SEPTOPLASTY AND TURBINATE SURGERY

Septoplasty is a surgical procedure to correct a deviated or crooked nasal septum. Patients often complain of nasal block and congestion, which can disturb their sleep. They may also have symptoms of rhinitis such as runny nose, sneezing and postnasal drip. Some patients have a deviated nasal septum as a result of trauma or blow to the nose. 

Turbinate surgery refers to a procedure performed to reduce the size of the enlarged nasal turbinates, which often contribute to the nasal block and congestion. There are many methods how the ENT surgeon reduce the size of the turbinates. Regardless of the surgical method used, the turbinates may slowly increase back in size if patients do not take care of their allergies.

The ENT surgeon may put the patient on a trial of medication which include nasal sprays and antihistamine to control their allergies. If the nasal block is still not relieved or minimally relieved with medication then septoplasty and turbinate surgery should be considered. However in severely deviated nasal septum especially post trauma, medication often bring little improvement. Septoplasty can also be indicated for recurrent epistaxis.

Complications of septoplasty and turbinate surgery are uncommon however patients should be aware of the possible complications including bleeding, infection, nasal crusting, numbness and septal perforation.

General care after septoplasty and turbinate surgery

The nose may be packed after surgery and patients are warned to breathe through their mouth upon waking up from surgery. The nasal pack is usually removed the following day after surgery. Following nasal pack removal, patients should expect bloodstained nasal secretions for a few days. Patients should not blow their nose for about 10-14 days. When sneezing, patients should keep their mouth open to reduce built-up pressure in the nose.

Patients may also experience swelling and pain around the nose including numbness of the upper teeth; which usually resolve in a few weeks. 

Patients are advised to take light soft cool diet when awake after surgery. Hot food and drinks are to be avoided for a few days after surgery.

Patients should rest with their head elevated on 2-3 pillows to reduce swelling around the nose area. Patient should also avoid straining and lifting heavy objects to reduce risk of bleeding.

Medications that can thin the blood, such as Aspirin and Warfarin, should be avoided until advised by the ENT surgeon.

The ENT surgeon would often prescribe nasal douching where patients will flush the nasal cavities using saline irrigation for a few weeks. This will ensure good healing and prevent formation of dried crusts or blood clots. Patients will also be prescribed with a course antibiotic that should be completed.

Patients are also expected to take some time off until the doctor says it is safe to return back to work. Patient should refrain from smoking or exposure to smoky areas as this can impair healing and cause further irritation to the nose.

When should you see your ENT surgeon urgently?

• Continuous bleeding despite nasal compression and ice
• Increasing swelling over the nose and eyes 
• Persistent high grade fever >38 Celcius
• Severe pain or headache not relieved by the pain medication given.

SUSAH BERNAFAS SEBAB HIDUNG TERSUMBAT

Hidung tersumbat boleh menyebabkan seseorang merasa sesak nafas, tidur berdengkur, bernafas melalui mulut, suara sengau, sakit kepala, berat kepala, letih dan lesu. Seringkali hidung menjadi tersumbat oleh sebab jangkitan virus atau bakteria semasa demam selsema dan ia akan pulih dalam masa yang singkat. Walaubagaimanapun ada sesetengah pesakit gejala hidung tersumbat ini berlaku pada bila-bila masa atau berpanjangan.

Ruang hidung manusia terbahagi kepada dua; belah kanan dan kiri. Ia dipisahkan oleh tulang tengah iaitu ‘septum’. Masalah hidung tersumbat boleh disebabkan oleh bentuk septum yang bengkok atau bengkakan pada selaput dalam hidung. Selaput hidung boleh menjadi bengkak disebabkan jangkitan kuman, alahan (alergi), polip hidung (nasal polyposis) atau ketumbuhan hidung (tumour). Pada peringkat umur kanak-kanak tisu adenoid yang besar seringkali menjadi punca hidung tersumbat. Terdapat juga insiden di mana bendasing menyebabkan sebelah hidung tersumbat dan berair pada kanak-kanak.

Apa lagi gejala lain berkaitan dengan hidung tersumbat?

