- Reasons for Surgery
- Surgical Treatment and Care
- Snoring and Sleep Apnea
- What Causes Snoring?
- What is Obstructive Sleep Apnea?
- How is Snoring Treated?
- How is Sleep Apnea Treated?
- How can Surgery Help Sleep Apnea?
- What is Somnoguard?
- Thyroid Disease
- Head and Neck Tumors
- Parotid and Other Salivary Gland Tumors
- Zenker’s Diverticulum
- Temporomandibular Joint Disorder (TMJ)
- Pediatric: Frenulectomy (Ankyloglossia)
- Pediatric: Branchial Cleft Cyst
Tonsils and Adenoid Disease:
The tonsils and adenoids are thought to assist the body in its defense against incoming bacteria and viruses by helping the body form antibodies. However, this function may only be important during the first year of life. There is no evidence to support a significant role of the tonsils and adenoids in long-term immunity. Medical studies have shown that children who have their tonsils and adenoids removed suffer no loss in their future immunity and their ability to fight infections.
Reasons for Surgery:
- Recurrent tonsil and/or adenoid infections despite treatment with medications
- Tonsil and/or adenoid enlargement causing upper airway obstruction (sleep apnea or difficulty breathing), nasal obstruction, or difficulty swallowing.
- Recurrent peritonsillar abscess
- Persistent foul taste or bad breath due to chronic tonsillitis and/or tonsilliths (stones in the depressions of the tonsils) not responsive to medical therapy.
- Large tonsils could be a concern for possible malignancy (cancer).
- Tonsil and/or adenoid enlargement in children can cause dental misalignment or adverse effects on facial growth due to chronic mouth breathing.
- Chronic otitis media (ear infections) – For children requiring ear tubes for chonic otitis media, adenoidectomy has been shown to reduce the likelihood of recurrent ear infections once the tubes come out.
- Chronic rhinitis (nose infection)/chronic sinusitis (sinus infections) – Studies have shown that adenoidectomy can reduce the number of sinus/nasal infections in children who have persistent nasal disease despite appropriate medical treatment.
Surgical Treatment and Care:
Tonsillectomy and adenoidectomy are commonly performed surgeries, generally performed in an outpatient setting. Surgery is performed under a general anesthetic. A typical procedure may take approximately 30 minutes.
The tonsils and adenoids are both accessed through the mouth. A variety of instruments can be used to remove the tonsils and adenoids. Popular methods include electrocautery, laser, and radiofrequency ablation (RFA, or Coblation). This technology is continually evolving, with the goal of reducing tissue injury and improving postoperative healing. The adenoids are visualized through the mouth by retracting the soft palate forward and upward. Blood vessels are cauterized with the surgical instruments and sutures are rarely used. Most patients will recover for about 1½ hours in outpatient recovery before being discharged home, although this process varies from individual to individual.
There is always throat pain following tonsillectomy. This begins to improve significantly after the first postoperative week. Ear pain is also common due to a nerve in the back of the throat that sends a branch to the ears resulting in “referred pain” to the ears.
Snoring and Sleep Apnea:
Snoring and sleep apnea may result in nightly jabs in the ribs and grumblings from your bed partner, or complaints and uncomplimentary remarks from your friends and family members. The noise you make can disrupt their sleep more than your own. However, snoring can also be the first sign of sleep apnea, a significant health problem for you.
What Causes Snoring?
As you breathe, air travels through passages in your nose and throat. When these air passages are wide enough to allow air to flow freely, you breathe quietly. However, if the passages become too narrow, the tissues of the throat may start to vibrate, leading to snoring.
Obstruction to normal airflow may occur at multiple levels. Problems in the structure of the nose may obstruct breathing. A crooked, or deviated, septum or swollen turbinates can lead to nasal obstruction. Nasal polyps, allergies, and chronic sinusitis can also cause nasal obstruction. These problems, in turn, can lead to mouth breathing and contribute to snoring.
Large tonsils, a floppy soft palate or an elongated uvula are common findings with snorers. These anatomic abnormalities lead to decreased movement of air through the mouth. A receding jaw or enlarged tongue may also obstruct oral breathing, by allowing the tongue to come into contact with the back of the throat.
