ENT Surgery Auckland NZ
ENT Surgical Procedures, performed by Dr David Vokes
Laryngeal & Throat Surgery
Head & Neck Surgery
Nasal Surgery
Microlaryngoscopy
What is Microlaryngoscopy?
Microlaryngoscopy is a surgical procedure in which the larynx (the voice box) is examined under general anaesthesia using an endoscope and a microscope to see the larynx. Depending on what abnormalities are found, additional procedures, such as taking a biopsy, removing a lesion, lasering a lesion or injecting the vocal folds, can be carried out at the same time.
Why is Microlaryngoscopy performed?
Microlaryngoscopy is used to diagnose conditions affecting the larynx and is also used to allow treatment of conditions affecting the larynx, especially those disorders that cause problems with the voice or with breathing.
What does Microlaryngoscopy involve?
Microlaryngoscopy is performed in the operating room of the hospital. The anaesthetist gives you a general anaesthetic so that you are asleep for the procedure. The anaesthetist controls your breathing during the procedure by either inserting a breathing tube (endotracheal tube) into the airway beyond the vocal folds (called the trachea or windpipe), or by using a special techniques that avoid the use of a tube in the airway, such as High Flow Nasal Oxygen (often referred to as THRIVE) or jet ventilation.
David then places a hollow metal tube-like instrument called a laryngoscope through the mouth to expose the larynx. An endoscope and/or a microscope is then used to examine the larynx in detail by looking through the laryngoscope. Long and small instruments may be passed through the laryngoscope so that various procedures can be carried out in the larynx, such as taking a biopsy, removing a lesion, lasering a lesion or injecting the vocal folds.
The operation usually lasts about 45-60 minutes. Most people can be discharged home the same day as their procedure, after about 3-4 hours of observation after they have woken up.
What are the risks of Microlaryngoscopy?
Microlaryngoscopy is a very safe procedure. The risks associated with insertion of the laryngoscope include injury to the teeth (and so to minimize the risk of this a mouthguard is used to protect the teeth); abrasions to the lips, tongue or throat; and temporary numbness of the tongue after surgery. Sometimes there is a chance that the surgeon is not able to use the laryngoscope to expose the larynx because of difficult access because of anatomical issues (for example, prominent teeth, a small jaw, limited mouth opening). In these situations, the procedure cannot be completed in the usual way and an alternative procedure is required. Breathing difficulties after a laryngoscopy may occur on very rare occasions.
There are also specific risks associated with each of the procedures that may be performed at the time of a microlaryngoscopy, and these include:
| Procedure | Specific Risk |
|---|---|
| Taking a biopsy (sample for diagnosis) |
|
| Removing (excising) a lesion |
|
| Lasering a lesion |
|
| Injecting the vocal folds |
|
Injection Laryngoplasty in the Operating Room
Injection laryngoplasty (IL) is one of the vocal fold augmentation procedures. The vocal fold is injected with a gel or paste that bulks up (augments) the vocal fold. This material is known as a “filler”, and so injection laryngoplasty is injection of the vocal fold with a filler.
Injection laryngoplasty is usually a temporary form of vocal fold augmentation. Often a temporary treatment may be recommended first either to confirm the diagnosis (for example, for suspected weakness); to confirm that augmentation will be helpful; and/or to determine how much augmentation improves the voice, to allow someone to try augmentation before they decide to undergo a permanent procedure. Sometimes a temporary treatment may be all that is required if recovery is expected and occurs – for example, in some cases of paralysis of the vocal fold.
What substances are injected into the vocal folds to augment them?
The laryngeal injectables David prefers to use are temporary injectables. These are:
Hyaluronic acid (eg. Restylane or Restylane Lyft)
Hyaluronic acid is a synthetic material made from bacterial fermentation. This is a clear gel that is very safe to inject into the vocal folds. It is used for temporary augmentation. Hyaluronic acid lasts for 1-6 months (average duration of around 3 months) before it is resorbed by the body, and then loses its effect.
Calcium hydroxylapatite (eg. Renu or Radiesse)
Calcium hydroxylapatite (CaHa) is a synthetic material composed of tiny calcium-based microspheres suspended in a water-based gel. This is a white paste that is also safe to inject into the vocal folds. CaHa lasts for 6-12 months before it is resorbed by the body, and then loses its effect. However, it may persist for longer than this on some occasions.
