoos and soaps irritating the skin.
• If you have experienced an external ear infection keep the ears dry from any entry of water.
• To keep the ears dry from water entry use cotton wool coated in petroleum jelly or ear plugs placed at the entrance to both ear canals.
• If the symptoms with your ear do not improve make an appointment with your doctor.

How to insert olive oil drops into the ear canal

To obtain the olive oil drops purchase olive oil and the glass dropper bottle that has been designed for ear drops from a chemist. If you have used previous wax dissolving drops, discard all the liquid, wash out the glass bottle and when the container is clean, insert olive oil (almond oil/ coconut oil could be used if you do not suffer from a nut allergy).

1. Insert the closed glass dropper bottle containing the oil into a cup of warm water for two minutes. Dry the container and insert one-drop of oil onto your hand to ensure that it is not too hot. If you feel the oil is too hot wait for it to cool prior to commencing. The correct temperature of the oil should be 37?C. Alternatively, for the oil to reach body temperature (37?C) place the bottle in a pocket of your clothing currently being worn for 20 to 30 minutes.
2. Holding the prepared dropper bottle lie on a bed with the affected ear towards the ceiling.
3. With one hand pull the top of your ear upwards and outwards to straighten the ear canal.
4. Placing the filled dropper part of the bottle of oil over the entrance to your ear canal and squeeze the dropper until one drop (or the amount specified by your nurse) is instilled. Maintain that position for a total of five minutes however, after one minute release the ear and massage the tragus (located at the front of the ear at the level of your cheek-bone) for one minute. Remain on your side and relax on the bed for a further 3 minutes.
5. Wipe the excess drops that pool outside the ear when you sit up. Do not insert cotton wool into the entrance of the ear canal as this will diminish the effect of the drops.
6. Unless instructed otherwise by the nurse insert the drops into both ears, repeating steps two to five on the opposite side.

Patient Advice Prior to Ear Irrigation

• Insert 1 to 2 drops of olive oil into the ear(s) requiring wax removal every morning and evening, commencing one week prior to the appointment (unless instructed otherwise by the nurse).
• Continue to use the drops twice daily until the wax has been successfully removed.
• Instilling olive oil (coconut or almond oil can be used as an alternative if you do not suffer with a nut allergy) will assist with the wax removal process and reduce discomfort that may be felt during the procedure.

Patient Advice Post Ear Irrigation.

• The ear canal may be vulnerable to an ear infection after irrigation. This is caused by removal of all the wax, which has inherent protective properties for the ear canal.
• Until the ear produces more wax to protect the canal keep the ear(s) that have been irrigated dry from entry of water for a minimum of four or five days after the procedure.
• To keep the ears dry when you are washing your hair, showering, bathing or swimming, insert ear plugs or cotton wool coated in petroleum jelly into the outside of the ear canal(s) to act as a protective seal.
• In the unlikely event that you develop pain, dizziness, reduced hearing or discharge from the ear after the procedure, consult with your nurse/ doctor.