Finally, weight gain increases the thickness of the tissues of the neck and throat, compromising the diameter of the airway.
It is common for snorers to have multiple anatomic factors that contribute to their snoring problem, as opposed to just a single factor.
What is Obstructive Sleep Apnea?
Obstructive sleep apnea is defined as a reduction or cessation of breathing during sleep due to blockage of the nose and/or throat. This can result in a decrease in oxygen in the blood and disruptions in sleep in which the body attempts to restart breathing.
To learn more about your snoring and possible sleep apnea, you need a thorough evaluation by an otolaryngologist. Your doctor will take a health history that includes detailed questions about your chief complaint, other symptoms, and any treatment you may have already had. A physical examination is performed in the office to evaluate the air passages. This may include a fiberoptic endoscopy in which a flexible telescope is placed through the nose and down into the throat. This is done with topical anesthesia and with minimal discomfort.
An overnight sleep study (polysomnogram) is the diagnostic test for sleep apnea. The sleep study involves spending a night at a sleep clinic where your breathing, heart rate, oxygen level, and other physiologic functions are measured and recorded. The findings help determine whether you have sleep apnea and which treatments will best help you.
How is Snoring Treated?
If your physician determines that you do not have a significant degree of sleep apnea, a variety of treatment options for snoring may be discussed. Non-surgical methods of treating snoring include weight loss, elimination of alcohol and sedatives before bedtime and treatment of nasal congestion. In some cases, an oral appliance designed by a dental sleep specialist may be effective.
Surgical treatment of snoring can take many forms, and is aimed at reducing airway obstruction. Traditional surgeries such as a septoplasty for a deviated septum, or a tonsillectomy for enlarged tonsils may be recommended. Most other procedures specifically designed to treat snoring are designed to reduce vibration of the palate and uvula. These include injection snoreplasty, and the pillar implant procedure, among others.
Injection snoreplasty is a procedure performed in the physician’s office under topical anesthetic. It consists of injecting a chemical into the tissue of the palate just above the uvula and takes about 5-10 minutes to complete. The chemical causes a breakdown in the tissue in this area, which is followed by scarring. The scarring increases the firmness of the soft palate, which leads to decreased vibration and decreased noise of snoring. The site of injection typically feels irregular for about two weeks. It may hurt, as well, but this will generally respond to over-the-counter pain medication. In properly selected individuals, the likelihood of improving snoring is approximately 85%.
The pillar implant procedure is performed in the physician’s office under local anesthetic. It consists of inserting three to five small Dacron struts under the skin of the soft palate. These struts provide stiffness to the soft palate, reducing vibration. This procedure typically takes about 15 minutes to complete. Pain and discomfort are relatively minimal and can be treated with over-the-counter pain medication. In properly selected individuals, the likelihood of improving snoring is approximately 85%.
How is Sleep Apnea Treated?
Changing a few habits may be all that is needed to stop snoring and prevent mild sleep apnea. Even if you need further treatment, these changes are a good place to start. Sleeping on your side may reduce the blockage caused by gravity pulling relaxed throat tissue down. Losing weight also helps as excess fat deposits in the neck make the structures in your throat more bulky and floppy. Avoid alcohol and sedating medications at night, as these may relax your throat muscles more than usual. A blocked up nose makes snoring and sleep apnea worse. Treatment of allergies and sinus problems may improve this problem. Nasal strips may make breathing easier. Stopping smoking can also improve a stuffy nose.
Oral appliances may also be a part of the treatment options. A dental specialist can build and fit an oral appliance that can move the jaw and tongue forward while you sleep, thus preventing blockage.
Continuous Positive Airway Pressure (CPAP) is the gold standard treatment for obstructive sleep apnea. The CPAP machine uses a mask and air pressure to hold the airway open. The machine is used at night and is generally the most effective treatment for sleep apnea. You will require a CPAP titration study performed in a sleep laboratory to arrive at the proper CPAP settings. A variety of masks and machines are available. Any CPAP setup must be tailored to meet your needs and preferences, so expect several adjustment before the setup suits you.
How can Surgery Help Sleep Apnea?
