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Sinus washouts were an operation of the past, where a large trochar was placed through the nose into the maxillary sinus low on the lateral nasal wall.The sinus was then aspirated and then washed out.Things have significantly developed with our understanding of the way that the sinus anatomy and physiology functions. This procedure is rarely performed nowadays as we have changed practice to open the natural openings of the sinuses to encourage their natural drainage rather than just making a hole which would typically seal over.

This new type of physiologically correct surgery is called FESS (functional endoscopic sinus surgery) and is aimed at using the bodies normal sinus physiology and encouraging it to work better to help the sinuses drain. An endoscope is used to visualise within the nose and specially designed instruments can be used to open up the nasal anatomy.

Nosebleeds (epistaxis) in children are a common occurence. It is important when seeing a child with nosebleeds that a full history and careful examination should be udertaken. It is important that imporatant diagnosis such as a foreign body in the nose is excluded as well as any other serious pathology.

Commonly a small vein or an area of irritation from nose picking is the cause. It is quite common practice is to use naseptin ointment in the first instance. If it is evidently a small vein easily seen then it is sensible to cauterise this. It is very unusual to have to cauterise a childs nose under general anaesthesia this is most often done in the out-patient setting.

At home basic first aid should be employed. If this fails a child should be taken to the emergency department for further treatment and investigation

When an individual has a nosebleed (epistaxis), basic first aid is essential in the management. This includes the following

1. Lean the patient forward and encourage them to spit out any blood. Blood swallowed is hidden and causes significant stomach irritation.

2. Pinch the lower soft partof the nose firmly in order to cause compresssion for approximately 10 mins. There is no point putting pressure on the non compressible bony part of the nose as this has no effect and the majority of bleeding occurs lower in the softer cartilaginous part of the nose.

3. Sometimes an icepack on the bridge of the nose or on the nape of the neck is of some benefit.

If these measure fail then the patient should go to the emergency department for further treatment.

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.

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.

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?

The anatomy of the nasal septum has been outlined in the anatomy and physiology section of septoplasty . However, the midline septal cartilage is one of a number of structures that support and create the framework of the nose. In addition there are two alar (lower lateral) cartlages and two upper lateral cartilages. The upper lateral cartilages snuggly fit under the two nasal bones.

The nasal dorsum in a lateral view is of significant importance to patients aesthetically. Too prominent a nasal dorsum contributed from the nasal septum and nasal bones can produce a nasal hump that can is possible to be reduced.

From a frontal view the nose aesthetically should be in proportion to the eyes and face. The nasal bones and septum together with the alar and upper lateral cartilages should be symmetrical and in line.

Lateral views of the nose demonstrate the nasolabial angle that should be approximately 90-100° in males and 100-110° in females.

Septorhinoplasty Surgery

Septorhinoplasty surgery is undertaken for functional and cosmetic purposes. There are many aspects that should be taken into account when planning with the patient. It is important to be honest with the patient about what can and cannot be achieved.

Surgery can be undertaken in a closed or open technique. Closed techniques involve incisions in the nose occasionally with tiny stab incisions for bony work around the nasal bones. Open techniques involve a mix of internal incisions together with some external incisions to allow the draping skin of the nose to be reflected to reveal the structural cartilages below. All the cartilages of the nose can be altered in different ways to reshape and support the nose in different ways. The nasal bones can be fractured and repositioned.

Because the surgical work of a septorhinoplasty is based on reshaping and repositioning of cartilages and bones which can include fracturing of bony tissues there can be some associated swelling and bruising that subsides fairly quickly after the operation. The internal incisions are closed with dissolving sutures and the nose is sometimes dressed lightly internally. A supportive plaster of paris or moulded splint is used to protect the newly shaped nose for the first 7-10 days.

Turbinate Surgery

Anatomy / Physiology

The turbinate’s are folds of mucosa and bone that exist on the lateral wall of the nose. Their absolute function is uncertain but clearly they contribute to the other functions of the nasal mucosa.

1. Warming the air
2. Filtering the air
3. Moistening the air
4. Immunological presentation
5. Assisting the sense of smell

Clearly however, the turbinates the are bony protrusions from the lateral nasal wall with mucosa overlying them and if this mucosa swells then they can cause a degree of nasal obstruction.

