Procedures

Before Surgery

All patients will need to be cleared for surgery by their primary care physician.  This usually includes a physical examination and blood work as well as any additional testing deemed necessary.  For procedures in the hospital or surgical center, nothing to eat after midnight (no solid food or liquids) the day before the procedure is the rule.  Certain medications need to be discontinued before surgery. If you are not sure, please ask our physicians   The attached list of medications needs to be discontinued at least 2 weeks prior to the procedure.

Medications to avoid before surgery

EAR

Ear tubes (Bilateral myringotomy and tubes (BMT))

When ear infections, fluid in the middle ear space or eustachian tube dysfunction become a chronic problem and do not respond to medications, they may cause hearing loss, pressure, balance and speech problems. In these cases, insertion of ear tubes may be necessary.

The procedure is called bilateral myringotomy and tubes (BMT) which involves making a small opening in the eardrum to promote drainage of fluid and restore hearing. A tube is placed in the opening to prevent it from closing and allow fluid to drain.  The tube remains in place for about 6 or more months and falls out by itself.  This is about as long as is required for the eustachian tube (the normal drainage path for ear fluid) to return to normal. While the tubes are in, you will notice a remarkable improvement in hearing and a decrease in the frequency of ear infections.

The tubes are made of surgical plastic and come in two basic types: short-term and long-term.  Short-term tubes are smaller and typically stay in place for six or more months before falling out on their own.  Long-term tubes are larger and may stay in place for several years.  Long term tubes are reserved for patients who have had several sets of tubes in the past or may need longer ventilation depending on their condition.  They may fall out on their own, but surgical removal is often necessary.
 
Ear tubes are inserted as an outpatient surgical procedure under a light general anesthesia.  A surgical microscope is used to create the opening with a small scalpel and the tube is then placed.  Fluid is suctioned clear during the procedure.  The entire procedure takes about 15 minutes.  Patients usually experience little or no postoperative pain and hearing is usually immediately improved.  Patients will be given a prescription for antibiotic ear drops to use for a few days.

BMT complications and risks

BMT postoperative instructions

Repair of a perforated eardrum (Tympanoplasty/Myringoplasty)

A hole in the eardrum (tympanic membrane) can occur from infection, trauma or previous surgery (ear tubes).  These holes can predispose patients to infection and may cause hearing loss.  A procedure known as tympanoplasty or myringoplasty involves repairing and patching the hole preventing further infections and restoring hearing.  The procedure is performed under general anesthesia and can be performed through the ear canal but an incision behind the ear may be required.  A graft (usually the patient's own tissue) is taken from behind the ear and used to reconstruct the eardrum.  Surgery may take 1-2 hours and the ear may feel blocked for 6 weeks until full healing has taken place.  It is extremely important to keep the ear dry during healing.

NOSE

Septoplasty (deviated nasal septum repair)

Septoplasty is a surgical procedure that is performed to straighten a deviated nasal septum.  This surgery may be combined with a rhinoplasty (nosejob) to change the external appearance of the nose, inferior turbinate reduction or sinus surgery.

The procedure is performed under general and local anesthesia as an outpatient.  The procedure is performed endonasally (though the nostrils) and does not involve external incisions and does not cause any bruising.
 
During the procedure, badly deviated portions of the septum (cartilage and bone) may be removed, reshaped or readjusted.  The procedure may take one hour or longer if ancillary procedures are performed.  Internal splints and/or nasal packing may be placed in the nostrils to hold the septum in its new position and to prevent excessive bleeding.
The packing and splints are removed in 1-2 days.  Nasal breathing will be dramatically improved when the swelling has resolved and healing has occurred in 6 or more weeks.

Septoplasty complications and risks

Septoplasty postoperative instructions

Septoplasty postoperative nasal care 

Inferior turbinate reduction (BITR)

The turbinates are bony structures in the nose lined with expansile tissue that regulate nasal airflow and produce mucus.  Enlarged turbinates can cause nasal congestion and obstruction.  Reducing the size of the turbinates will greatly increase the nasal airway and decrease mucus production. 

This procedure can be performed under general anesthesia as an outpatient and is usually performed with a septoplasty.  The procedure can also be performed alone under local anesthesia in the office.  We currently use Coblation® turbinate reduction in both settings. Coblation® is a technique that uses radiofrequency energy to remove and shrink tissue.  The areas that have undergone treatment shrink as they heal thus reducing the size and function the inferior turbinates.  The procedure takes about 20 minutes and healing takes about 6 weeks.  Nasal packing is generally not needed unless a septoplasty is performed as well.