The goal of surgery is to widen the air passages in the nose and the throat. Although non-surgical options of treatment are generally encouraged, surgical treatment can be useful if a patient is unable or unwilling to comply with non-surgical treatment, or if readily identifiable anatomic abnormalities are found where correction is likely to result in improvement.
Nasal surgery may involve reducing the turbinates, straightening a deviated septum, or endoscopic sinus surgery to remove nasal polyps or treat sinusitis. Problems in the nose can make snoring or sleep apnea worse and make CPAP harder to use. Surgery to open the nasal passages tends to help snoring and apnea problems and can help patients become more compliant with CPAP.
Palate surgery may be required if excess tissue of the soft palate is blocking the airway. The most common surgical procedure for sleep apnea is a Uvulopalatopharyngoplasty, or UPPP. This involves trimming the soft palate and uvula and removing any tonsillar tissue. This procedure is done under general anesthesia, may be combined with nasal or tongue surgery, may require overnight hospitalization, and takes a minimum of one week for recovery.
Tongue surgery may be needed if the base of tongue is found to be too large or too posterior. Tongue advancement procedures include hyoid myotomy and suspension, radiofrequency ablation of the tongue base, genioglossal advancement, and mandibular advancement. These surgeries attempt to move the tongue forward, so that it does not collapse against the back wall of the throat during sleep.
What is Somnoguard?
One of the most unobtrusive and proven effective therapy options for Obstructive Sleep Apnea is Oral Appliance Therapy. Oral Appliances, also known as Mandibular Advancement Devices, are designed to maintain an open airway by mechanically holding the jaw in its normal position, or slightly advanced if necessary, in order to hold the muscles and tongue from collapsing when you are asleep.
There are numerous varieties of Oral Appliances that range from over the counter devices that are not cleared by the FDA for treating Obstructive Sleep Apnea, to complicated Custom Manufactured devices that are appropriate for some patients, but typically cost thousands of dollars and require multiple office visits to obtain. The Somnoguard family of Oral Appliances are a new class of Appliances designed and manufactured to be provided to the majority of patients suffering with Obstructive Sleep Apnea in a single-office visit, that is Custom Fitted to your bite and adjustable to address your specific anatomy.
defined as an abnormal voice caused by interruption of vocal cord closure and vibration. Most commonly hoarseness develops from benign causes such as upper respiratory infections, vocal abuse, gastroesophageal reflux disease and advancing age. Vocal cord nodules, polyps, granulomas, paralysis, and cancer are less common causes.
- Symptoms and Types: Unexplained hoarseness lasting more than three weeks should usually prompt an evaluation as to its cause. An ear, nose and throat specialist will first obtain a history of the complaint, including the quality of the hoarseness, its severity, the length of time the hoarseness has been present, and any factors that either aggravate or alleviate it.
- Diagnosis and Tests: After obtaining the history, the physician reviews any pertinent medication history and social history that may affect the voice, including the use of tobacco and alcohol. A thorough head and neck examination, including inspection for neck masses or surgical scars, the state of oral hydration, or the presence of any nasal or postnasal drainage, is then performed. Finally, the physician examines the larynx, or voice box, to determine whether any visible pathology exists. This is usually accomplished using fiberoptic laryngoscopy. A simple procedure performed in the office, usually requiring only a few minutes.
Based on the specific findings on this examination, the specialist can present a diagnosis and treatment plan to the patient.
Treatment and Care:
- Do not smoke, avoid noxious fumes and secondary smoke
- 8 glasses of water a day
- Chew gum, suck on hard candies
- Keep environment humid
- Avoid caffeine and alcohol – these cause the body to lose water
- Treat Gastroespohageal Reflux Disease (GERD) if present
- Avoid loud of prolonged voice use
- Do not clear throat
- Get plenty of sleep
- Avoid over the counter antihistamines that cause dryness
- Avoid menthol throat lozenges that dry the throat
- “Warm up” vocal muscles prior to prolonged use
- Rest your voice after vigorous use
- Use a microphone where you need to project your voice
Thyroid disease is a common condition that occurs when the thyroid gland does not produce the proper amount of hormones needed by the body. Thyroid hormones help regulate the body’s heart rate, temperature and metabolism. A malfunctioning gland may be producing too much or too little of these hormones for a number of different reasons, such as an autoimmune disease, exposure to radiation, reaction to medication or pregnancy. Treatment for thyroid conditions usually includes medication to increase or decrease hormone production, or surgery to remove part or all of the thyroid gland.
