ADENOIDECTOMY
Adenoidectomy (removal of adenoid tissues) is usually done for obstruction of the space at the back of the nose (blocked nose, mouth breathing, obstructive sleep apnoea) or as part of the treatment of otitis media.
The adenoids may be assessed in the office pre-operatively, either by a flexible fibreoptic nasopharyngoscopy or by reviewing an Xray of the region. Careful review of the palate to exclude a submucous cleft palate is performed.
The operation is performed through the mouth. It is usually a straight forward procedure but is not regarded as a “simple” procedure because of the potential for bleeding into the airway. This may occur at the time of surgery, or up to 10 days later in less than 0.1% of patients. Generally, therefore, patients should not leave the Perth area for 1 day postoperatively. The procedure is performed under general anaesthetic, usually as day case surgery. Patients are treated with antibiotics post-op to prevent infection and reduce bad breath. Very rarely adenoidectomy may result in changes in the voice and in some cases where we believe this might be a possibility, then a partial adenoidectomy is performed.
Aspirin or Nurofen should not be used before or after the operation but Panadol is satisfactory. Often the child may go back to school 3 – 5 days after surgery if he or she is well. This operation is often done in conjunction with surgery (cautery) to the inferior turbinates.
ATTICOTOMY and
RECONSTRUCTION OF THE DEFECT
These procedures are usually performed if there is evidence of a retraction of the ear drum in the upper weak part of the ear drum which is causing concern, for chronic ear infections or for the eradication of Cholesteatoma. The condition known as Cholesteatoma, or Skin Cyst, which can develop if the retraction pocket enlarges to the extent that it cannot be completely seen and starts to cause discharge, or infection and damage to vital structures such as the bones of hearing, balance, facial nerve and rarely the tissue around the brain or the brain itself.
Usually the Atticotomy procedure can be performed through the ear canal, and involves lifting up the ear drum in that area and either curetting or drilling out overhanging bone so that the whole area of the retraction pocket can be seen and removed. Usually, because the ear drum area has been weakened, we strengthen it with a piece of tragal cartilage, usually obtained from the ear canal itself. This will strengthen the ear drum in that area and prevent further retraction of the drum.
Complications arising postoperatively may include (1) hearing loss, either temporary or permanent, (2) recurrence of the retraction pocket despite the treatment, (3) persistence of some skin in the middle ear that has not been able to be detected causing cholesteatoma and requiring a more surgery, and (4) remote risks of damage to the facial nerve or to the bones of hearing (the risk of total hearing loss is less than 1:1000 and the risk of damage to the facial nerve is 1:10,000 operations) and dizziness rarely.
There is a risk of postoperative infection, but this is uncommon due to the administration of antibiotics postoperatively. Occasionally a grommet tube is inserted in the ear drum to relieve the pressure on the healing drum. If a tube has been inserted, it is necessary to keep water out of the ear canal at all times. There may be some packing in the ear which should be left intact until you see the doctor post-op. Overall, these procedures of the ear drum, middle ear and mastoid bone are relatively safe major ear procedures with excellent results.
CAUTERY OF THE TURBINATES/TURBINOPLASTY
Some children with rhinitis have very enlarged inferior turbinates which can be reduced in size by surgery either alone, or in conjunction with other operations, e.g. tonsillectomy.
The operation causes the turbinates to swell and the nose will be runny, occasionally smelly, and after, the slough will appear as a white or pink lump in the nose. (This is not packing). Usually the slough is removed at the postoperative visit, and the nose should not be blown until that time (or 10 days), as it may separate early and bleed. Use of Drixine nose spray from your chemist will help reduce the swelling and any minor bleeding. Nozoil will help reduce any crusting Vaseline around the nasal openings will help any irritation in that area.
MYRINGOTOMY AND INSERTION OF VENTILATION TUBES (GROMMETS)
Myringotomy tubes are usually inserted for treatment of otitis media with effusion (glue ear), or recurrent middle ear infection. The procedure can be done either by itself as a same day care unit type situation, or occasionally in association with an adenoidectomy or other procedure, where the child usually spends a night in hospital. Myringotomy tubes usually remain in place for between 3 and 9 months, at which time they come out of the eardrum by themselves into the ear canal.
