Welcome to an Introduction of the Services We Offer.

Adenoidectomy

What is an adenoidectomy?

An adenoidectomy is a surgical procedure performed to remove the enlarged (ADENOID HYPERTROPHY) or chronically infected ADENOID.

When is adenoidectomy (removal of the adenoid) a consideration?

Your doctor may have sent you to an ear nose and throat specialist to be evaluated for removal of the adenoid, with symptoms of sinusitis or a history of ear infections. 

Some of the guidelines that we follow in order to consider an adenoidectomy are:

• Chronic infection of the adenoid (sinusitis-like symptoms) despite adequate treatment
• Adenoid hypertrophy (enlargement) causing mouth breathing, nasal blockage, snoring,and restless sleep
• Recurrent ear infections

What is involved with removing the adenoid?

Every patient who is to undergo removal of adenoid tissue is first screened to make sure they are not at an increased risk to have HYPERNASAL speech (sounds like talking through the nose) following surgery. The surgery is done through the mouth under a general anaesthetic. One technique used for removal uses a curette to remove the tissue behind the nose. Many times we use CAUTERY (removal with suction and heat) to perform the surgery, resulting in very little, or no blood loss. This surgery is performed on an outpatient basis. The surgery lasts about 20 minutes.

Your child will be given specific instructions regarding activity, diet and medications after surgery. Please follow instructions given to you by your physician and office staff and not friends, neighbors and other interested individuals.

Microlaryngoscopy, Brochoscopy (Evaluation of Airway Problems) and Oesophagoscopy

Microscopic laryngoscopy and bronchoscopy is a procedure that uses a special telescope to look into the upper and lower airway. The telescope allows for a close-up view of the airway. The telescope is passed through the mouth into the throat. The larynx (voice box), trachea (windpipe) and bronchi (lower branches of the windpipe) can be seen.

This procedure is done to look at the parts of the airway and to look for any problems. Symptoms Leading to a Microscopic Laryngoscopy and Bronchoscopy A Micro L and B may be needed when your child has symptoms such as:

• Noisy breathing 
• Persistent coughing 
• Weak cry 
• A hoarse voice 
• Blockage of the airway 
• Repeated breathing problems 
• A foreign body in the airway 
• Severe neck injury

Oesophagoscopy 

An esophagoscopy is performed to look at the esophagus (swallowing tube). Problems in this area can sometimes affect the airway or cause difficulty feeding. A special telescope is placed through the mouth into the esophagus.

This is done to check for any problems that may cause or increase breathing problems or cause swallowing difficulty.

After the Procedure

Following the procedure, your child may have a dry or sore throat. You may offer your child clear liquid after you return home. This may help soothe the throat. 

Paracetamol may be given for a sore throat. Your child may also have a hoarse voice or cough. This should be mild and go away soon. If you would like, you may use a humidifier at home.

Your child may continue with the same symptoms they had before the procedure. However, if your child displays any serious changes, or if the symptoms increase, you should call your Otolaryngology (Ear, nose, and throat or ENT) doctor immediately.

Laryngotracheal Reconstruction (LTR) and Cricotracheal resection (CTR)

What is Laryngotracheal Reconstruction?

Laryngotracheal reconstruction is a procedure in which the airway is made larger by placing a graft in the area that is narrowed. Most grafts are made of ear cartilage, thyroid cartilage, or rib cartilage. The ENT doctor will decide what type of graft is best for your child. 

The ENT doctor will also decide where the graft needs to placed: in the front of the airway (also called anterior), the back of the airway (also called posterior), or both in order to make the airway larger. 

What is Cricotracheal Resection?

CTR is a procedure where the narrowed part of the airway is removed and the two adjacent healthy parts of the airway are connected. This procedure is more complicated than a LTR and therefore is reserved for more severe cases.

The main surgery is followed by a series of scopes (or Microlaryngoscopy and Bronchoscopy) in the operating room to check the airway for healing. If your child has a tracheotomy tube, the tracheotomy tube may come out during the surgery and the hole (also known as a stoma) may be closed. There will be an incision in the neck where the surgery was done.

A small drain will be in the neck to allow fluid and air to drain after the surgery. If rib cartilage is used, there will be a small incision on the chest and a drain will be in place after the surgery. The ENT doctor will decide how long the drains will remain in place. A breathing tube (also known as an endotracheal tube or ETT) will be in place through the nose after the surgery.

The breathing tube holds the airway and graft in place while it heals so it does not shrink back down. The ENT doctor will decide how long the breathing tube needs to stay in place. 

What can I expect after my child's surgery?

Your child will be cared for and closely monitored in the intensive care unit (ICU) after surgery. The ICU doctors will closely monitor your child's total care, while the ENT doctors will closely monitor the airway. While your child is in the ICU, medications may be given to help prevent them from pulling out their breathing tube. These medications make them sleepy and comfortable. 

Before the breathing tube is removed (also called extubation), often children return to the operating room for a microlarynoscopy and bronchoscopy (ML&B) to see how well the airway is healing. The ENT doctor will decide when the breathing tube should be removed. 

Once the breathing tube is removed, your child's breathing will be closely monitored. When the medications that make your child sleepy are stopped, some children experience jitteriness or slight unsteadiness (also called withdrawal) for a short period of time. 

The ENT doctor will decide when the next microlaryngoscopy and bronchoscopy is needed, usually before discharge. Once breathing is stable, the child will be transferred to a high observation unit (also called airway unit) for monitoring. As children continue to progress with breathing on their own, tolerating feedings and healing overall, they will be cared for in the hospital until ready for discharge.

Tonsillectomy

What are tonsils?

The tonsils are two pads of tissue located on either side of the back of the throat. Tonsils can become enlarged in response to recurrent tonsil infections. They can also become a reservoir for bacteria. 

Reasons for Tonsillectomy

• Infection
• Recurrent tonsil infections despite antibiotic therapy.
• Upper Airway Obstruction
• Enlarged tonsils can block the airway and cause difficulty breathing.

Preoperative Care

No aspirin products or products containing Ginko Biloba or St. John's Wort should be given for two weeks prior to surgery. No ibuprofen products or anti-inflammatory medications (Brufen, Celebrex, Naprosyn) should be given for one week prior to surgery. None of these products should be given for 2 weeks after surgery. 

Paracetamol may be given as well as over-the-counter cold medications and antibiotics. Please notify your doctor is there is a family history of bleeding tendencies or if your child tends to bruise easily. 

Surgery

Tonsillectomy is performed under general anesthesia either as an outpatient or with overnight observation. Tonsillectomy is frequently performed with an adenoidectomy. The surgery takes 30 – 45 minutes. Children usually remain overnight for observation.

Postoperative Care

It takes most children 7 – 10 days to recover from a tonsillectomy. Some children feel better in just a few days and some children take as many as 14 days to recover. 