Head and Neck Tumors:
Head and neck cancers encompass several different diseases that can affect the mouth, nose, throat and other surrounding areas. Over 50,000 Americans are diagnosed with head and neck cancer each year, as these diseases account for 3 to 5 percent of all cancers. Many cases of head and neck cancer can be prevented through life changes.
Several different types of cancer can affect the areas of the head and neck. Most begin in the lining of moist, mucosal surfaces such as the mouth, nose and throat. The cells in the lining are known as squamous cells, and may therefore be affected by squamous cell carcinomas. The different types of cancer associated with the head and neck include:
- Oral Cavity
- Salivary glands
- Nasal cavity
- Pharynx (including nasopharynx, oropharynx and hyperpharynx)
- Lymph nodes
Like other types of cancer, these diseases can spread to other areas of the body and lead to serious complications. Prompt, thorough treatment is essential in restoring the health and overall well-being of patients with head and neck cancer.
Parotid and Other Salivary Gland Tumors:
Tumors can arise from the various cells in the salivary glands when the body’s normal regulating mechanisms do not function the way they are supposed to. Salivary gland tumors can be either benign (non-cancerous) or malignant (cancerous). Tobacco use is a risk factor for the development of malignant salivary gland tumors. As a general rule, the likelihood of a salivary gland tumor being malignant is inversely proportional to the size of the gland. Tumors of the parotid glands, the largest salivary glands, have only a 20% likelihood of malignancy, whereas tumors of the minor salivary glands have an 80% likelihood of being malignant. The most common type of benign salivary gland tumor is a benign mixed tumor, or pleomorphic adenoma. The next most common benign tumor is a Warthin’s tumor, which is found only in the parotid gland, and which can sometimes occur bilaterally. The most common types of malignant tumors of the salivary glands are mucoepidermoid carcinoma, adenoid cystic carcinoma, adenocarcinoma, carcinoma ex pleomorphic adenoma, and acinic cell carcinoma.
Most salivary gland tumors are noticed by the patient as a lump in the face or neck. There are rarely any other symptoms. Pain is uncommon. Weakness of the muscles of the face on the side of the tumor is a worrisome finding. Once a salivary gland tumor has been detected, further diagnostic testing, such as a CT or MRI scan, may be recommended. A fine needle aspiration (FNA) biopsy of the tumor may also be recommended to try to determine the type of tumor. It is important to realize that needle biopsies are not 100% accurate. Results of these biopsies should be thought of as a guide, but not an absolute indication as to whether the tumor is benign or malignant.
Surgery to remove the parotid gland is called a parotidectomy. This surgery is performed through an S-shaped incision starting in the crease in front of the ear, extending below the earlobe and sweeping forward onto the upper neck. A parotidectomy involves locating the facial nerve (the nerve that moves the muscles of expression in the face) and dissecting the parotid gland off of this nerve. The facial nerve runs through the middle of the gland. Approximately 75% of the gland is superficial to the nerve (the superficial lobe), with the remaining 25% lying deep to the nerve (the deep lobe). Most tumors of the parotid gland reside in the superficial portion of the gland, although some tumors may reside in the deep lobe or in both. When only the superficial lobe of the gland is removed, this is referred to as a superficial parotidectomy. When both the superficial and deep lobes are removed, this is referred to as a total parotidectomy. Parotid surgery is performed under general anesthesia and may take two to three hours to complete. It is usually well tolerated, not painful, and most patients resume normal activities within a few days.
