Operations and Procedures

Please use the navigation on the left for a brief guide to some of the common operations and procedures, where possible I have tried to keep to the format of using the term quoted by most Doctors and then an explanation of the reasons for the operation, what it involves and some of the possible risks and complications of which the patient should be aware. All these should be discussed with the surgeon as they will influence the decision as to whether or not to proceed with an operation and it is important that patients have a realistic expectation as to what can and cannot be achieved by surgery.

A Grommet or ventilation tube

This is one of the most common operations performed in this country and indeed one of the commonest performed on children. The usual reason for this operation is children who suffer from glue ear and who therefore have impaired hearing or recurrent infections (acute otitis media) In children the operation is performed under general anaesthetic but in adults it can be performed under local anaesthetic. After the incision has been made in the eardrum the fluid is usually sucked out and the small plastic grommet is inserted through the hole so that one flange lies on either side of the eardrum. Risks and complications – these are rare but occasionally the grommet will become infected. If this is the case the infection can usually be treated by a combination by antibiotics by mouth or in the ear. Rarely it is necessary to remove the grommet. Scarring – repeated grommet insertion is associated with some scarring of the eardrum. In persistent cases of glue ear it occasionally advisable to insert a long-term grommet, (T tube). This has similar complications to the ordinary grommet although they may occur slightly more frequently. The other complication is a persistent perforation of the eardrum once the grommet has fallen out.

For Grommet links click here

Adenoidectomy

This is removal of the adenoid tissue. The adenoid is situated at the back of the nose above the soft palate and is therefore not normally visible. If enlarged this may block the nose and contribute towards nasal obstruction, also glue ear. It is removed under general anaesthetic using a curette. It is usually a simple and painless procedure however the most serious complication is that of persistent bleeding and rarely a patient will have to stay in overnight with some packing in the nose if this occurs.

For Adenoidectomy links click here

Tonsillectomy

This is another very common procedure and the usual indications are recurrent and acute tonsillitis but also children with obstructive sleep apnoea who because the tonsils tissue is so large that they cannot breath properly at night. There are many surgical techniques for removing the tonsil and at present there is no clear advantage of one over the other, although this is at present a subject of a Royal College of Surgeons of England Audit and so it may be possible in the near future to make more specific recommendations. The major complications of tonsillectomy are 1) pain, this is inevitable to some degree and some patients experience minimal pain, others particularly adults may suffer badly. Interestingly children may well complain of earache more than a sore throat, we call this referred pain and is due to the unusual nerve supply of the ear. If this should occur it does not mean that anything has gone wrong with the operation at all. Pain is often worse between the 5th and 10th day after the operation and may require quite strong painkillers. 2) Haemorrhage, this is the most serious and dreaded complication. Haemorrhage may occur within 24 hours of the operation, which we call reactionary haemorrhage. If this does happen then of these cases approximately 80% occur within the first six hours of the operation and the person is usually taken straight back to the operating room to have the bleeding point stopped. After 6-8 hours the chances of bleeding over the next day or two are extremely small, although spitting the odd bit of blood is not unusual. For this reason surgery as a day case is becoming increasingly popular. The second period, during which haemorrhage can occur is between day 5 and day 10 after the operation, this is called secondary haemorrhage. It may or may not be associated with an infection of the area. It is usually treated by admission to hospital with bed rest and antibiotics. The approximate incidence of these complications are that secondary or reactionary haemorrhage occurs in about 3% of cases, approximately half of those patients admitted with secondary haemorrhage can be treated by bed rest and antibiotics alone and approximately half will require a second operation to stop the bleeding.

For Tonsillectomy links click here

Septoplasty/SMR

This is a common operation used to overcome nasal obstruction when due to a distortion in the mid line cartilage or septum of the nose. Some people are born with a bent septum; others acquire a bend as a result of trauma, often a sporting injury. The operation is performed usually with the patient asleep and the incisions are all made inside the nose, there should be nothing visible externally. If you put one finger up each of your own nostrils you will feel between those fingers the septum, which should be in the mid line! The skin on one side is incised with a knife and lifted off the cartilage, the bent bit of cartilage is then removed and the remaining septum is repositioned toward the mid line to improve the airway. It was traditional to leave the patient with plastic splints in their nose with or without packing, in order to prevent bleeding and encourage the septum to heal in the mid line. Nowadays this is not thought to be necessary and indeed most patients find it far more comfortable not to have any form of packing or splints in their nose and certainly it is my practice to avoid it where at all possible. Disposable sutures are often used to close incisions and to quilt the septum to prevent any bleeding.