Precautions must be taken to prevent water entering the ear canal whilst bathing. If water enters, or the patient has a cold, there may be some drainage from the ear, which fortunately is easily treated with antibiotic eardrops. The treatment of choice for discharging grommets is the application of 3 – 4 drops of Ciproxin HC ear drops or Ciloxan eye drops 3 times a day for 3 days. Occasionally ear washouts using 0.05% hypochlorite solution, or Betadine 5% solution, and a plastic syringe are necessary – followed by the use of the drops as described. In younger children ear putty or “Blue Tac” is effective in preventing water entering the ear while bathing or swimming. Effective protection for older children may be obtained by use of a moulded ear plug which gives a more accurate fitting, and use of a bathing cap or “ear wrap”. Children should not do “bombies” or dive or swim underwater, as water may enter the ear despite the ear protection.
Children are reviewed every 6 – 9 months while the tubes are in place, to ensure that no discharge or problems have occurred, and to check the postoperative hearing. They are reviewed once the tubes have come out as well, in case fluid has reaccumulated. A second set of myringotomy tubes are required in approximately 30% of children. Adenoidectomy has been shown to reduce the rate of ear infections and may be recommended at the second grommet operation if required. Depending on the type of grommet between 1-10% of grommets may extrude leaving a persistent hole in the eardrum which may need further surgery to correct.
PLEASE KEEP THIS TO SHOW TO YOUR FAMILY PRACTITIONER IN CASE OF DISCHARGING EARS
MYRINGOPLASTY
(REPAIR OF PERFORATED EARDRUM WITH SPECIAL GRAFT)
Myringoplasty is performed to reconstruct the eardrum if there is a perforation. This improves the hearing generally, allows the child to swim and prevents ingrowth of skin at the edges of the perforation (cholesteatoma). The perforation may result from previous ear infections or grommet tube insertions where the ear drum did not heal. The graft material varies, but is always taken from the patient either as a subcutaneous tissue/fat/fascia graft, or a tragal cartilage graft. The success rate varies according to the size of the perforation, and the presence or absence of infection pre- or postoperatively. Success rate is usually greater than 70 – 80%.
Complications include infection and rejection of the graft, hearing loss (uncommon), tinnitus and vertigo, and very rarely (1 in 10,000) facial nerve palsy.
Following the repair of your ear drum there will be drainage of blood stained debris from the ear canal for up to 4 weeks. If this discharge becomes malodorous, please contact my office. If there is an incision behind the ear, water should be kept off this for 1 week. Similarly, water should not be allowed to enter the ear canal. To prevent water entering the ears, use a mixture of Vaseline and cotton wool, or “blue tac”, and insert as a plug into the ear canal.
Popping sounds are to be expected but persistent pain is not usual. If this occurs, please contact my office. Similarly, severe dizziness after leaving hospital is unusual and should be reported to me.
SEPTOPLASTY, SMR OF THE TURBINATES, CAUTERY OF TURBINATES
Septoplasty is performed to straighten a deviated septum. Reduction or cautery of the turbinates is done to improve the airway as well, by reducing the turbinate enlargement often seen in allergic rhinitis. The main aim is to improve a blocked nose or as part of the surgical treatment of sinusitis.
The main complications of the operation involve bleeding postoperatively, later redevelopment of the septal deviation due to the “cartilage memory”, or further injury. If the nasal septum has been severely damaged by previous injury, problems with further growth of the nose will occur. Rarely some people develop a perforation in the septum which may have no consequence or may cause a whistling noise with breathing and may cause nose bleeding. The turbinates regrow to some extent in all patients.
Following septoplasty, your nose may be packed for a day. This will be uncomfortable but not painful. After you leave hospital, your nose will probably still be congested for a few weeks. You should not blow your nose for 7 days, but rather sniff the secretions back. The crusts and debris in your nose will be cleaned out at your postoperative visit. Also avoid bumping your nose.
It is not unusual to have some blood stained discharge on and off for a month after the operation. Swimming in the ocean a week after the operation may help clean the nose out. Panadol rather than aspirin should be used for discomfort and pain. You may also be given a prescription for antibiotics.
Saline nasal spray and sometimes Drixine nasal spray, should be used for congestion with the use of 2-3 pillows at night if needed.
