CARE AFTER ENDOSCOPIC SINUS SURGERY

Endoscopic sinus surgery is a procedure that is performed to open up blocked sinuses. It entails using scopes which provide good visualization of the nasal cavity structures without having to make any external skin incisions. Compared to yesteryears of open sinus surgery, endoscopic sinus surgery allows shorter hospital stay and faster recovery.

Endoscopic sinus surgery is recommended when there is failure of medical therapy in treatment of sinus infections.  It is also performed when there are polyps or tumours within the nasal cavity. Correction of deviated nasal septum causing nasal blockage can also be performed by endoscopy.

What to expect when you wake up from the surgery?

Usually the nose will be blocked with nasal packing and a gauze dressing is placed at the front of the nostril to absorb any blood stained discharge and changed whenever soaked. There are two types of nasal packing; dissolvable and non-dissolvable. The non-dissolvable nasal packing which looks like nasal tampon is usually removed 24-48 hours after the operation. The dissolvable nasal packing is left in place and will dissolve within few days.  Patients may have to breathe through their mouth because of the nasal pack.

Patients will experience some pain over the nose area and mild headache is expected. Analgesics are prescribed for pain relief. Inform the surgeon if you still experience considerable pain.

Once the nasal pack is removed, the patient is advised to pinch the nose for at least 15 minutes to stop the bleeding. The patient is also propped up in a sitting forward position and a kidney dish/basin is placed in front so that the patient can spit out any blood discharge trickling at the back of the throat.

The patient is then observed for any serious bleeding before allowed home. A small amount of blood stained discharge is expected for the next few days.

Post op advice for patients

• When lying in bed, keep the head elevated to reduce bleeding from the operated site.
• Patients should not blow their nose for 1 week after surgery. When they sneeze, make sure the mouth is open to reduce pressure in the nasal cavity and prevent bleeding.
• Nasal douching will be prescribed by the surgeon using pre-prepared salts which are dissolved into cooled boiled water. Patients are expected to perform the douching twice a day until healing is complete. The nasal douching will prevent dry crusting in the nasal cavity and allows easy dislodgment of blood clots.
• Patients should also avoid straining, heavy lifting, swimming and flying for a few weeks.
• Patients should avoid allergies and any food known to cause an allergic reaction. Reduce intake of dairy products which can increase mucous production. Refrain from smoking and exposure to secondhand smoke. Patients should also avoid crowded places in case they may catch an infection.
• Patients must comply with the medications prescribed by the surgeon which often includes antibiotics.
• Patients are required to come for follow-up at 5-7 days post operation. During the follow-up visits, the surgeon will monitor the recovery process by endoscopic examination in the clinic and suction removal of blood clots or secretions will be performed.

What next?

The recovery period can take between 2-4 weeks. Patients are often given at least 1 week home rest after the operation. The recovery process varies from patient to patient.

Some patients require long term medication after the endoscopic sinus surgery to prevent recurrence of the disease such as polyps.

Follow up is necessary until the recovery is complete and in patients with polyps they may still need a 6-12 monthly checkup to monitor for recurrence.

NOSEBLEEDS: WHAT TO DO?

Most of us would have had a nosebleed, especially during childhood. However it can still occur in adults. It is usually incited by trauma such as nose digging and upper respiratory tract infection. Sometimes the amount of bleeding can be alarming. Doctors would refer nosebleeds as epistaxis in its medical term.

What to do during nosebleeds?

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1.       Sit down calmly.

2.       Bend upper body and head forwards, this will prevent swallowing of the blood which can upset the stomach and cause vomiting.

3.       Use a tissue paper of soft towel to pinch the soft part of the nose using the thumb and index finger.

4.       Breathe through the mouth and spit out any blood trickling down the back of the throat.

5.       Continue to pinch the nose between 5 to 15 minutes. Check after first 5 minutes to see if the bleeding has stopped.

6.       It may help to gargle with ice water or to suck on an ice cube.

7.       Once the bleeding stops, do not pick the nose or blow harshly to remove the blood clots. Avoid straining and lifting heavy objects.