Doktor akan bertanya beberapa soalan seperti berikut:

• Berapa lama masalah ini berlaku?
• Hidung sebelah mana atau kedua-duanya yang tersumbat?
• Adakah masalah ini semakin serius dalam jangka masa terdekat?
• Adakah tuan/puan mengalami sentiasa bersin, hidung gatal, hidung berair?
• Adakah tuan/puan mengalami masalah sakit kepala, tidur berdengkur?
• Bagaimana dengan deria bau dan rasa? Adakah ia berkurangan?
• Pernah mengalami hidung berdarah?
• Pernah mengalami trauma pada hidung?
• Adakah tuan/puan menggunakan ubat sembur hidung yang mengandungi pseudoephedrine atau mengambil ubat aspirin?
• Adakah tuan/puan mengalami masalah kesihatan yang lain seperti lelah, darah tinggi, masalah tiroid etc?

Bagaimana doktor pakar ENT mengenalpasti punca hidung tersumbat?

Setelah mendapat riwayat penyakit dengan teliti, pakar ENT akan memeriksa bahagian ruang hidung dengan menggunakan skop di klinik. Ini membolehkan pakar tersebut melihat dengan lebih jelas ruang dalam hidung dan mengenalpasti punca hidung tersumbat. Selalunya imej skop tersebut disambung kepada kamera dan dipaparkan di atas skrin TV agar pesakit juga dapat melihat dengan sendiri.

Kadangkala doktor akan mengesyorkan pemeriksaan lanjutan seperti ujian darah, ujian alahan atau CT scan. Tetapi ini bergantung kepada setiap kes pesakit dan bukan semua pesakit perlu pemeriksaan lanjutan tersebut.

Rawatan bagi hidung tersumbat

Rawatan hidung tersumbat bergantung kepada puncanya. Sekiranya ia berkaitan demam selsema, rawatan perubatan dapat memulihkan keadaan yang selalunya bersifat sementara.

Rawatan perubatan yang sering disyorkan termasuk ubat sembur hidung (intranasal steroids, nasal decongestant, saline wash/spray) dan pil (antihistamine, decongestant) dalam pelbagai kombinasi. Antibiotik juga perlu sekiranya ada jangkitan bakteria. Ia adalah penting bagi pesakit menggunakan ubat seperti yang disarankan oleh doktor yang merawat. Kadangkala ia mengambil masa beberapa minggu untuk hidung tersumbat menjadi lega.

Sekiranya rawatan perubatan gagal untuk memulihkan masalah hidung sumbat, pakar ENT mungkin mengesyorkan pembedahan (surgeri). Jenis pembedahan bergantung kepada punca masalah hidung tersumbat. Contohnya pembedahan septum (septoplasty) dinasihatkan sekiranya pesakit mengalami tulang septum yang bengkok. Ada juga pembedahan turbinat hidung untuk mengecutkan selaput yang bengkak. Endoscopic sinus surgery pula disyorkan bagi mereka yang bermasalah polip hidung dan sinusitis. Tisu adenoid yang bengkak juga boleh dibedah sekiranya rawatan perubatan gagal. Perlu diingatkan bahawa ada beberapa cara untuk mengatasi masalah hidung tersumbat dan doktor pakar akan menasihatkan rawatan yang paling sesuai bagi setiap pesakit.

POST TONSILLECTOMY CARE

TONSILLECTOMY

Tonsillectomy is a surgical procedure to remove the tonsils which are lymphoid tissues situated at the back of the throat. It is recommended when the patient has repeated tonsillitis, enlarged tonsils, suspicion of tumour or peritonsillar abscess. The surgeon would only advise for tonsillectomy when the benefits of the procedure outweigh the possible risks and complications. Tonsillectomy is performed under general anaesthesia via trans-oral approach; that is through the mouth opening.

Typical appearance of the back of the throat three days post tonsillectomy
(Wikipedia.org)

COMPLICATIONS OF TONSILLECTOMY

Bleeding- the tonsil area has a rich blood supply and care is taken to stop any bleeding intraoperatively. The risk of bleeding after tonsillectomy is very low and usually present with blood stained saliva. On rare occasions the bleeding can be severe and have to be managed in the operating theatre. Risk of bleeding is higher when there is infection.

Infection- it is a potential risk especially in patients with inadequate food and fluid intake after tonsillectomy. Patients with infection post tonsillectomy will have symptoms of severe throat pain and bleeding. Treatment is mainly antibiotics and may require re-admission.