Patients who undergo parotidectomy will typically experience permanent numbness in the area around the earlobe, and will have a small depression in the area where the parotid gland was located. The most important risk of parotidectomy is the possibility of injury to the facial nerve, resulting in weakness in some, or all, of the muscles on that side of the face. This injury, if it occurs, is usually transient, although permanent injury to the nerve is also possible. Transient injury to the facial nerve may take weeks to months to recover from. The likelihood of nerve weakness after surgery is significantly higher following a total parotidectomy than it is after a superficial parotidectomy. The risk of facial nerve weakness is also significantly higher with malignant tumors, since these may be attached to the nerves. Other risks of surgery include the development of gustatory sweating, or Frey’s syndrome, a condition in which stimulation of the salivary glands by eating leads to sweating of the skin over the parotid area, and salivary fistula, in which saliva from residual parotid tissue leaks out through the incision.
more formally known as a hypopharyngeal diverticulum, is a pouch that can form at the junction of the hypopharynx (lower part of the throat) and the esophagus, an area known as Killian’s Triangle. This pouch typically causes problems by trapping food as it is being swallowed, leading to choking and aspiration.
A Zenker’s diverticulum typically arises due to tightness of the cricopharyngeus muscle. This muscle makes up the upper esophageal sphincter, and is located just below the level of the voice box. Normally, it relaxes during swallowing to allow food to pass into the esophagus. When this muscle fails to relax, the pressure of swallowing pushes the food against the posterior wall of the hypopharynx, causing it to bulge slightly. The combination of obstruction, pressure and bulging, repeated over thousands of swallows, eventually leads to a permanent bulge or pouch — a Zenker’s diverticulum. The diverticulum continues to enlarge as more and more food is pressed into it.
The classic symptoms of a Zenker’s diverticulum consist of difficulty swallowing, a feeling a lump or fullness in the throat, and subsequent regurgitation of undigested trapped food minutes to hours after eating. This unexpected regurgitation of food can lead to aspiration (food particles entering the windpipe and lungs) and, in some cases, pneumonia.
A Zenker’s diverticulum is usually diagnosed radiographically with a study called a barium swallow. This study uses radioopaque liquid, barium, which is swallowed, revealing the contour of the hypopharynx and esophagus. The Zenker’s diverticulum is readily visible on the lateral view of a barium swallow. The indentation of the tight cricopharyngeus muscle may also be noticeable.
If a Zenker’s diverticulum is causing symptoms, surgical treatment may be recommended. Surgery generally consists of severing the tight cricopharyngeus muscle, and eliminating the pouch. Severing the muscle is critical to the success of this surgery. With a very small diverticulum, simply dividing the muscle can occasionally allow the pouch to decompress, creating a normal esophageal contour. With larger diverticula, muscle division must be combined with a procedure to eliminate the pouch. This can be performed through either an external or endoscopic approach. With an external approach, an incision is made in the neck allowing the surgeon to expose the esophagus. The cricopharyngeus muscle is identified and severed. The diverticulum pouch is identified and excised. With an endoscopic approach, no external incision is made. The esophagus and diverticulum are visualized through a specialized tube called a diverticuloscope placed through the mouth. The wall between these two structures is divided using an endoscopic stapler, which simultaneously severs the cricopharyngeus muscle and opens the diverticulum directly into the esophagus. Endoscopic diverticulectomy is now a relatively quick procedure that can be performed as an outpatient or with an overnight hospital stay.
Temporomandibular Joint Disorder (TMJ):
a painful condition that affects the joint connecting the jawbone to the skull. This joint is located just in front of the ear and can be felt when the jaw opens and closes. TMJ may also involve the surrounding muscles and soft tissues.
There are a large number of muscles, ligaments, and connective tissues at the base of the skull, upper spine and lower jaw that maintain the position of your head and jaw throughout the day. The pain from TMJ syndrome originates in these connective tissues. These activities create fatigue and even spasm of these connective tissues that people experience as pain.
Eliminating the cause of TMJ syndrome (if it can be identified) is the primary goal of therapy. Reduction of stress is helpful, but may be hard to accomplish. A soft diet, including eliminating hard, crunchy or chewy foods (especially chewing gum) is helpful. Management of jaw clenching and bruxism may require a dental appliance (“mouth guard” or ‘bite-block”) that can be worn at night to prevent nocturnal episodes. Acute episodes of pain respond to non-steroidal anti-inflammatory medications (ibuprofen, naproxen, etc.), as well as hot compresses. In severe cases, muscles relaxants can be prescribed.