Turbinate Surgery

Submucosal Diathermy to the Inferior turbinates (SMDIT’s)

This surgical procedure is aimed at either superficial or deeper cautery to the mucosal layer overlying the bony inferior turbinate. This theoretically shrinks back the mucosa, causes some scarring and improves the nasal airway. It is common for this too cause significant airway obstruction for the first week postoperatively and then some improvement of symptoms. A similar technique using the laser can be employed. As this surgery is aimed at improving nasal obstruction if the patient has a deviated septum it is often combined with a septoplasty .

Turbinate Surgery

Turbinectomy

This surgical procedure requires removal of part or all of the inferior turbinate surgically. This is associated with occasional heavy nosebleeds and although is still performed is not frequently undertaken.

Degloving of the Inferior turbinates

This surgical technique involves the removal of the swollen mucosa overlying the bone of the inferior turbinate and leaving it to heal with fibrosis and scarring. It requires nasal packing and a course of oral antibiotics postoperatively.

Nasal Polypectomy

Anatomy / Physiology

What are nasal polyps?

Nasal polyps are not an infrequent finding in the nose. Typically they are simple nasal polyps that are related to swellings from the lining of the nasal sinuses and protrude into the nasal cavity. Their presence in the nasal cavity causes a blocked feeling in the nose and sometimes a feeling of intermittent blockage due to the possibility of a ball valve effect. These smooth, insensate swellings in the nose are usually not visible to the naked eye and require a careful examination in the ENT Outpatient environment with an endoscope.

Polyps are usually a change and reaction of the sinus mucosa in response to an allergen. They may swell more in response to an upper respiratory tract infection, or certain alcoholic drinks. It is not unreasonable to have a trial of intranasal steroids for polyps or occasionally an oral course of steroids but if persistent then it is reasonable to consider surgery.

If asymptomatic polyps are seen in the nose by chance then these usually do not require surgical treatment. However, the presence of a unilateral polyp in the nose does warrant an examination under anaesthetic and removal of this polyp for histological diagnosis. Very occasionally a unilateral polyp arises solely from the maxillary sinus (under the cheek). This requires a complete polyp removal and the attached lining to the maxillary antrum to prevent recurrence.

Unilateral nasal polyp (Antrochoanal polyp)

Gross bilateral intranasal polyps

Nasal Polypectomy Surgery

Surgery for this condition has improved significantly over the past few years with the use of powered instrumentation. Rather than the simplistic manual removal by just pulling the polyps out one can carefully suction and then debride the polyps out of the nose using a ‘microdebrider’ leaving as much normal anatomy possible behind in the nose.

This surgery is performed using the endoscope and is a variation on Functional Endoscopic Sinus Surgery and often is combined especially if the polyps have been causing obstructive symptoms leading to chronic sinusitis.

Similar risks are incurred especially as often the nose is filled with abnormaltissue and therefore this has to be removed before normal anatomy is identified. The risks to the skull base and the breach of it producing leakage of the fluid that bathes the brain together with orbital injury although rare are a possibility. Bleeding is not uncommon in very small quantities in the post operative periods and if significant require presentation to a local emergency department. Packing the nose postoperativeley may be performed sometimes to tamponade any initial bleeding.

Postoperativeley the patient should be sent home with a nasal douche and a course of intra nasal steroids to decrease the chance of the polyps coming back quickly. Polyps cannot be cured by surgery and the surgery is aimed at improving the nasal airway and aiding the delivery of intranasal steroids that will be preventative in the longterm future.

Functional Endoscopic Sinus Surgery (FESS)

Anatomy / Physiology

TThe anatomy of the sinuses has not changed for many years, but our understanding of the physiology of the nose and sinuses has evolved significantly in more recent years. Our concept of how sinuses naturally drain has been the source from which we have adapted our surgical techniques in order to improve these natural drainage patterns.

There are a number of sinuses.

