Pediatric ENT Disorders

[tonsil surgery] [ear tube surgery]

Tonsil Surgery

Tonsils are collections of tissue in the back of the throat. They are composed of lymphatic tissue (part of the immune system). Overactive immune system can lead to enlargement of tonsil and adenoid tissues

Enlargement of tonsil and adenoid tissues in the throat can lead to narrowing of small airways in chilren which can lead to variable symptoms of mouthbreathing, snoring, periods of stoppage of breathing at nights (apnea), frequent awakenings (occasionally waking up gasping for air), day time sleepiness, daytime hyperactivity, problems with concentration, failure to thrive (poor growth and development), difficulty swallowing large chunks of solid food and many other issues.

What is tonsil and adenoid surgery?
Surgical removal of the tonsils and adenoids (known as a T&A) is one of the most common operations performed on children in the U.S. As noted in the illustration above, tonsils are located on either side of the throat and adenoids are located behind the nose. When these are enlarged they can block flow of air through the nose and the mouth. Additionally recurrent infections can lead to tonsillitis (sore throat episodes) and recurrent ear infections.
What are the risks of surgery?
T&A procedures are not without risk. Bleeding is the most important risk of surgery and is most prominent with tonsil surgery and less common with adenoid surgery alone. This can happen up to 2 weeks after surgery in up to 3% of children even when the surgery is performed perfectly. A few of these children may need a blood transfusion or additional surgery. All children experience throat discomfort/pain for several days. Some children whose speech was previously normal develop hypernasal speech because the soft palate no longer closes completely. This is usually temporary and resolves after a few months but occasionally it may be permanent and require further procedures.

When is surgery necessary?
Sometimes the tonsils should come out. But the benefits must outweigh the risks. Your provider will decide if the tonsils, adenoids, or both need to be removed. All of the following are valid reasons for evaluation.

1. Persistent mouth-breathing

 Mouth-breathing during colds or hay fever is common. Continued daily    mouth-breathing is less common and deserves an evaluation to see if it is due to large adenoids. The open-mouth appearance results in teasing, and the mouth-breathing itself leads to changes in the facial bone structure (including an overbite that could require orthodontics).

2. Abnormal speech

The speech can be muffled by large tonsils or made hyponasal (no nasal resonance) by large adenoids. Although other causes are possible, an evaluation is in order.

2. Severe snoring and obstructive sleep apnea
Snoring can have several causes. If snoring occurs every night and enlarged adenoids are the cause, they should be removed. In severe cases, the loud snoring is associated with retractions (pulling in of the spaces between the ribs), choking, and interruptions of breathing. This is called obstructive sleep apnea. Long term effects of obstructive sleep apnea include lack of oxygen to the brain resulting in impaired growth, impaired cognition and hyperactivity.

3. Heart failure
Rarely, large tonsils and adenoids interfere so much with breathing that blood oxygen is reduced and the right side of the heart goes into failure. Adults and children with this condition are short of breath, have limited exercise tolerance, and have a rapid pulse.

4. Persistent swallowing difficulties
During a throat infection, the tonsils may temporarily swell enough to cause swallowing problems. Some children refuse meats because they are difficult to swallow. Some children refuse solid foods. If the problem is persistent and the tonsils are touching each other, an evaluation is needed. This problem more often occurs in children with a small mouth.

5. Recurrent abscess (deep infection) or frequent infections of the tonsil
Your provider can check this.

6. Recurrent abscess of a lymph node draining the tonsil
Your provider can check this.

7. Suspected tumor of the tonsil
These rare tumors cause one tonsil to be much larger than the other. The tonsil is also quite firm to the touch, and usually enlarged lymph nodes are found on the same side of the neck.

How is the surgery done?

In children, Dr. Oliaei uses coblation, a plasma technology that uses low temperature dissection technique to remove tonsils and ablate the adenoids in children. This technology has been associated with less pain. Occasionally electrodissection or cautery is used in conjunction. The surgery is performed through the mouth without external incisions. It is done under general anesthesia with intubation.

What to expect after surgery?