Nausea and Vomiting

Some children experience nausea and vomiting from the general anesthetic. This usually occurs during the first 24 – 36 hours after surgery. If there is nausea or vomiting, give Phenergan, maxalon or ondansetron are given as directed. Please call the office nurse if vomiting continues after giving these medications.

Fever

A low grade fever is normal for several days after surgery and should be treated with paracetamol or paracetamol with codeine, whichever your doctor has prescribed. Please call the office nurse if the temperature is over 102°F.

Pain

Most children experience a fair amount of throat pain after surgery. Some children complain of jaw pain and neck pain. This is from positioning in the operating room. Many children also complain of earache several days after surgery. 

The same nerve that goes to the throat goes to the ears and stimulation of this nerve may feel like an earache. Many children have trouble eating, drinking and sleeping because of pain. Severity of pain may fluctuate during recovery from mild to very severe and pain may last up to 14 days. 

Pain Control

Please medicate your child every 4 hours for pain with paracetamol or paracetamol with codeine, whichever your doctor has prescribed, but do not exceed 5 doses in a 24 hour period. An ice collar to the neck, chewing gum, or a humidifier in your child's room may also help relieve pain. 

Breathing

Snoring and mouth breathing are normal after surgery because of swelling. Normal breathing should resume 10 – 14 days after surgery.

Scabs

A membrane or scab will form where the tonsils were removed. This looks like two separate scabs or sometimes the whole back of the throat is scabbed. The scabs are thick and white and cause bad breath. This is normal. The scabs fall off a little at a time 5 – 10 days after surgery and are swallowed.

Bleeding

If there is any bleeding at all from the mouth or nose bring your child to the Princess Margaret Hospital Emergency Department to be examined by the ENT doctor on call. Bleeding usually means the scabs have fallen off too early and this needs immediate attention.

Speech

If tonsils are very large, the sound of the voice may be different after surgery. 

Drinking

The most important part of recovery is to drink plenty of fluids. Some children do not want to drink because of pain. Frequently offer and encourage fluids such as juice, soft drinks, popsicles and Jelly. 

After 24 hours, milk products such as pudding, yogurt and ice cream in addition to a normal diet may be offered. Please call the office if you are worried that your child is not drinking enough or if there are signs of dehydration (urination less than 2 – 3 times per day, crying but no tears). 

If your child absolutely will not drink, bring your child to the Emergency department for IV fluids. Some children may have a small amount of liquid come out of the nose when they drink. This should stop a few weeks after surgery.

Eating

There are no food restrictions after surgery. The sooner eating and chewing are resumed, the quicker the recovery. Many children are reluctant to eat because of pain. As long as your child is drinking well, don't worry about eating. Many children are not interested in eating for up to a week. Some children lose weight, which is gained back when a normal diet is resumed. 

Activity

Most children rest at home for several days after surgery. Activities may be resumed with no restrictions if your child feels up to it. 

Generally, children may return to school when they are eating and drinking normally, off of all pain medication and sleeping through the night. This is 7 – 10 days on average and can be less or more for some. 

Even though children may be feeling well, they are at risk for bleeding for up to 14 days after surgery. Keep this in mind as your child is resuming normal activities. Please do not travel away for 2 weeks after surgery. 

Follow-up

Some of our doctors recommend a post operative appointment 2 – 3 weeks after surgery. If so, call for an appointment. Some of our doctors recommend a postoperative phone call 2 – 3 weeks after surgery. If there are problems or questions before that time, call the office.

Removal of Foreign Bodies

What is considered a "foreign body"?

An object is considered a "foreign body" if the object is in a location in the body where it is not normally found. Common foreign bodies found in children include coins, small toys, foods (like peas, beans, nuts, or even candy), and, other small objects (like beads or pills, for example). Occasionally dislodged teeth or insects, may be found. Probably the most concerning object is a button type battery (like camera and watch batteries) as these can leak harmful substances.

Common locations of foreign bodies include the ear, airway, or anywhere along the gastrointestinal tract (tubes which pass into the stomach and intestines), among other locations.

How are foreign bodies discovered?

Often a parent will see the foreign body being placed by the child and will bring the patient to the emergency department or general practitioner. In other instances, the symptoms noted in the patient will point to the possibility of a foreign body. Through various tests or procedures, this can be confirmed.

Foreign bodies in the ear usually lead to ear pain, hearing loss or discharge. Airway foreign bodies can cause noisy breathing, difficulty breathing or even recurrent pneumonia (lung infection). When objects are lodged in the swallowing tube (oesophagus), children may have excessive drooling or stop eating or drinking.

Do foreign bodies always need to be removed?

Some foreign bodies, such as those swallowed into the gastrointestinal tract, may pass out of the body along with a bowel movement and do not cause any significant problems. However, a suspected foreign body should always be investigated.

The focus of an ear, nose, and throat specialist is possible foreign bodies of the ear, nose, throat, and airways. If a foreign body is lodged in any of these areas, it is important to have it removed, as there is no natural way for these to pass out of the body. Additionally, there are complications associated with the objects if they remain in the abnormal location.

The remainder of this discussion will discuss how foreign bodies are removed from the ear, nose, throat, and airways.

THE EAR

What are the symptoms associated with a foreign body in the ear canal?

Generally, the symptoms can range from little to no discomfort to a lot of inflammation, pain, and discharge. The longer the object goes unrecognized, the more inflammation can occur. Hearing loss can be present due to blockage of the ear canal.

Who can remove a foreign body in the ear canal?

Usually, removing a foreign body in the ear canal is not an emergency and can be done by anyone experienced in this type of procedure. However, the ear, nose and throat specialist has special tools to remove foreign bodies without causing pain or damage to the ear. Inexperience in removing the object can cause more inflammation and make it harder for removal.

General anesthesia is not usually required for removal, although young or frightened children may benefit from this painless technique.

Batteries should be removed as soon as possible to avoid permanent damage to the ear canal and/or ear drum (tympanic membrane), so general anesthesia may be required depending on the age and cooperation of the patient.

How is a foreign body in the ear canal removed?

It is important that the patient remain very still while the procedure is performed. Holding the patient still is done with a parent and a medical assistant. We do not use restraints on children. There are a variety of methods used in removal depending on the size, shape, and location of the object. You may see attempts at removal using suction (like a vacuum cleaner) or different types of forceps (tweezers) to grab and pull the object out. 

Are there any complications from this procedure?

The complications related to leaving the object in the ear canal far outweigh the complications associated with its removal. That said, some common complications can include irritation and bleeding from the ear canal and damage to the ear drum (tympanic membrane). 

THE NOSE

What are the symptoms of a foreign body in the nose?

The most common complaint associated with a foreign body in the nose is a very bad smelling discharge from the nose, usually on one side. Sometimes the patient will have a history of one-sided sinusitis over several weeks or months.

Who can remove a foreign body from the nose?

As with objects in the ear, some types of objects can be removed by an experienced practitioner. More commonly, an ear, nose and throat specialist is involved, especially if there is a higher possibility of pushing the object back into the throat and getting into the airway or the object is a battery that can leak harmful substances and damage the area.