8.       If it continues to bleed, please seek medical help.

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When to seek medical treatment?

·         If the bleeding does not stop despite the above measures after 15-20 minutes

·         Nosebleeds following trauma to the nose or head/face area

·         Repeated episodes of nosebleeds

·         When you feel faint, dizzy or appear pale

·         Large amount of bleeding especially with blood clots

·         If you are taking medications that thin the blood such as Aspirin or Warfarin

·         Nosebleeds associated with bruising on other parts of the body

What are the causes of epistaxis?

• Upper respiratory tract infections
• Nose digging or vigorous nose blowing
• Dry, low humidity air
• Trauma to face or nose
• Allergic and non allergic rhinitis
• Foreign objects inserted into the nose
• Use of medications such as Aspirin and Warfarin
• High blood pressure
• Tumours

The nasal cavity is well vascularized.
Epistaxis commonly occurs from the Little area.
Posterior epistaxis is often more serious.

Printable leaflet

http://www.entheadandneckclinic.com/web_documents/leaflet__epistaxis_.pdf

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SNORING AND OBSTRUCTIVE SLEEP APNEA

Snoring occurs due to narrowing of the airway causing vibration of the soft tissues of the throat during sleep. It is more common in men generally whereby 45% of men and 30% of women snore on a regular basis.

Risk factors for snoring include overweight, increasing age, nasal blockage, sedating medications, alcohol, sleeping position and thick neck. It is important to recognize if snoring is related to an underlying medical problem such as obstructive sleep apnea (OSA) or is an isolated problem


What is obstructive sleep apnea (OSA)?
It is a severe form of snoring which has serious health consequences. OSA occurs due to complete collapse or obstruction of the upper airway, at one or a combination of these levels:

• Nasal Airway  

• Soft Palate/Tonsils

•  Tongue Base 

• Pharyngeal Walls

Symptoms of OSA

• Loud, irregular snoring
• Daytime tiredness and sleepiness
• Early morning headaches
• Poor concentration
• Deterioration of intellectual capabilities
• Mood swings

Diagnosis of OSA

A complete ear, nose and throat examination by endoscopy is performed in the clinic to assess the possible sites of airway obstruction during sleep. The body mass index is measured.

Sleep study is often recommended to confirm and determine severity of OSA
OSA severity is indicated by the Apnea / Hypopnea Index (AHI)
· Mild: 5 – 15 events / hour
· Moderate: 16 – 30 events / hour
· Severe: > 30 events / hour
(events is when there is almost or total obstruction of the airway causing a drop in oxygen blood saturation)

Consequences of OSA
It is very important to recognize and treat OSA because if left untreated it can lead to serious health consequences:
Hypertension
Myocardial infarction
Stroke
Type II diabetes
Depression
Cognitive dysfunction
Impotence, sexual dysfunction, or reduced libido
Morning headaches

General preventive measures for snoring
§ Sleep hygiene
     - Regular sleep-wake times
     - Peaceful surroundings
     - Moderate room temperature
     - Avoidance of night shift and changing work shifts
§ Reduction of weight
§ Exercise
§ Avoid alcohol and sedatives before bedtime


Treatment options for OSA



APAP (Automated Positive Airway Pressure) with Mask
It is the Gold Standard treatment for Sleep Apnea. Patients are required to wear a face or nasal mask which blows in humidified air. This will help to ‘splint’ the airway open during sleep.

Oral appliance
Oral Appliance Therapy is a suitable front-line treatment option for mild to moderate OSA sufferers and simple snorers. The Oral Appliance is worn during sleep to maintain the patency of the upper airway.


Surgical treatment options for OSASurgery is aimed to relieve the obstruction. Therefore the type(s) of surgery recommended varies between patients.

The surgeries that can be performed include
· Tonsillectomy and adenoidectomy
· Septoplasty and turbinate surgery
· Soft palate surgery
· Base of tongue surgery
· Surgery to facial bones in selected cases

OSA in children 

The symptoms may differ from adults as children with OSA can present with mouth breathing, behavioural problems/ irritability, learning difficulties, hyperactivity and bedwetting. Often these children have large tonsils and adenoids which cause the airway obstruction and snoring. Obesity is a less common reason for OSA in children.