Injury to lip/mouth- instruments are inserted to help open up the mouth during surgery. There is a small risk of injury to lip, mouth or teeth during this procedure.

POST OP CARE

• Pain post tonsillectomy can be severe and lasts up to 2 weeks. However in children the recovery is much faster usually within 1 week. Sometimes the pain can get worse between 3 to 5 days after the surgery before it gets better. Patients are advised to take their painkiller medication regularly.
• Swallowing can be difficult after surgery because of the pain. However patients are encouraged to drink and eat as soon as they wake up after surgery. It may be easier to take cold fluids and soft food initially. Taking small sips of fluids may be easier than big swallows. Avoid taking any spicy or hot food to reduce risk of bleeding. Eating well would also lead to better and faster healing of the operated area.
• Avoid going out to public places. Patients are advised to rest at home for about 1-2 weeks. This can prevent exposure to infection.
• Small amounts of blood stained saliva can be normal in the first 2 weeks and can be stopped with ice gargles. However if bleeding is continuous and increasing in amount, do seek immediate medical attention at the hospital where the surgery was performed.

Printable patient leaflet

http://www.entheadandneckclinic.com/web_documents/leaflet_tonsillectomy1_.pdf

NASAL POLYPOSIS

Nasal polyps are growths or masses in the nasal cavity which is not cancerous. It usually arises due to chronic inflammatory process and will continue to increase in size if not treated. It can even cause distortion in the shape of the nose and eventually bulge out through the nostrils in severe cases.

Nasal polyps usually occur in young and middle aged adults. It is uncommon in children. Nasal polyps are often bilateral (both nasal cavities involved). A unilateral polyp is called an antrochoanal polyp which usually arises from the maxillary sinus and affects teens and young adults.

The cause of nasal polyps is open to much debate but it is agreed that an ongoing inflammatory process is the main pathophysiology. There are however certain associated conditions which increase the risk of developing polyps.

These conditions include asthma which is an inflammatory condition of the airways triggered by allergens, chronic rhinosinusitis which is a chronic infection of the sinuses, aspirin sensitivity, allergic fungal sinusitis which is an allergy to airbone fungi, cystic fibrosis especially suspected in children with nasal polyps (rare disease in Malaysia) and other less common syndromes such as Churg Strauss syndrome, Kartagener’s syndrome and Young’s syndrome. Recent understandings have also shown the relevance of family history and certain genetic predisposition to nasal polyps.

SYMPTOMS

The symptoms or nasal polyps are similar to other inflammatory conditions of the nose such as runny nose, post nasal drip and pressure around the face. However when there is persistence in the symptoms especially when associated with unrelenting nasal block/stuffiness, loss of sense of smell or taste, headache, pain around face and teeth and snoring then possibility of nasal polyposis should be considered.

HOW TO DIAGNOSE NASAL POLYPS?

Diagnosis of nasal polyposis can only be confirmed with an endoscopic examination of the nose. A small rigid or flexible scope is inserted into the nose to fully inspect the nasal cavities. It is a simple procedure performed in the ENT clinic. Polyps appear as grapelike structures protruding into the nasal cavities.

Imaging studies are also performed to see the origin of the polyps and extent of the disease. A computed tomography (CT) or magnetic resonance imaging (MRI) is usually requested. The imaging studies can also reveal possible fungal disease or complications.

Other tests such as allergy test, test for cystic fibrosis or others may be indicated depending on a patient to patient basis.

TREATMENT

The treatment of nasal polyps is long term suiting its nature; underlying chronic ongoing inflammatory process. The aims of treatment are to shrink the size of polyps and prevent complications. Most polyps would respond to medical treatment however some would require surgical intervention.

Medical treatment would consist of topical intranasal steroids, oral corticosteroids, antihistamines and antibiotics in various combinations.

Endoscopic sinus surgery is considered when the polyps do not respond to optimal medical treatment. Surgical intervention is also recommended earlier if patients present with complications. Large nasal polyps often may not shrink considerably with medication alone. However patients have to be aware that nasal polyps do recur after surgery. Therefore adequate followup care and ‘maintenance’ medication is necessary to prevent recurrence.

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.