How is a foreign body removed from the nose?

As with the ear canal, the patient must be very still during the procedure. The parent and a medical assistant will help the doctor remove the object. A medicine that helps control bleeding may be used in the nose. Both suction (like a vacuum cleaner) or forceps or hooks (to grab the object) may be used.

In the case of harmful materials or batteries, removal is usually performed as soon as possible by an ear, nose, and throat specialist in the operating room. After the object's removal, nasal endoscopy (looking at all the surrounding area through a small tube like instrument) may be carried out to look for any further damage.

What are the complications of this procedure?

Some slight bleeding from the involved nostril usually accompanies removal. Damage to the nasal passages could also occur. Other complications can include pushing the object further backward in the nasal passage, with the possibility of having it lodge in the airways. However, an ear, nose, and throat specialist has the expertise in managing this type of complication should it occur.

THE AIRWAYS (throat to bronchi)

The back of the mouth or upper throat (the area visible when you open your mouth wide) can occasionally have a foreign object such as a fishbone stuck in the tonsils. These are usually easily visualized and removed by spraying an anesthetic (numbing) spray into the back of the throat. The tongue is held down and forceps are used to grab and pull out the object.

NOTE: The rest of this discussion will discuss removal of foreign bodies that are not visualized by just opening the mouth, but instead require the use of special instruments to visualize and remove the object.

What are the symptoms of foreign bodies located in the airways?

The symptoms depend on the location of the foreign body in the airway.

The size and shape of the object also affect the severity of the symptoms. A chest x-ray may also confirm the presence of a foreign body in the airway; however, a chest x-ray may not show anything, as not all objects can be seen on an x-ray.

Who can remove foreign bodies located in the airways?

Ear, nose, and throat specialists, who have extensive training and experience in this procedure, should remove objects that lodge in the airways. Many times, pediatric respiratory physicians (lung doctors) help decide whether your child's symptoms are due to a foreign body or represent conditions like asthma.

How is a foreign body removed from the airways?

If a foreign body is suspected in any part of the airway, a BRONCHOSCOPE will be used to confirm the presence of and remove the object. A bronchoscope is a tube like instrument that allows the doctor to see and remove the foreign body with many different specialized instruments. It is called rigid bronchoscopy as opposed to flexible bronchoscopy, which is done with a flexible tube. (Please see EVALUATION OF THE AIRWAYS for more information on bronchoscopy).

The patient must be in an operating room "asleep" (under general anesthesia) during a rigid bronchoscopy. The bronchoscope is then passed into the airway. The anesthetist can then help the child breathe at the same time the ear, nose and throat doctor is working. Once the object is seen, forceps (tweezers) can be passed through the bronchoscope to grab the object and pull it out. As some objects may break into smaller pieces (especially true with food particles), insertion and removal of the bronchoscope may be performed several times to ensure all the objects are removed before ending the procedure. 

What are the complications of rigid bronchoscopy?

Complications that can be associated with this procedure include bleeding, problems with the heart rhythm, difficulty breathing, and possible damage to the teeth.

Aural Atresia Repair

Aural Atresia means the ear canal has failed to form and there is no opening from the outside ear to the hearing bones. In most cases, this congenital abnormality is present on one side only (>80%). It is usually found more often in males and the hearing organ (cochlea) is usually not affected. Repair of this condition starts with repair of any outside ear abnormality present. This is known as MICROTIA and it takes several different forms.

Repair of the missing ear canal involves several steps. First, your child will be given a “score” that will allow your doctor to tell you if your child is a candidate for surgery and the approximate chances for hearing return.

Generally, if your child is a surgical candidate, approximately 2/3 of the time, hearing can be improved to the 30-35dB range. Approximately 50% of the time, hearing can be improved to the 25dB range (just outside normal). Most children have a maximum conductive hearing loss to start meaning they hear = 50dB.

The “score” your child gets is determined partly from a CT scan of the ear. This scan is usually done about 4-5 years of age. It does not help to get scans earlier because, growth, to some extent will affect the outcome. 

Surgery consists of making an incision behind the ear and creating an ear canal in the bone with a drill. The ear bones are uncovered and a new ear drum is made from tissue under the skin behind the ear. A skin graft (usually from the hip) is then used to make the new ear canal skin. Finally, an opening is made in the outside ear itself. This will look large at first because there is some expected shrinkage. This surgery takes about 4 hours.

About 10 days after surgery, packing is removed from the ear.

You should be prepared that minor revision surgery is sometimes necessary in the first 6months to a year due to scar formation or narrowing of the ear canal opening.

Patients usually stay overnight and are discharged the following morning. Regular follow-up is crucial to the success of the operation. Therefore, if you cannot commit to regular visits as directed by your doctor, it is best not to start the process initially.

Success of this operation is measured primarily by the hearing result and it outlined above.

Complications of this procedure include: bleeding, wound infection, loss of graft, infection or scaring at graft site, failure to achieve expected hearing result and hearing loss. Your doctor will discuss these possible complications with you before surgery.

Mastoidectomy/ Atticotomy

What is the mastoid bone?

The mastoid bone is a bone located behind the ear (felt as a hard bump behind the ear). Inside it looks like a honeycomb, with the spaces filled with air. These air cells are connected to the middle ear through an air filled cavity called the mastoid antrum. Although the mastoid bone serves as a reserve air supply to allow normal movement of the eardrum, its connection to the middle ear may also result in the spread of middle ear infections to the mastoid bone (mastoiditis).

What is a mastoidectomy?

A mastoidectomy is a surgical procedure designed to remove infection or growths in the bone behind the ear (mastoid bone). Its purpose is to create a "safe" ear and prevent further damage to the hearing apparatus.

When do we perform mastoidectomy?

CHOLESTEATOMA. This procedure allows complete removal of these benign yet destructive growths MASTOIDITIS that does not respond to antibiotics. A mastoidectomy is also helpful in preventing further complications of mastoiditis. These include meningitis (infection in the fluid surrounding the brain), brain abscess (pocket of infection in the brain), or blood clots in the veins of the brain. 

Occasionally, a mastoidectomy may be used to help find and repair an injured FACIAL NERVE.

What is done in preparation for a mastoidectomy?

A complete evaluation of the ear area including the appearance of the outer ear, eardrum, and middle ear is performed. FACIAL NERVE function is also evaluated. Hearing tests and CT scan are also often obtained prior to surgery.

What is involved with a mastoidectomy?

A mastoidectomy is performed with the patient fully asleep (under general anesthesia). A surgical cut (incision) is made behind the ear. The mastoid bone is then exposed and opened with a surgical drill. The infection or growth is then removed. The incision is closed with stitches under the skin. A drainage tube may also be placed.