Post operative complications

There is often a degree of bleeding from the nose for a day or two afterwards. The tissues inside the nose swell as a result of the operation and so it is common to feel quite blocked for a week or two until the swelling goes down. During this recovery phrase I encourage patients to douche with salt-water solution in order to rinse away any blood and crusts and freshen the nose, this is preferable to blowing the nose or any other form of drug. Other rare complications which can occur as a result of surgery are 1) subtle change in the shape of the nose, whereby a slight indentation appears above the tip (supra tip depression). The bony bridge of the nose is thrown into prominence and it is sometimes misinterpreted as a hump rather than the depression it really is. The treatment is usually fairly straightforward and involved putting a small cartilage graft under the skin from the inside of the nose. Perforation of the septum can occur, very rarely and this may or may not be symptomatic.

Turbinectomy

Cautery of turbinates/trimming of turbinates This procedure may be performed in isolation or as part of a septoplasty/SMR. The turbinates are the shelf like lining of the nose. If they are particularly reactive or prominent then it may be worth attempting to shrink them down using cautery/diathermy.

Nasal polypectomy

Nasal polyps are another common condition seen in the nose. There exact cause is not known but they represent the end point of an inflammatory process, which affects the whole of the nose and sinuses. A polyp is a protrusion of the lining of the sinuses into the nose, treatment therefore requires the underlying inflammatory condition be identified and treated as well as possible mechanical removal of a polyp if it is causing obstruction either to the nose or to the sinuses. Surgery therefore is not an alternative to medical management but only one part of the treatment. Sometimes small polyps can be removed easily in out patients under local anaesthetic, however often they require removal under general anaesthetic. There are various ways of removing these, each of which has its advantages and disadvantages and the preference of each individual surgeon has some part to play. As with all nasal operations I try and avoid any form of packing although this is occasionally necessary. Post operative nasal douching is often very comforting and one must never forget the long-term medical management of the inflammatory process underlying the condition.

Rhinoplasty / nose job / Septorhinoplasty

A rhinoplasty is an operation, which may be done for several reasons. The most common indications are to overcome as part of the treatment of nasal obstruction, if there is deformity of the external nose, accompanying a deformity of the internal nose. The other main indication is cosmetic improvement. The two of course are not mutually exclusive and may well go together if there is gross deformity of the nose or a desire to improve the aesthetic appeal requires very careful consideration on the part of both surgeon and patient. It is important that the patient has a very clear idea of what they do and do not want and an informed consultation with the surgeon as to what is and what is not possible. Each operation has to be tailored to the wants of the individual and adapted to the current anatomy. I would be pleased to discuss cosmetic changes to the shape of the nose without any obligation.

Myringoplasty

This operation is used to close a hole in the eardrum. The main reason for doing this is to prevent recurrent infection. The main nuisance with a hole in the eardrum is the person may have a degree of hearing loss and sometimes they expect that the hearing will be improved after the hole is closed. This is not always the case, indeed if the hearing is improved it should usually be regarded as a bonus rather than something to be expected. A hole in the ear drum does not always has to be repaired and some people are busy leading their lives with a small hole, however in a young person it does preclude certain forms of employment and sports e.g. scuba diving and in the more elderly it may prevent the wearing of a hearing aid if recurrent infection is the result. There are many ways of doing the operation but the commonest is to take a piece of thin tissue from under the skin covering one of the muscles (temporalis fascia) and putting this underneath the ear drum. The ear is approached from either an incision behind the ear or a small incision that comes from inside the ear canal out to the front of the ear. After the operation a dressing will be put in the ear canal and sometimes a fresh dressing covering the ear itself. My personal practice is to put in a sponge dressing in the ear canal, which we keep wet with antibiotic drops for a fortnight. If there is a pressure dressing it will usually be removed the day after the operation and there may be some blood stained cotton wool in the outer part of the ear canal. This can be removed and changed as necessary. A blood stained ooze may come out of the ear for several days afterwards but if it becomes yellow or bad smelling one might suspect an infection which although unusual is possible. Under these circumstances you should contact the surgeon immediately. I usually review the patients after two weeks and remove the sponge dressing and then again in six weeks by which time it should be possible to tell whether the graft has been successful or not and we would usually do a post operative hearing test at that point. Complications – complications are rare but some discharge from the ear is to be expected as above. If however the ear becomes painful and the discharge becomes more profuse rather than less one should seek the advice of a Doctor immediately.

The success rate of the graft depends on many factors and no body can claim 100% success in every operation. My own success rate for closing the hole in a long term is approximately 80%. I believe this is not dissimilar to most other ENT surgeons practice in the UK. Any operation on the ear carries a small but real risk that the hearing will be made worse rather than better, although this has never happened to me yet (touch wood) after a simply myringoplasty this remains a theoretic possibility. No patient should have an ear operation without realising that this complication could occur.