In the case of SEVERE bleeding, which occurs in 2% of patients, please contact me, or if this is not possible, go to the emergency department.
TONSILLECTOMY
This operation is often combined with adenoidectomy and cautery of the nose, and usually requires one night in hospital. One parent is encouraged to stay with the child overnight. When the child returns home from hospital, he/she should be put to bed. The child may sit up out of bed and play inside the house but should not be allowed to get overtired. The child should not return to school for 7-10 days after the operation and should restrict strenuous exercise for a further 10 days. Swimming is not permitted for three weeks after surgery.
DIET
The child should eat as close to a normal diet as possible. Chewing gum between meals is recommended as this helps to reduce pain and stiffness in the area. Fresh oranges, lemons and bananas as well as hot or spicy foods may cause severe pain and should be avoided. In the case of small children adequate fluid intake is more important than food intake and any favourite liquid or “popsicles” should be encouraged.
ANTIBIOTICS
Routine post-operative antibiotics are given for 7-10 days, as it has been shown that this reduces the possibility of bleeding from the throat and reduces the normal post surgical bad breath.
EAR ACHE
This is common after tonsillectomy and is due to a phenomenon known as “referred pain”. It is not usually due to ear disease.
PAIN RELIEF
The degree of pain suffered by children following tonsillectomy varies widely and some children require pain medication for up to 10 days. It is important to get “on top of the pain” and then provide a maintenance level of pain medication until it is no longer necessary.
Panadol can be given to enable the meal to be swallowed with less discomfort. Local anaesthetic lozenges such as Cepacaine or Strepsils may be sucked to reduce the tonsillar bed pain. Stronger pain medication such as Oxynorm maybe prescribed by the anaesthetist.
Under no circumstances should any compounds containing aspirin (there are 30 available) or Nurofen be used for 2 WEEKS before or after tonsillectomy as they can affect blood clotting and cause secondary haemorrhage.
APPEARANCE OF THE THROAT
If you look at the child’s throat, do not be alarmed if the tonsil bed is raw and becomes coated with a thick white slough. This dislodges or disintegrates on about the 7th day and the throat looks “raw” for another week. Occasionally black ties of suture material will fall off in due course. If, after finishing the antibiotics, the child becomes feverish and develops a foul breath, a secondary infection may be developing and further antibiotics should be sought from your family practitioner. This infection may lead to an increased risk of secondary bleeding from the tonsil bed.
BLEEDING
As mentioned above, infection of the tonsil beds or separation of the slough may occur with bleeding (called secondary bleeding). This happens to one child in fifty and can usually be managed without the need for further surgery. If the loss is only a few drops there is nothing to worry about. If, however, the bleeding continues and does not stop after 10 minutes, you should telephone me. Please contact me at any time of the day or night if you are alarmed by the child’s condition. Day calls should be made to 9389 1622, and in the evenings and weekends, you should ring Dr Coates on 9335 5808. If you cannot contact us and the bleeding is severe, go to the emergency section at Princess Margaret Hospital for Children (phone 9340 8222).
NOTE, Because of occasional severe secondary bleeding country children should stay in Perth for 14 days postoperatively.
SOME INTERESTING FACTS ABOUT TONSILS AND ADENOIDS
Tonsils and adenoids are composed of tissue similar to the lymph nodes or “glands” in the neck, groin and other parts of the body.
Tonsils and adenoids are located near the entrance to breathing passages where they can catch incoming infections.
Tonsils and adenoids may help form antibodies to bacteria and viruses as part of the body’s immune system to resist and fight further infections. This function becomes less important as the child gets older.
There is no evidence that tonsils and adenoids are important and their removal, if necessary, does not lead to any loss of future immunity to disease.
Tonsillectomy for recurrent tonsillitis has become less necessary with the advent of modern antibiotic therapy.
In children’s hospitals throughout the world, the most common reason to perform tonsillectomy today is for obstruction of the upper airway. Enlarged tonsils and adenoids may cause snoring and disturbed sleep patterns that lead to daytime sleepiness and behaviour problems in children.
Some orthodontists believe chronic mouth breathing from large tonsils and adenoids causes malformation of the face and improper alignment of the teeth. Children who have abnormal breathing problems (or obstructive sleep disorder) will usually be monitored post-operatively with an oxygen monitor attached to the fingers or toes.