Depending on the amount of infection or cholesteatoma present, various degrees of mastoidectomies can be performed. In a cortical mastoidectomy, the surgeon opens the bone and removes any infection. A myringotomy tube (grommet) may be placed in the eardrum to drain any pus or secretions present in the middle ear. Antibiotics are then given intravenously (through a vein) or by mouth.

A radical mastoidectomy removes the most bone and is indicated for extensive spread of a cholesteatoma. The eardrum and middle ear structures may be completely removed. Usually the stapes (the "stirrup" shaped bone) is spared if possible to help preserve some hearing.

A modified radical mastoidectomy means that some middle ear bones are left in place and the eardrum is rebuilt (TYMPANOPLASTY). Both a modified radical and a radical mastoidectomy usually result in less than normal hearing.

A hospital stay is usually required overnight for children. 

Atticotomy

Atticotomy is a limited mastoidectomy. It is indicated for small cholesteatomas or pre-cholesteatomatous changes in the ear drum. In this procedure only the front part of the mastoid bone which is adjacent to the middle ear is removed. 

What are the risks and complications of a mastoidectomy?

Bleeding and/or infection of the wound area are possible complications with any incision. Antibiotics and good surgical technique help prevent this. Some blood-tinged drainage is common in the first two days. 

Other complications can include injury to the balance system, hearing loss, or FACIAL NERVE INJURY. Dizziness or a ringing in the ear (tinnitus) could also result.

Your doctor will discuss the possibility of these complications with you prior to your child's surgery.

Neck Abscess Drainage

Neck abscesses (collections of pus) can be located in either a superficial (just under the skin) layer of the neck or deep in the neck.

SUPERFICIAL NECK ABSCESS

What is a superficial neck abscess?

Superficial neck abscesses are usually the result of an infection in a lymph node in the neck (lymphadenitis) turning into an abscess. Please see LUMPS OR MASSES IN THE NECK for additional information. The most common cause of these abscesses are Staphylococcus or Streptococcus bacteria. If the abscess will not resolve on antibiotics by mouth, the abscess may need to be drained. 

What is involved with drainage of a superficial neck abscess?

Drainage of a superficial neck abscess is a relatively simple procedure. It is performed under general anesthesia. Local anesthetic (numbing medication) is injected into the area. The physician will then feel the lump caused by the abscess to find the area most full of pus. An incision (surgical cut) is then made to drain the pus and a drain is inserted through the skin to keep the fluid from collecting again.

The pus obtained is then cultured to determine the type of organism causing the infection. A specific antibiotic can then be used to treat the infection.

What are the complications of this procedure?

Complications of this procedure can include minor bleeding. Certain abscesses should not be drained because of fistula (connection to skin) formation. These types of abscesses are treated long term with special antibiotics instead. 

DEEP NECK ABSCESSES

Please see DEEP NECK INFECTIONS for details on these types of infections.

What is involved with drainage of a deep neck abscess?

The most important factor when draining any deep neck abscess is to make sure that the airway is not obstructed. Therefore, these procedures are always undertaken in a hospital setting where emergency airway management is available.

Deep neck abscesses can be drained through the mouth (orally) or through the neck (transcervically).

The oral (through the mouth) drainage procedure is used for peritonsillar space abscesses and for specific cases of retropharyngeal space abscesses. All other deep neck space abscesses are usually approached through a surgical cut in the neck.

ORAL APPROACH OF NECK ABSCESS DRAINAGE

What is involved with the oral (through the mouth) approach of peritonsillar abscess (quinsy) drainage?

As with any deep abscess drainage, an adequate airway must first be secured. Most cases of peritonsillar abscesses are identified before the airway is obstructed; therefore, breathing tubes are usually not needed.

In younger children, the oral abscess drainage procedure is performed under general anesthesia in hospital setting.

In older children and adults, an anesthetic (numbing) spray is sprayed around the affected area in the back of the throat. This is usually done in the hospital. A local anesthetic is then injected around the area that is to be drained. A needle is then placed in the bulging area in the back of the throat, and the pus contained in the abscess is drained out.

Complete drainage may require placing the needle in more than one area of the bulge or using a scalpel (knife) to open the abscess. The material drained from the abscess is usually sent for bacterial culture to make sure the correct antibiotic will be used. This procedure usually lasts about 1/2 hour.

After this procedure, the patient usually feels much better and can swallow more easily. Antibiotics are usually given for another three weeks. Cases in which the peritonsillar abscess recurs may require, a TONSILLECTOMY.

What are the complications of the oral drainage technique?

Local bleeding at the surgical site is the most common complication. Although pus will sometimes continue to drain down the throat, this rarely results in any other problem except nausea. Because this abscess occurs near big blood vessels, your physician will take precautions not to puncture too deeply causing damage to the blood vessels.

SURGICAL CUT THROUGH THE NECK (TRANSCERVICAL) APPROACH

What is involved in the transcervical approach for deep neck abscess drainage?

The patient is placed under general anesthesia for this procedure. A surgical cut is made in the neck, and the abscess is located and drained. The drainage is then for a bacterial culture. A drain is usually left in the neck so the abscess does not return. The length of this procedure varies with the size and complexity of the location of the deep neck abscess. 

Usually, the patient will continue on IV (in the vein) antibiotics in the hospital to ensure complete resolution of the infection. Once the drain is removed and the infection is resolving, the patient may be sent home from the hospital on antibiotics by mouth. 

What are the complications of this procedure?

The most common complications are bleeding, reaccumulation of the abscess and damage to nerves. The most common nerve at risk is the marginal mandibular nerve which moves the muscles around the mouth. Special care is taken to protect this nerve during these procedures.

Injury to other vital structures in the neck is also a possibility, although uncommon with an experienced surgeon.

Neck Mass Excision

Thyroglossal duct cyst excision

What are the indications for thyroglossal duct cyst removal?

Thyroglossal duct cysts (and/or tracts) that do NOT contain thyroid gland tissue and are NOT infected when identified are candidates for excision. If the cyst is infected the infection is treated first, then surgery can by performed.

What are the treatment options for thyroglossal duct cysts that contain thyroid tissue?

Thyroglossal duct remnants that contain THYROID GLAND (ectopic) tissue can also be candidates for removal if a normal functioning thyroid gland is identified, so removal of the ectopic tissue will not cause the patient to become HYPOTHYROID (have too little thyroid hormone).

If the only thyroid tissue found in the patient is located in the thyroglossal duct cyst, the treatment options are more complicated:

What is involved with thyroglossal duct remnant removal?

Prior to a thyroglossal duct cyst removal, thyroid function tests (to measure thyroid hormone levels in the body), as well as an imaging study (such as ultrasound, CT scan, thyroid scan) may be acquired to check for a normal thyroid gland. Many times, a normal physical exam and an ultrasound showing a normal thyroid gland is all that is required before surgery. Any infection detected will be treated with antibiotics before removal.