FACIAL EXERCISES FOR BELL'S PALSY

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Bell’s palsy is a common cause for facial nerve palsy. It causes a temporary paralysis of the facial muscles of expression usually on one side of the face. However it is important that the doctor exclude other more serious causes of facial nerve palsy such as stroke, Ramsay Hunt syndrome, otitis media, tumours or trauma.

The facial nerve weakness in Bell’s palsy usually recovers within a month and some up to one year. Progress of recovery is best when treatment is commenced as early as possible. The doctor would often prescribe oral steroids within 72 hours of onset. Physiotherapy is also recommended as part of the treatment. It may consist of electrical stimulation or facial exercises, or both. The facial exercises can be performed at home whilst the electrical stimulation is done by the physiotherapist at their clinic.

The facial exercise involves doing different muscle movements to work each group of the facial muscles. Patients do not need to exert themselves and not get disheartened when there is little muscle movement when doing the exercises. These exercises should be repeated three times a day.

STEPS FOR FACIAL EXERCISE

• Sit relaxed in front of a mirror
• Gently raise eyebrows, you can help the movement with your fingers
• Draw your eyebrows together, frown
• Wrinkle up your nose
• Take a deep breath through your nose, try and flare nostrils
• Gently try and move corners of mouth outwards
• Try and keep the movement the same on each side of your face
• You can use your fingers to help. Once in position take your fingers away and see if you can hold that smile
• Lift one corner of the mouth …. then the other

EXERCISES TO HELP CLOSE THE EYE

• Look Down
• Gently place back of index finger on eyelid, to keep the eye closed
• With opposite hand gently stretch eyebrow up …. working along the brow line. This will help relax the eyelid and stop it from becoming stiff.
• Now try and gently press the eye lids together
• Narrow eyes as if looking into the sun 

Link
Facial exercise chart (The Bell's Palsy Association UK)

ALLERGY AND ALLERGIC RHINITIS

What is allergy?

Allergy is the body’s reaction to certain substances (allergen) that brings about symptoms of itchiness, rash and swelling. The symptoms are commonly mild but rarely can be life threatening (anaphylaxis). Allergic reaction is unique to each person. Conditions such as asthma, frequent upper respiratory tract infection, nasal polyps, eczema are commonly associated with allergy.  

Risk of developing allergy

The development of allergy is a complex interaction of genetic factors and environmental factors. The increasing rise of pollution has been associated with increased risk of developing allergies. Family history of allergies will also put a person at risk. On the other hand, breastfeeding has been associated with reduced incidence of developing allergies.

Diagnosis of allergies

A full history of allergy is obtained to ascertain the diagnosis. Diagnostic tests which can help to determine the allergens include skin prick test, contact patch testing and RAST blood test.

Allergic rhinitis

Allergic rhinitis is one of the manifestations of allergy. The main symptoms are stuffy blocked nose, sneezing, runny nose and itchiness. The itchiness can also affect the eyes. It is commonly associated with asthma. Patients often notice that the asthma symptoms improve when there is better control of rhinitis symptoms. Common triggering factors (allergens) include house dust mite, cockroaches, pet dander, mould and certain seafood.

Treatment of allergic rhinitis

First and foremost is AVOIDANCE. Avoiding the triggering factors will ensure better control of allergy symptoms. However some patients require medical treatment depending on the severity of the symptoms. Treatment which may be suggested by your doctor would include antihistamines and nasal sprays. The response to treatment should be closely monitored.

How to get rid of house dust mites?

	House dust mites are everywhere especially in mattresses, pillows, carpets and upholstered furniture. It thrives in humid environment and warm temperatures. They are too small to be seen with the naked eye and feed on dead human shedded skin.

Suggested ways to get rid of them:

·         Use allergy proof mattress and pillow encasings

·         Wash sheets, pillows, blankets, soft toys once a week in hot water and dry in a clothes dryer

·         Vacuum regularly with vacuum cleaners with HEPA filter

·         Dust furniture with damn cloth