• Maxillary sinus x2
• Anterior ethmoid sinus x2
• Posterior ethmoid sinus x2
• Frontal sinus x2 (variable in size and development)
• Sphenoid sinus x1 (often split into 2 by a bony septa)

The maxillary sinus (located under your cheek) drains into a narrow area between two bony folds in the lateral wall of the nose, called the middle meatus (area between the middle and inferior turbinates). In addition the anterior ethmoids and the frontal sinus drains here too. This is a crucial area of confluence referred to as the osteomeatal complex and is where a lot of problems exist with respect to sinusitis. Surgery is often focused here to improve the drainage.

FESS

The surgery is referred to as Functional as you are not just anatomically looking at creating a solution but you are improving on the normal function / physiology of the sinus drainage pathway.

The surgery is referred to as Endoscopic as the surgeon uses fine telescopes intranasally to give an excellent visualization of the nose. With the use of fine instruments too the surgeon can rectify any anatomical or pathological anomalies in order to improve the natural drainage of the sinuses.

The surgeon almost always uses a CT scan as a map through the nose and sinus and this will have been performed preoperatively to help with the diagnostic workup of the patient.

Preoperative CT Scan showing opacification of the left maxillary and ethmoid sunuses.

Access sometimes has to be improved with an additional procedure of a Septoplasty to allow visualization of areas obstructed by a deflected nasal septum.

This surgery can often be performed as a day case but occasionally warrants an overnight stay. The nose may be dressed with small soft intranasal packs that are removed after a set length of time depending on the surgeon.

It is not uncommon to feel blocked in the nose for approximately a week as the swelling intranasally goes down and regular nasal douching with appropriate products as recommended by your surgeon should be used to flush out any crusts or blood from the nose. It strongly advised not to blow your nose in the postoperative period.

Anatomy / Physiology

The dividing partition between the left and right nostril is called the nasal septum. It is composed of both cartilage (soft and flexible) in front and bone (solid and inflexible) further back.

The nasal septum is lined with a tightly adherent mucoperichondrium that supplies it with nutrients. It has a number of growth centres from birth that continue with growth until the late teenage years therefore it is sensible not to operate in this area unless there is good reason to do so.

The cartilage is necessary for the support of the nose and surgery to the cartilage may affect this support. The cartilage is sensitive to trauma that can occur at birth and any point afterwards.

If the cartilage or the bone of the nasal septum is deviated it may produce symptoms of nasal obstruction. It is surprising how often people have an asymptomatic deflection of the nasal septum and also the fact that the nasal septum can be deflected in more than one direction. It is for this reason that a septoplasty can be useful in the correction of the symptom of nasal obstruction. Occasionally a septoplasty is used for access in the nose such as with Functional endoscopic sinus surgery.

Septoplasty

An incision is made in the mucoperichondrium of the nasal septum and this layer is carefully dissected off the cartilage below. The forwardmost strut of cartilage is preferably preserved to maintain support of the nasal structures together with a strut of cartilage under the midline portion of the nose.

Whatever cartilage is deflected should be augmented, resected or scored in order to straighten the nasal septum. Once this has been achieved then the mucoperichondrium should be replaced and is often stitched back to the nasal septum to firmly replace it and prevent blood from accumulating in the pocket that has been created for the operation.

The nose is not infrequently packed with a soft nasal pack that stays in the nose only for a few hours.

If performed alone this case can be discharged on the same day. This surgery however, is often performed with other procedures in the nose such as turbinate surgery.

Post-operatively the patient will feel very blocked in the nasal cavities and it takes approximately 7-10 days before the swelling goes down and people start to get the benefit from the surgery.

Nasal polyps cause onbstruction of the nose and can be very symptomatic causing patients to suffer with nasal obstruction, snoring, decreased smell sensation and a runny nose.

Polyps are an inflammatory / allergic response of the nasal (sinus)mucosa that then prolapses and obstructs the nose. A large number of polyps can be treated with intranasal steroid sprays, but I often see patients who have tried these already. If the polyps are symptomatic then it is not unreasonable to remove the polyps surgically via an endoscopic surgical technique (no external scars). This gives the patient immense relief after the intranasal swelling goes down.

Whilst this removes the majority of the polyps there is a tendency for the condition to recurr as it is the sensitivity of the nasal (sinus) mucosa to swell and prolapse that causes them and this still remains. It is for this reason I will often treat people again with intranasal steroid sprays following surgery as the delivery is improved and it will decrease the chance and the need for further surgery.