The surgery is performed under general anesthesia. A skin incision is made in the center of the neck near the lump in a natural skin crease (to decrease the scar). The entire thyroglossal duct cyst, along with a small portion of the hyoid bone (a small bone in the neck) and the cyst tract is then removed. This operation results in a 10-fold decrease in recurrences of the cyst compared to other types of surgical techniques. The surgical site is then sutured with techniques to minimize any visible scarring.

What are the complications of this procedure?

Wound infections and bleeding are complications of any surgical procedure. These complications are minimized using antibiotics and surgical techniques to reduce bleeding. An additional complication of the surgery could be creating an opening into the throat. This would be repaired immediately if recognized. Complications are more likely with repeat or revision procedures. Recurrence of a thyroglossal duct remnant is also a risk. 

HYPOTHYROIDISM, is an expected concern in those patients with all the body's thyroid tissue located in the thyroglossal duct remnant. An endocrinologist (gland specialist) will be required with the follow up of these patients.

Lymphatic Malformation Excision

What are the indications for excision of a lymphatic vascular malformations?

All lymphatic vascular malformations are candidates for surgical removal as soon as they are identified unless removal would put normal structures (nerves, blood vessels, etc.) at risk, or if surgery would likely cause a significant cosmetic deformity (abnormality of appearance). 

In some very small infants, who do not have symptoms associated with a lymphatic vascular malformations, the excision of the cyst should be performed promptly, before the cyst becomes larger and involves other structures. Removal is also performed as soon as possible if a cyst blocks the airway and causes BREATHING DIFFICULTIES; occasionally a TRACHEOSTOMY (breathing tube placed into the neck below the obstruction) will need to be placed until the cyst is removed. 

What is involved with the excision of a lymphatic vascular malformations?

Prior to surgical removal, the extent of the cyst is evaluated by imaging studies such as MRI or CT scans, Excision is performd under general anesthesia (patient is fully asleep). A surgical incision is made in the area of the cyst. As the size of these cysts can be very large and can extend in to multiple different head, neck and chest areas, the location of the incision varies among patients. These cysts also do not have a very defined capsule and often wrap around vital structures in the neck (blood vessels, nerves, muscles). For this reason, the surgeon will need to carefully perform a neck "dissection", removing the growth from normal neck structures before the rest of the cyst can be removed. 

If part of a cyst is too close to a vital structure, part of the cyst may not be able to be removed. The length of this potentially complex surgery varies with the extent of the cyst.

If part of the cyst is unable to be removed, regular follow up is necessary to check for recurrence. This may be done simply by physical exams (looking to see if a lump reappears). However, cysts removed in areas of the body that can't be seen will require periodic MRI studies.

If surgery is not an option due to extent of the lesion, sclerotherapy may be considered. This would involve injecting chemicals into the cyst to create shrinkage and scarring. In patients with large cysts, this is can be very successful.

What are the complications of this procedure?

Infections of the surgical site and bleeding are potential complications.

Recurrence of the lesion is always a concern, even if it appears that the entire cyst has been removed successfully. Recurrence is assured if any of the cyst remains after surgery.

Also of concern is the fact that the lesion is often is in close contact with important structures in the neck and complications can arise from damage to these structures. Some of these structures include the FACIAL NERVE, RECURRENT LARYNGEAL NERVE, and carotid artery (supplies blood to the head). It is important to remember that not all patients will have cysts close to these vital structures, decreasing this concern for those patients.

Damage to these structures is also minimized during surgery by your surgeon, who has extensive training and expertise in locating these structures. Your surgeon will discuss with you at length the specific concerns associated with removing your child's cyst prior to surgery.

Septoplasty and Septorhinoplasty

What is a septoplasty?

A septoplasty is a procedure performed to correct or repair an crooked nasal septum (the partition between the two sides of the nose). 

What are some of the causes of an abnormal nasal septum?

The most common reason a child may develop a crooked (deviated) septum is through injury or trauma to the nose and face. In contrast, as a person gets older, the nasal septum may start to bend to one side or another with normal growth; few adults have a straight nasal septum.

What are the indications for a septoplasty?

A septoplasty is indicated when the nasal septum is abnormal (crooked or deformed) to the point that it interferes with normal breathing. This deformity creates a narrowing in the nasal passage that makes it hard to breath. Unless the symptoms are very severe, septoplasty is usually not indicated in a child that is still growing, as the septum contains the "growth center" of the nose. Therefore, septoplasty is more commonly performed in adolescence or adulthood (at least 16 years of age in girls and 17 to 18 years of age in boys).

In certain situations, a limited conservative septoplasty may be necessary at an earlier age. Septoplasty itself is NOT a cosmetic procedure (it may not change the outer appearance of the nose). However, it can be performed along with rhinoplasty, which is a surgical procedure that does change the outer appearance of the nose. This is called a septorhinoplasty. This operation is designed to straighten a deformed external nose AND correct the septum. A septorhinoplasty is very individualized and involves close communication between the patient, parents and surgeon to achieve the desired cosmetic result. Small hidden in incisions are made in and on the nose during this procedure. These operations are usually 21/2 to 3 hours long and require 2 to 3 weeks for recovery.

What is involved with a septoplasty?

In children, septoplasty is performed under general anesthesia. A small surgical cut (incision) is made inside the nose. The tissue lining the septum (mucous tissue, similar to the lining of the inside of the mouth) is lifted away from the cartilage and bone. The crooked or abnormal portions of the bone are then either removed or straightened. The mucous lining is then replaced, and the septum may be splinted (kept in the new position) for a few days. These splints support the repaired cartilage and prevent haematoma formation (blood collection under the tissue).The procedure usually lasts about an hour and a half and usually does not require a hospital (overnight) stay. 

What are the risks and complications of septoplasty?

Complications can include bleeding, which is usually easily controlled. A perforation or hole in the septum, infection of the surgical site, or a change in the appearance of the outer nose are other, less common complications.

Functional Endoscopic Sinus Surgery

What is functional endoscopic sinus surgery (FESS)?

Functional endoscopic sinus surgery (FESS) is a surgical technique used to help open the SINUS drainage pathways and remove mucus from the sinuses, which helps to eliminate or decrease the number of infections in the future. Because this technique opens the natural sinus openings, FESS has been shown to produce better results than procedures used in the past.

When is sinus surgery necessary?

If your child has had 6 episodes of ACUTE SINUSITIS in the past year or has long-standing CHRONIC SINUSITIS which does not seem to go away completely with antibiotics, sinus surgery may be recommended.

What is involved with FESS?

Before endoscopic sinus surgery, a CT scan will be performed to see how your child's sinuses are formed and how big they are. Your child may need to receive sedation (a calming medicine) through an IV (catheter in a vein) in order to have the CT scan taken.

These pictures can be used to show the amount of infection in the sinuses, as well as help your doctor know exactly what kind of surgery your child will need.

The surgery is performed using small telescopes which are placed through the nose allowing the doctor to open the natural drainage pathways of your child's sinuses under direct vision. This allows for drainage of mucus from the sinuses and helps prevent future infections. 