Pediatric: Frenulectomy (Ankyloglossia):
Tongue-tie is an abnormality present from birth in which the membrane linking the tongue to the floor of the mouth (lingual frenulum) is too short. This prevents the tongue from protruding past the lower gums. Tongue-tie can occur to varying degrees, from minor shortening to complete fusion of the tongue to the floor of mouth. Sometimes patients with tongue-tie may have other abnormalities of the mouth such as a high arched palate or recessed chin. Tongue-tie is usually an isolated finding in otherwise normal infants. Up to 5% of all babies have some form of tongue-tie.
Tongue-tie is usually diagnosed during a routine baby exam either in the hospital or the pediatrician’s office. The most common symptom of tongue-tie in infants is difficulty with breast-feeding due to problems latching on to the nipple. As the child grows older, speech difficulties may develop. Children with tongue-tie may have problems articulating of the sounds requiring elevation of the tongue, such as /l/ and /th/. A short frenulum may inhibit normal swallowing by preventing the tongue from coming into contact with the roof of the mouth. This may eventually lead to a protruding lower jaw due to repeated efforts to thrust the tongue forward while swallowing. These repetitive efforts may also cause the lower incisor teeth to move forward. Older children may experience social stigma due to a “forked-tongue” appearance. Certain social experiences, such as licking an ice cream cone or kissing may be difficult.
Tongue-tie is diagnosed by physical exam. The physician evaluates the patient’s ability to protrude the tongue beyond the lower dental ridge. During protrusion, the tip of the tongue may become grooved and heart-shaped as the short frenulum pulls against the midline.
Two schools of thought exist regarding treating infants and children with tongue-tie. The first is a “wait and see” approach. It is possible that compensatory behaviors may allow children to develop normal speech and swallowing over time without treatment, thus avoiding surgery.
Another approach is to perform surgery (frenulectomy) at the time of diagnosis. Surgery may avoid speech problems that may develop and become more difficult to correct as the child grows older. Surgery may also avoid the other social and cosmetic effects of tongue-tie may persist, even with normal speech. Frenulectomy is usually a simple procedure, lasting no more than a few minutes. In the newborn, this can be done in the office without sedation using local anesthetic. Older children will usually require a general anesthetic. Recovery is usually rapid, with resumption of breast-feeding or liquid diet immediately after surgery.
Pediatric: Branchial Cleft Cyst:
epithelial (skin) lined cavities filled with mucous that form a mass along the side of the neck. These are congenital (abnormality during fetal development) cysts, resulting from a failure of gill-like embryonic structures (branchial arches) to disappear during maturation of the fetus, as they normally should. This results in a persistent pouch, which later can fill with fluid. Although the cyst is present at birth, it may not present until years later.
Branchial cleft cysts typically appear between childhood and young adulthood as a slow-growing, painless mass on the side of the neck. Infection of the cyst causing an abscess may be the presenting complaint. Depending on the size, it may cause trouble swallowing and shortness of breath. Two percent may be bilateral.
The four types of branchial cleft cysts are named after the branchial arches that they arise from — first, second, third, and fourth. The first branchial cleft cyst has two types: type I and type II. Type I first branchial cleft cysts are rare, and represent a duplication of the external ear canal. These can be near the facial nerve, which is responsible for movement of the face. A type II first branchial cleft cyst is more common and can present as a mass just below the angle of the jaw. The cyst can have a persistent tubular structure through the parotid gland (the large salivary gland located on the face) with close association to the facial nerve. The tubular structure may end at or in the external ear canal. Second branchial cleft cysts are the most common and may present as a painless mass under the jaw line but in front of or under the large neck muscle known as the sternocleidomastoid muscle. Third and fourth anomalies are rare. The third may present as a mass in the lower lateral neck while the fourth may drain into the throat.
Branchial cleft cysts create problems as they enlarge or become infected. Abscess formation often leads to emergency incision and drainage to control infection. Consequently, this can lead to additional scarring, making eventual definitive surgery more challenging. Dissection of the deep tubular remnants of these cysts from around the facial nerve and other nerve and vascular structures of the neck is important to prevent their recurrence.
Elective surgical removal is the treatment of choice. If there is an abscess, emergency incision and drainage is necessary. The goal, however, is to remove the cyst prior to infectious complications. Your doctor may order a CT scan or an MRI to aid in diagnosis and surgical planning.