Sinus surgery has changed significantly over the years. The previous operations that were the norm such as a Caldwell Luc or inferior meatal antrostomies are unusual to perform nowadays. Our technique has been refined to encorporate the normal sinus drainage patterns which is what we refer to as ‘Functional Endoscopic Sinus Surgery’ or ‘FESS’.

What is interesting, when I teach General Practitioners who have had a good grounding in ENT Surgery, this newer approach to sinus surgery is not fully appreciated. This may be because it is simply a development that has occured since they had any formal ENT training so it is essential that we spread the word with this up to date form of treatment of the sinuses.

The treatment does not usually require any surgical scars and is performed through the nose using an endoscope, which is a thin rod that can allow the surgeon to visualise inside the nose and then instrument it. A variety of specialist instruments can then be used intranasally to open the natural drainage patterns of the sinuses and thus improve the symptoms of sinusitis by improving the natural drainage pattern and not creating an unnatural one.

Snoring is a common phenomenon and has an increased incidence with age. Certain physical attributes such as weight and alcohol consumption can worsen the effect of snoring. The symptoms and complications associated with snoring cover a number of specialities and it is therefore imperative that there is a working relationship with these other specialities if the correct management is to be offered to patients.

If a patients Epworth Sleepiness score (see website) is high then this implies that the snoring is significantly affecting the quality of sleep and this may be best assesed by a physician with the ability to undertake a sleep study.

If a patient is not overweight and does not drink excessively together with a low scoring  Epworth Sleepiness score, it is not unreasonable to offer snoring surgery. The patient should be advised carefully as to the success and more importantly the long term effect of this success. They also must be aware of the complications associated with this sort of surgery.

Ultimately, surgery for simple snoring is not an unreasonable treatment option as long as the patient has been assesed correctly in the Out-Patient setting and is given realistic expectations for the future

A septoplasty is an operation undertaken by ENT surgeons to straighten the midline cartilage of the nose and is often combined with minor surgery to the fleshy turbinate tissue in the nose. It is aimed at improving nasal obstruction.

If patients are carefully selected then the operation can be extremely successful. However, patients should be aware that on occasions if the cause of their nasal obstruction arises from the lining of the nose then the operation may not be a success as this does not change.

A careful examination of the nose often revels the deflection of the nasal septum, that can obstruct both sides of the nose if the cartilage is in a S shape. If this deflection is noticed and nasal obstruction is the main symptom without significant other nasal symptoms then septoplasty carries a high chance of success.

Just be warned that immediateley following a septoplasty the nose is blocked significantly as the operation causes swelling and inflammation. This takes approximateley 10-12 days to start settling and then the patient starts to feel the benefit of surgery.

Nosebleeds also referred to as epistaxis are a common phenomenon. It occurs in all age groups, both sexes and thankfully most of the time is fairly self limiting. However, as an ENT surgeon I see the more troublesome end of the spectrum and always treat them seriously as every year in this country a few people die as a consequence of a nosebleed.

It is important to take a full history to look for any causes of a tendency or cause for nose bleeds. A careful examination of the nose is important to look for a cause.Occasionally blood tests are undertaken to look for a bleeding tendency and if there is a mass in the nose special XRays may be organised.

Treatment is dependant upon the cause. The commonest cause is related to bleeding from the nasal septum where there are some fragile blood vessels. These can be easily cauterised even in the younger age group. Occasionally nasal packing or even surgical intervention is required to stem a brisk nosebleed.

Patients should be seen for a significant nosebleed or recurrent nosebleeds.

The nose continues to develop in both its cartilaginous and bony components. It does so via a numer of different growth centres that have a dedicated blood supply. The growth continues significantly until at least 16-17 years of age.

Surgery to the nasal septum and nasal bones disrupts the blood supply to these growth centres and as a result most patients aged below 17 would not be considered for a nosejob before this age. This is not to say that it should not be done as sometimes if there is a trauma causing a significant injury to the nose and distortion of shape it is better to correct this rather than let the nose continue to grow in the wrong fashion for the rest of the deveoment of the nose.

or further information about nosejobs please look at the website http://www.myentsurgeon.com/septorhinoplasty.html