FESS is performed under general anesthesia. This procedure does not require an overnight stay in the hospital, and the length of surgery depends on the amount of disease and blockage in the sinuses. However, surgery usually does not last more than an hour.

About 2-3 weeks after surgery, your child may be scheduled to return to the operating room for another examination under anesthesia. This will allow the doctor to clean out any crusting and evaluate the area where the surgery was performed to make sure it is healing properly.

Is endoscopic sinus surgery dangerous?

Endoscopic sinus surgery as described above involves operating on your child's sinuses through the nose using small telescopes. As the sinuses are located near the eyes and directly under the brain, there is always a risk that damage may occur to those areas. However, because the surgery is performed under direct vision and because of the experience of the surgeons, these complications are very rare.

These risks and possible complications will be described for you prior to your child's surgery.

Tympanoplasty/Myringoplasty

What is a tympanoplasty?

A tympanoplasty is a surgical procedure that repairs or reconstructs the eardrum (tympanic membrane). This procedure may also involve repair or reconstruction of the small bones behind the tympanic membrane (ossiculoplasty) if needed. Both the eardrum and middle ear bones (ossicles) need to function well together for normal hearing to occur.

What are the indications for a tympanoplasty?

A tympanoplasty is recommended when the eardrum is torn (perforated), sunken in (atelectatic), or otherwise abnormal and associated with hearing loss. Abnormalities of the ear drum and middle ear bones can occur through injury, OTITIS MEDIA, congenital (at birth) deformities, or chronic ear conditions such as a CHOLESTEATOMA.

How successful is tympanoplasty in restoring normal hearing?

Return to a normal range of hearing after tympanoplasty is dependent upon the extent of the abnormality. Surgeries that involve repair of the eardrum only usually have a success rate of 85-90%. A second operation may be necessary in some cases if the hearing is not restored to an acceptable level.

Are there any other options aside from tympanoplasty?

Tympanoplasty in most cases is an elective procedure, meaning that it can be scheduled whenever the patient is ready to have it done. Another option instead of this procedure includes the use of a hearing aid. When the tympanic membrane has a hole (perforation) in it, earplugs are usually recommended to protect the middle ear from infection. In a few cases, such as a significant infection or a CHOLESTEATOMA, this procedure may prevent more significant damage to the ear and the surgery may need to be performed more urgently.

What is done in preparation for a tympanoplasty?

Usually other ear, nose, and throat conditions are treated before a tympanoplasty is considered. For example, if an ADENOIDECTOMY is indicated, this surgery is usually completed before tympanoplasty. 

OTITIS MEDIA of any type should not be present at the time of surgery, as infections in the ear makes the operation much more difficult and may ruin the reconstruction. If your surgeon has suggested certain medications prior to surgery, these should be taken without exception to ensure a successful outcome. 

A hearing test is performed. The more significant the hearing loss, the sooner the procedure should be performed. 

What is involved with a tympanoplasty?

A tympanoplasty is performed with the patient fully asleep (under general anesthesia). A surgical cut (incision) is usually made behind the ear, the ear is moved forward, and the eardrum is then carefully exposed. In other cases the ear drum may be approached through the ear canal or through a small incision at the top of the ear canal. The eardrum is then lifted up (tympanotomy) so that the inside of the ear (middle ear) can be examined. The hole in the eardrum, it is cleaned (debrided) and the abnormal area can be cut away. A piece of fascia (tissue under the skin) from the temporalis muscle (behind the ear) is then cut and placed under the hole in the ear drum to create a new intact ear drum. This tissue is called a graft. The graft allows your child's normal eardrum skin to grow across the hole.

If needed, reconstruction of the middle ear bones (ossiculoplasty) or CHOLESTEATOMA removal may also be performed at this time.

This surgery may require an overnight hospital stay. The child has a dressing (large bandage) over the surgical site. This is removed the next morning and the patient is discharged home. Occasionally, in older children, or those undergoing a less involved procedure, same-day surgery is possible. Eardrops may be prescribed after discharge. 

The most important part of this surgery for the parent is your part in restricting activity as outlined by your surgeon. By following these instructions very closely, you can make sure your child's result is the best it can be. 

What are the risks and complications of a tympanoplasty?

Because this surgery takes place in and around the ear, there are special risks for this surgery in addition to the usual risks of infection and bleeding. Because each child's situation is different, your surgeon will relate to you just how likely these complications are to occur.

HEARING LOSS - A tympanoplasty is performed to help restore normal hearing. However, some hearing loss (more common with ossiculoplasty) may still be present after the procedure. An operation is termed successful if the hearing is restored within 10-15 decibels of normal.

FACIAL NERVE INJURY AND PARALYSIS - Because the facial nerve runs close to the surgical site, injury although uncommon, can occur. This may result in temporary facial muscle weakness and/or loss of taste on one side of the tongue.

DIZZINESS - This complication after surgery is rare and is more likely to occur when MASTOIDECTOMY is performed for CHOLESTEATOMA when the cholesteatoma has eroded the balance system. 

LOSS OF GRAFT - Because this operation involves grafting using your child's own tissue, very rarely this tissue will not survive long enough for the hole in the eardrum to heal completely. In this case, another operation may be necessary. Because the success rate of this surgery is so high, re-operation also has a very high success rate.

Your surgeon will schedule follow up visits after surgery to look at the eardrum, to check hearing and to ensure normal healing. It is important to keep these appointments, as they will help to maximize the success of the procedure.

Tympanostomy Tubes (grommets)

What are Tympanostomy Tubes (grommets)?

Tympanostomy tubes are small plastic or silastic tubes that are inserted into the ear drum (tympanic membrane) to help ventilate the ear and prevent fluid from building up (OTITIS MEDIA WITH EFFUSION. Grommets help prevent infections in the ear (OTITIS MEDIA). These tubes allow the pressure in the middle ear to be equal to the pressure outside the ear. 

When are grommets a consideration?

Tympanostomy tubes may be suggested when your child's ear infection has failed to improve with antibiotics or has fluid which will not clear after an appropriate length of time. Grommets are especially helpful in reversing the hearing loss due to fluid trapped behind the ear drum. 

What is involved with Grommet placement?

Placement of tubes occurs through the ear canal under a brief (five to ten minutes) general anesthetic, and rarely requires a blood test or IV. A tiny hole (myringotomy) is made in the eardrum, through which fluid is suctioned. Then a tiny tube (the grommet) is placed in the hole allowing air to enter the middle ear. The procedure is painless and allows your child to resume normal activity upon leaving the hospital.

Tubes usually fall out of the ear (as the ear drum grows) within one to two years unless specified by your doctor. 

Frequently Asked Questions

1. Do grommets cause scarring of the ear drum? 

   The tubes selected for use in this practice are unlikely to cause changes in the ear drum. However, if ear drum scarring occurs due to tubes or repeated infection, this rarely causes hearing loss.