1. Discharge: Most patients go home the same day. Children under three years of age and certain adults with comorbid conditions may stay in the hospital for observation after surgery.

2. Pain: Throat pain is common after surgery and is more pronounced in adults and older children and those with history of recurrent infections in the past. Drinking cold fluids and placing ice on the neck is helpful with the pain. Use of tylenol and ibuprofen is encouraged. Narcotic pain medications occasionally become necessary, but their use is discouraged in younger children due to risk of over sedation and rare complications.

3. Bleeding: Small amounts of bleeding usually resolves on its own. For severe bleeding, vomiting of blood and clots, immediate return to the hospital for cauterization is necessary. Risk of significant bleeding after tonsil surgery is generally around 3%. With prompt attention and intervention, these rare episodes can be managed without sequela.,p

4. Dehydration: If throat pain is not adequately managed, severe dehydration can occur. Adequate pain management and encouraging large amounts of liquids after surgery is important. If dehydration and lethargy occur, patient may need to go to the emergency room for IV hydration.

Ear Tube Surgery

 

What is ear tube surgery? 
Placement of a small plastic tube (tympanostomy tube) after making a small opening in the ear drum (tympanic membrane). This tube helps ventilation of the space behind the ear drum (middle ear) to help eliminate negative pressure and fluid in the middle ear. Placement of ear tubes can reverse certain types of hearing loss and abnormalities of the ear drum.

What are the risks of surgery? 
Ear tube surgery is done under general anesthesia with mask ventilation. Risks of general anesthesia including airway obstruction is present. Ear tubes often stay in the ear drum from 6-18 months after which fall out and the ear drum opening closes on its own. Occasionally tubes fall out earlier or later than expected and the opening does not close. This opening (aka perforation) of the ear drum may require repair via a surgical procedure at a later date.

When ear tubes are in place, water in the ear canal can enter into the middle ear and cause an infection. It is important to keep the ear dry after surgery. This can be done with ear plugs or cotton balls covered with Vaseline.

When is surgery necessary? 
Sometimes ear tubes are necessary. But the benefits must outweigh the risks. Your provider will discuss the options with you. All of the following are valid reasons for evaluation.
Recurrent middle ear infections
More than 3 infections a year for several years or more than 5-6 infections in one year is an indication for ear tube placement. Although tube placement does not guarantee that infections will not happen again, it is likely to reduce frequency and severity of the infections. Additionally, it allows treatment of middle ear infection with antibiotic drops rather than oral antibiotics.
Delayed speech
The speech can be muffled by presence of fluid or negative pressure in the middle ear. Although other causes are possible, an evaluation is in order.
Persistent failed hearing tests
Poor conduction of sound due to middle ear dysfunction can cause abnormal speech development and poor performance at work or in school.
Abnormal shape of the ear drum
Negative middle ear pressure can deform the ear drum and pull it into the middle ear. Over time this can cause destruction of the bones of the middle ear and a destructive condition known as cholesteatoma.
Persistent swallowing difficulties
During a throat infection, the tonsils may temporarily swell enough to cause swallowing problems. Some children refuse meats because they are difficult to swallow. Some children refuse solid foods. If the problem is persistent and the tonsils are touching each other, an evaluation is needed. This problem more often occurs in children with a small mouth.
Severe acute middle ear infections with complications
A severe middle ear infection that does not resolve with antibiotics and leads to other complications such as an abscess, meningitis or other morbid infections, will require immediate tube placement.

What to do/what to expect on the day of surgery
What to eat?
 How long does the surgery take?
Surgery lasts between 5-10 minutes with additional time for anesthesia. Additionally, a certain amount of time is spent in the recovery room and the pre-operative area. Allow several hours of hospital stay for this procedure.
 How is the surgery done?
Surgery is done using a microscope with microsurgical instruments.
What to expect after surgery?
Discharge: Most patients go home the same day.
Pain: Pain is often minimal and resolves with administration of drops or over the counter tylenol.
Bleeding: Small amounts of bleeding usually resolves on its own or with antibiotic drops.

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May 9th, 2017 by Sepehr Oliaei, MD