BITR complications and risks

BITR postoperative instructions

BITR postoperative nasal care

Sinus Surgery (FESS)

When sinus infections are recurrent and not responsive to medications, sinus surgery to enlarge the openings that drain the sinuses may be necessary.  Prior to any surgical procedure, a sinus computed tomography (CT) scan will be performed to identify the affected sinuses and the sinus anatomy that may be responsible for the blockage.  Sinus surgery can then be performed to drain chronic infections, remove diseased tissue and polyps and enlarge the natural openings of the sinuses. 

The procedure is called Functional Endoscopic Sinus Surgery (FESS) since the goal is to preserve as much normal sinus anatomy as possible and restore normal sinus function and drainage.  An endoscope, a long thin fiberoptic telescope with a camera is used to look into the sinuses, while at the same time the procedure is being performed.  Specially designed state of the art instruments and shavers are used to perform the procedure.  The entire procedure is performed through the nostrils, leaving no external scars.  The advantage of this procedure is that the surgery is less extensive, there is less removal of normal tissues, and it can frequently be performed on an outpatient basis.   The procedure usually takes about 2 hours and nasal packing is used in most cases.  The packing will usually be removed after 1-2 days.

Image guided endoscopic sinus surgery

The sinuses are anatomically close to the brain and eye and this is a concern during an operation.  Image guided endoscopic sinus surgery is a three-dimensional mapping system that combines computed tomography (CT) scans and real-time information about the exact position of surgical instruments during the procedure. This is similar to a computer navigation system used in your car.  Using this state of the art system allows us to navigate our surgical instruments through sinuses more precisely and safer than ever before and avoid normal anatomy targeting only the diseased areas.

FESS complications and risks

FESS postoperative instructions

FESS postoperative nasal care

Cosmetic Nasal Surgery (Nosejob) (Rhinoplasty)

The procedure used to alter the external appearance of the nose is called rhinoplasty.  Crooked noses, nasal bumps and humps and misshapen nasal tips can be cosmetically altered to a more pleasing appearance.  A full description of the procedure can be found in the facial plastic surgery section of this website.

THROAT

Tonsillectomy and adenoidectomy (T&A)

Tonsil and adenoid surgery may be necessary due to chronic infections, halitosis or enlargement that causes obstructive leading to difficulty breathing, snoring or obstructive sleep apnea.  Surgery can be very effective in treating these problems and having your tonsils and adenoids removed will not affect your immunity or resistance.
The current method we utilize for T&A surgery is Coblation® which is a technique that uses radiofrequency energy to dissect through natural tissue planes, remove and shrink tissue.   This is less traumatic to the surrounding tissue, decreases the bleeding during the procedure, decreases the pain after the procedure and decreases the recovery time.   The procedure takes approximately 45 minutes and is performed as an outpatient in most cases.  Patients should expect a sore throat for at least 7-10 days after surgery and will usually only tolerate liquids and a soft diet.  No heavy lifting, exercise, sports or travel is permitted for 3 weeks after surgery. 

T&A complications and risks

T&A postoperative instructions

Snoring procedures

Surgery may be necessary to relieve the obstruction to breathing that contributes to snoring and obstructive sleep apnea (OSA.)  The obstruction can be nasal or throat in origin.  Nasal procedures include: straightening a deviated nasal septum (septoplasty), inferior turbinate reduction (BITR), sinus surgery (FESS) and removal of nasal polyps if they are present.  Throat procedures include: surgery on the tonsils and adenoids (T&A) if these structures are enlarged and obstructing and surgery on the palate (Pillar implants®, Coblation® and Uvulopalatopharyngoplasty (UPPP)).  A combination of the above procedures performed together or at different times may be necessary for a complete treatment.

Coblation® is a technique that uses radiofrequency energy to remove and shrink tissue of the soft palate that is contributing to snoring and OSA.  The treatment can be performed in the office or in the surgical center as an outpatient depending on the severity of sleep apnea.  Channels are created in the soft palate with the Coblation® wand which creates submucosal lesions that stiffen the palate as healing occurs.  The procedure takes approximately 15 minutes to perform and pain postoperatively is minimal.  Results can be expected in 3 months.

Pillar implants® are a technique that uses three tiny polyester implants that are placed into the soft palate.  This procedure is performed in the office under local anesthesia and takes about 20 minutes.  Over time, the implants, together with the body's natural fibrotic response, add structural support to and stiffen the soft palate that reduces the flutter and vibration that causes snoring and/or obstruction of the upper airway.

Pillar implants® information and consent

Uvulopalatopharyngoplasty (UPPP) is a surgical procedure that is used to remove redundant soft palate tissue that is contributing to snoring and OSA.  This procedure is performed in the hospital and takes approximately one hour to perform.  Most patients stay overnight in the hospital to monitor breathing.  A UPPP is sometimes performed with a tonsillectomy and/or adenoidectomy if these structures are obstructing.