2. Do the grommets ever fall in the ear instead of out? 

   No, the tubes migrate out as the ear drum skin sheds, bringing the tube out into the ear canal.

3. Can my child reach the grommet? 

   No, the ear drum (and tube) cannot be reached without a long narrow instrument.

4. When the grommet falls out, is there a hole left in the ear drum? 

   The ear drum heals as the tube is pushed out. Very rarely, the ear drum does not heal completely, leaving a hole. This can be repaired by "patching" the ear drum, a common and highly successful procedure.

5. Do grommets cause drainage? 

   No. Once tubes are placed, the ear should not drain except in the first three days after surgery. If drainage occurs, this is usually the result of a cold, sinus infection, adenoid infection, or rarely, a mastoid infection.

6. Will my child need a second set of tubes? 

   Generally, no. About 20 percent of all children who get grommets in the first place need a second set. Risk factors include: infection starting before six months of age, adenoid disease, immune system problems, cleft palate and sinusitis.

7. Are there any restrictions involved after the tubes are placed in my child?

   Diving should be avoided while the tubes remain in the ears. In addition, ear plugs or ear putty will be recommended if the child lies with ears submerged in bath water, swims deeper than 18 inches, or in dirty water (eg. lake water).

Laryngeal Surgery (including laser surgery)

What is Laryngeal surgery?

Laryngeal surgery is a general name for many different types of procedures that can be performed on the larynx (the vocal cords and related structures) . 

What are the indications for laryngeal surgery?

Surgery is performed when the vocal cords have growths, such as, polyps, tumors, or other masses that need to be removed for biopsy or to improve function. The child will usually exhibit a hoarse or raspy voice. 

Laryngeal surgery is also indicated to normalize vocal cord functioning when the vocal cords are scarred from various causes, paralyzed, or are otherwise abnormal. These conditions may interfere with the complete opening and/or closing of the vocal cords, which is necessary for normal speech and breathing. 

Please see HOARSENESS and VOCAL CORD DISORDERS for more information.

How is laryngeal surgery performed?

Surgery on the vocal cords can be performed either directly in an open surgical approach (making an incision in the neck) or indirectly through an endoscopic approach (through a tube inserted into the mouth and throat). Either procedure is performed under general anesthesia (the patient is fully asleep). An open surgical approach is most often performed after trauma or fracture of the larynx (upper front of neck) has occurred. Please see REPAIR OF FACIAL AND NECK TRAUMATIC INJURIES.

Although the open surgical approach allows somewhat better control of the vocal cords during the procedure, the endoscopic approach may be more successful in restoring more normal voice sound. The endoscopic approach also has the advantage of allowing extremely close observation of the vocal cords, therefore resulting in a precise and accurate cut or removal of tissue. However, not all procedures can be performed endoscopically. 

Recovery after either an open or endoscopic approach includes minimizing damage to the larynx during surgery, as well as reducing inflammation after the surgery. Therefore, your surgeon will recommend the procedure he/she feels will minimize these complications. 

What is involved with endoscopic laryngeal surgery?

Endoscopic vocal cord surgery is basically MICROLARYNGOSCOPY (magnified examination of the vocal cords) in addition to a corrective procedure performed on the vocal cords.

As mentioned above, this surgery is performed with the patient under general anesthesia (fully asleep). The patient is lying on the back and a laryngoscope is inserted in the mouth to hold down the tongue and visualize the vocal cords. A special telescope or operating microscope is used to get very close and detailed views of the vocal cords and surrounding areas.

There are many different methods used to correct vocal cord abnormalities. These can include using forceps (like tweezers) to hold a bump or nodule and small scissors or the laser (see below) may be used to remove it. Powered instruments may also be used to remove lesions. These rotating blades remove growths such as papillomas with very little damage to normal tissue. 

Defects on the vocal cords or surrounding areas may be repaired by injections, flaps of tissue, or grafts depending on the size of the defect.

The surgery itself usually lasts about an hour, but is highly variable. Removal of nodules or bumps or more simple reconstructive procedures may not require an overnight stay in the hospital. 

More complex procedures may require a hospital stay.

Carbon Dioxide(CO2) Laser

What is the carbon dioxide(CO2) laser?

Laser stands for "light amplification by stimulated emission of radiation". The CO2 laser device increases the intensity of light waves using carbon dioxide and concentrates them in an intense, penetrating beam of light. This is similar in a way to using a magnifying glass to concentrate the sun's rays; the "concentrated" sun rays underneath the magnifying glass get hot enough to burn paper for example. Similarly, the laser beam can be used to very accurately "burn off" areas of tissue that need to be removed, (vaporized). 

Why is the CO2 laser used in vocal cord surgery?

The CO2 laser can be passed through the glass of the operating microscope, allowing for very accurate placement of the laser beam on the vocal cords. This method of tissue removal is much more precise than surgical scissors, and results in less bleeding and inflammation to the surrounding tissues. As mentioned previously, the less traumatic the surgical procedure, the more favorable the outcome, including faster recovery. 

What are the risks of using the CO2 laser?

Although the laser can precisely vaporize the desired tissue, it can also accidentally burn basically anything else it may come in contact with. Therefore, safety precautions have been made to avoid this complication. These safety precautions include protective eye gear for both the patient and the operating team. The patient's face and eyes are covered. Also, as the breathing tube can catch on fire, these surgeries are usually performed with a special laser-safe tube or without a breathing tube in place while the laser is in use. In addition, the lowest amount of oxygen needed is used during the procedure.

What are the risks and complications of vocal cord surgery?

The risks with the use of the CO2 laser are described above. The short-term risks of vocal cord surgery in general include chipped teeth (protective teeth guards are used during surgery to help prevent this), bleeding, breathing difficulties, hoarseness, change in voice quality, or infection. Long term risks include a less than desired outcome in regaining normal voice or scarring from the surgery that may need additional surgical repair in the future. Your surgeon will discuss these with you in detail.

What is involved with recovery after vocal cord surgery?

Recovery after vocal cord surgery is dependent on the surgical procedure, as well as how well inflammation and swelling are controlled after the surgery. Your surgeon will give you guidelines on how to start reusing your voice. It is important to follow to these guidelines and keep all recommended follow up appointments to regain optimal vocal cord function.

Tracheostomy

What is a tracheostomy?

The TRACHEA is the part of the AIRWAY (or breathing passage) commonly known as the "windpipe". A tracheotomy is a surgical procedure that creates a temporary opening in the trachea. The hole itself is called a tracheostomy. The tube that is placed through this hole is called a tracheostomy tube.

What are the indications for a tracheostomy?

A tracheotomy is a temporary or permanent treatment for a variety of causes of BREATHING DIFFICULTIES in which the creation of a new breathing pathway is required, by-passing the nose, mouth, and throat. A tracheotomy is usually considered when an endotracheal (ET) tube (a tube that goes in the throat through the mouth) either will not be effective (in some emergency situations for example), or would be required for a long time. Sometimes, a tracheostomy is performed when an ET tube cannot be placed due to narrowing of the windpipe or blockage of the voice box (larynx).