Facial nerve weakness or palsy

Again this is a dreaded complication of any ear surgery. The immediate onset of a nerve weakness after ear surgery may be due to the effect of the local anaesthetic or bruising of the nerve or more seriously due to permanent damage. None of these are common occurrences. If the weakness is due to local anaesthetic it will wear off in a few hours but bruising may take some days or weeks to recover. Rarely is the onset of weakness may be delayed by a few days or even a week but under these circumstances the prognosis for recovery is good. Permanent damage to the facial nerve is fortunately rare and can be minimised by careful appreciation of the anatomy possibly enhanced by pre operative scanning such as CT, and the use of intra operative nerve monitors. If it does occur as a result of severe trauma then the situation can be to a certain extent redeemed but then long-term weakness is likely to result. This again is exceeding unlikely in a simply myringoplasty but and a rare but unfortunate complication of mastoid surgery which involves drilling away the bone of the mastoid.

Tympanoplasty, myringoplasty, ossiculoplasty, mastoidectomy

These words are sometimes used loosely and are interchangeably by doctors, which can add to a degree of confusion. A myringoplasty means a repair or refashioning of the eardrum, an ossuculoplasty involves removal of replacement or refashioning of the three little bones of the ear and a mastoidectomy implies drilling away the bones over the mastoid air cells to improve aeration or remove cholesteatoma. A tympanoplasty can mean combining one or more of the above previously mentioned operations. The purpose of a tympanomplasty/mastoid operation is first and foremost to remove disease from the mastoid air cells; this is usually cholesteatoma or other infective material. The first aim of the operation therefore is to render the ear “safe”. Unfortunately the price to be paid for making the ear “safe” may be either the creation of a mastoid cavity which requires long term care or become infected or indeed a reduction in the level of hearing. For this reason over the years many methods have been sort to try and get the best of both worlds, i.e. a safe ear and a dry ear, which hears normally. This is not always achievable and depends entirely on the original anatomy and also on the skill and training of the individual surgeon. There is debate within the medical profession as to the optimum treatment for various conditions affecting the ear and you would be advised to read some of the following links and to discuss cases with a surgeon with an interest in ear disease.

Cholesteatoma

Stapedectomy

This is an operation for a disease called otosclerosis, it is not the only option to treat this disease, other options include wearing a hearing aid or a bone anchored hearing aid. In the operation of stapedectomy the stiffened stapes bone is broken off and replaced by a plastic piston. It is a highly skilled operation and one, which requires experience, and practice and not all ENT surgeons practice this operation. There is a growing tendency to concentrate the expertise in those with a particular interest and talent for this type of fine surgery. Anyone contemplating this sort of operation would be wise to ensure that his surgeon was not an occasional operator but the recipient of referrals from other consultants.

Otosclerosis

Parotidectomy/superficial parotidectomy

The parotid gland is one of the salivary glands and can produce a variety of tumours, most of which are benign, some are malignant, and some behave in a way, which can only be described as in-between. Removal of the parotid gland or its superficial portion may be both diagnostic and curative. Often lumps within the parotid may be diagnosed using a fine needle biopsy but unfortunately the interpretation is difficult and sometimes equivocal. The operation of parotidectomy is performed by those surgeons with a particular interest in the disease, as the surgery is quite delicate. The key issue is that the nerve which supplies movement to the side of the face runs through the middle of the gland and therefore has to be identified and preserved. Danger to the nerve is minimised by experience, careful tissue handling and the use of a nerve monitor within the operation. Post operatively the patient will normally have a drain i.e. a small plastic tube leading out of the side of the wound in order to drain away any blood that may accumulate within the wound. This drain is usually removed the next day. The wound is not usually particularly painful; indeed there would be an area of numbness over the side of the face and the ear due to the division of the superficial nerves. This area of numbness will regress over a period of 6-12 months but at least 50% of patients are left with the tip of the ear lobe being numb. Facial nerve weakness mentioned above may be temporary due to stretching or bruising of the nerve at operation and this will recover within a few weeks. Permanent weakness is possible and may be inevitable if the tumour is surrounding a nerve. Another complication is Frey’s syndrome where by the patient complains of a sweating of the ear on the side of the face when they eat or chew. This can be a little alarming at first but it is harmless and to most patients a minor irritation, however there are treatments available should it become a major problem.

Salivary gland tumour, Salivary gland non malignant tumour

Thyroidectomy

The thyroid gland may be removed or partially removed for two reasons. Firstly if there is a lump in the gland which is suspected to be a tumour or secondly if the gland has become overactive. Other less common reasons would be to remove a gland, which has become so bulky as to the cosmetic problem or in the relatively rare cases of a thyroid cancer, which requires the other side of the gland to be removed. Subject of thyroid surgery is a complex issue and the reader is advised to consult one the reviews.

Thyroid Cancer