The reasons for performing a tracheotomy in children generally fall into three major categories:

1. To bypass an obstruction in the airway (most common reason)
2. To help with long term ventilation in patients who cannot do this on their own (patients with respiratory muscle problems or lung problems)
3. To provide a temporary airway while reconstructive surgery is performed that may cause breathing problems

Who can perform a tracheotomy?

You may have heard of situations in which a tracheotomy was performed in an emergency, outside of the hospital. This procedure is actually called a cricothyroidotomy and is strongly discouraged even when the person performing it has some experience. It is a difficult procedure to perform in an adult, and even more dangerous on a child, as the child's airway is much smaller and more difficult to locate than in adults. If a patient is choking and unable to breathe, the Heimlich maneuver (hands pushing in and up on the abdomen) should usually be the first option considered.

A tracheotomy is traditionally performed in a hospital setting by a physician who has extensive experience in this procedure. With advances in airway management, the number of tracheotomies required has been reduced. 

This procedure is usually performed by an ear, nose, and throat specialist, especially in children.

What is involved with a tracheostomy in a paediatric patient?

The airway anatomy is different in a child compared to an adult; therefore, the surgical technique used is different for paediatric (child) patient.

In the child, a tracheotomy is almost always performed under general anesthesia (patient fully asleep). Because of the small size (like a straw) of the airway, this procedure may be performed with a BRONCHOSCOPE or endotracheal tube in place during the procedure to help localize the trachea. The patient is placed on the back and a rolled towel is placed under the shoulders and neck to put the trachea in its most accessible position. A cut is carefully made in a specific location in the trachea and sutures (stitches) are placed on each side of the cut to help easily locate the new hole (tracheotomy). A tracheotomy tube is placed into this hole and tied securely in place. After the tracheotomy tube has been tested to make sure airflow is adequate, the bronchoscope or endotracheal tube is removed. Sometimes, a chest x-ray is taken to check for proper placement.

The tracheotomy tube will be changed 5 days after surgery. After this, parents are thoroughly educated in the care of the tracheotomy tube prior to the child going home. 

How long does the tracheotomy tube need to remain in place?

The length of time a tracheotomy tube needs to remain in place depends on the exact reason the tube was needed. For a temporary breathing problem, the tracheotomy tube may be removed after just a few months. Home nursing support is arranged for a period of time after discharge. The ear, nose, and throat surgeon and other health care providers perform close follow-up. Speech/language pathologists are usually involved with your child as well. They will help with swallowing and speech while the tracheotomy tube is present.

How is a tracheotomy tube removed?

The name for tracheotomy tube removal is decannulation. Decannulation is always performed in the hospital setting. First the patient's airway is re-examined by MICROLARYNGOSCOPY AND BRONCHOSCOPY to make sure there are no reasons the tracheotomy tube should not be removed. 

Depending on the situation, there are several different ways decannulation may be carried out. Among these are:

• Simply remove the tube and allow the tracheotomy site to heal
• Put in a smaller tracheotomy tube in and plug over the hole of the tube during awake hours only until the child can tolerate plugging comfortably for one month
• If the airway is being reconstructed (a small airway being enlarged for example), the tracheotomy tube may be removed along with this procedure or after the surgical site heals.
• Remove the tracheotomy tube during a surgical procedure with surgical closure of the opening

What are the risks and complications involved with a tracheotomy? 

Early Complications that may arise during the tracheotomy procedure or soon thereafter include:

• Bleeding 
• Air trapped underneath the skin around the tracheotomy (subcutaneous emphysema) or in deeper layers of skin in the chest (pneumomediastinum) that may leak around the lungs (pneumothorax) 
• Damage to the tube going to the stomach (esophagus) 
• Injury to the nerve that moves the vocal cords (recurrent laryngeal nerve)
 

However, many of these early complications can be avoided or dealt with appropriately with an experienced surgeon in a hospital setting.

Later Complications that may occur while the tracheotomy tube is in place include:

• Accidental removal of the tracheotomy tube (accidental decannulation) 
• Infection in the trachea and around the tracheotomy tube

These complications can usually be either prevented or quickly dealt with if the caregiver has proper knowledge of how to care for the tracheotomy site.

Delayed Complications that may result after longer-term presence of a tracheotomy include:

• Thinning (erosion) of the trachea from the tube rubbing against it. 
• Development of a small connection from the trachea to the esophagus. 
• Development of abnormal scar tissue (granulation tissue) that may need to be surgically removed before decannulation can occur. 
• Narrowing or collapse of the airway above the site of the tracheotomy, possibly requiring an additional surgical procedure to repair it.
• Once the tracheotomy tube is removed, there may remain a small hole between the trachea and the skin, which may need surgical closure .

A clean tracheotomy site, good tracheotomy tube care, and regular examination of the airway by an otolaryngologist should minimize the occurrence any of these complications.

Parotidectomy

What is Parotidectomy?

Parotidectomy is an operation to remove parotid glands. These glands are saliva producing glands in the side of the cheek.

What are the indications for parotidectomy

Parotidectomy is indicated for several reasons...

• chronic recurrent infection – Parotitis
• tumours
• congenital vascular malformations
• congenital branchial arch anomalies

What is involved in the surgery?

The procedure is performed under general anaesthesia. An incision is made in the skin in front of the ear and into the neck. The Facial nerve is identified. This is a nerve that supplies nerve fibers to the muscles that move the face. The affected gland is then removed and the incision is closed with great care taken to ensure the safety of the facial nerve at all times. A small drain is placed and this is usually removed after 1 or 2 days.

What are the complications of Parotidectomy?

1. The usual complications of any surgery – bleeding, infection and a scar
2. Injury to the facial nerve – occurs very rarely. Injury to this nerve will affect movement of the facial muscles.
3. Frey’s syndrome – a rare complication where the skin of the cheek sweats a little with eating.

Inferior Turbinate Cautery or Resection

The inferior turbinates are shelves on the side of the nose which swell in response to chronic infection or allergy. The swelling causes an obstruction to airflow through the nose resulting in a blocked nose and may contribute to snoring and sleep apnoea.

Indication for surgery

The inferior turbinates are cauterized (reduced in size by touching them with a hot needle) or partially removed (resection/ submucous resection) if they are enlarged and causing nasal obstruction despite antibiotic and allergy treatment. The surgery is often combined with adenoidectomy.

What does it involve?

The procedure is usually undertaken as part of an adenoidectomy/adenotonsillectomy or sinus surgery. Therefore it is done under general anaesthesia.

Complications

• Bleeding – usually is minor and settles by itself
• Blocked nose – until the swelling settles
• A “slug” – like piece of tissue is blown out of the nose about one week after surgery – this is expected.
• Regrowth of the turbinates – to some extent occurs in all cases but usually not to their original size.