Permanent injectable fillers, such a Teflon or Silicone, are best avoided in the vocal folds, because of the risk of adverse reactions to these fillers.
How is Injection Laryngoplasty performed?
Injection laryngoplasty may be performed in the office with local anaesthetic (LA), in which case the person receiving the injection is awake, or in the operating room where the person receiving the injection is asleep under general anaesthetic (GA).
How is Injection Laryngoplasty under GA performed?
When IL is performed under general anaesthetic (GA) the injection is carried out in the operating room in hospital. You are put to sleep by the anaesthetist. A hollow metal tube called a laryngoscope is placed through the mouth into the throat. The laryngoscope exposes the vocal folds, allowing the vocal folds to be examined.
A microscope is used to examine the vocal folds in detail, and so procedure is called a microlaryngoscopy. A very long needle is then placed through the laryngoscope and is inserted into one or both of the vocal folds. The filler is then injected through the needle until the shape and size of the vocal folds have been improved.
After the procedure, there is nothing to eat or drink for one hour. You are discharged home after about 3 hours of observation. Voice rest (no whispering, talking, or shouting) is recommended for 2 days after the procedure. Sometimes there is a mild amount of discomfort after the procedure, and this usually settles after 2 days. A simple pain reliever such as Paracetamol may be taken as required.
What are the risks of Injection Laryngoplasty?
IL is a very safe procedure. Complications after IL are not common, however the following complications may occur: pain, poor voice quality, injection of too much or too little filler, early resorption of the filler, bruising of the neck, bleeding into the vocal fold, shortness of breath or infection.
Laryngeal and Pharyngeal Laser Surgery
Some disorders of the larynx and pharynx (voicebox and throat) are treated with a medical Laser, which is a tool that delivers energy to the larynx and/or pharynx to remove and/or modify abnormal tissue in the larynx and/or pharynx.
Laser treatment of the larynx and/or pharynx may be carried out under general anaesthetic in the operating room, or it may be carried out in the office using local anaesthesia, as an in-office Laryngeal Laser Procedure
The medical Lasers that Dr Vokes uses most often in the operating room are the TruBlue Laser, and the CO2 Laser
The laryngeal and pharyngeal conditions treated with a Laser in the operating room include:
- RRP (Recurrent respiratory papillomatosis)/Laryngeal papillomatosis
- Laryngeal dysplasia (precancerous/premalignant lesions)
- Cancer of the larynx and pharynx
- Cricopharyngeal dysfunction (an excessively tight upper oesophageal sphincter)
- Pharyngeal pouch (Zenker’s diverticulum)
- Stenosis (narrowing) of the larynx and pharynx
- Scar tissue in the larynx and pharynx
- Abnormal blood vessels in the larynx (varices or ectasias)
- Reinke’s oedema
- Vocal fold polyps (haemorrhagic polyps)
- Laryngeal (arytenoid) granulomas
Medialisation Thyroplasty
What is Medialisation Thyroplasty?
Medialisation Thyroplasty (MT) is a surgical procedure in which one of both of the vocal folds is/are augmented by placing an implant into the vocal fold. If both vocal folds are augmented this is called a bilateral medialisation thyroplasty. MT is carried out in the operating room in hospital. David usually performs the procedure with local anaesthetic (LA) and intravenous (IV) sedation, so that he is able to hear the voice and make adjustments to the implant. Sometimes a general anesthetic may be used.
What material is implanted into the vocal folds to augment them?
David prefers to use GoreTex which is a sheet of synthetic material that is tolerated by the body very well. The sheet of GoreTex is cut into a strip which is packed into the larynx through an opening in the main cartilage of the larynx – the thyroid cartilage. This is a permanent implant for augmentation of the vocal folds, although the implant can be removed or adjusted in the future if required.
How is Medialisation Thyroplasty Performed?
You are brought into the operating room and lie flat on the operating room bed. The anaesthetist puts in an IV line and gives you IV sedation. This makes you very sleepy, but you are not completely asleep. A small incision line (approximately 4cm) is drawn over the lower part of the neck. Local anaesthetic is then injected into the skin around the incision line. The neck is then prepared with antiseptic and drapes are placed on the neck.
An incision is made in the skin, and the muscles over the larynx are separated to expose the larynx. A small hole (called a window) is created in the cartilage on the side being augmented using a drill. If augmentation of both vocal folds is required windows are created on both sides of the cartilage.
After the window has been created, some anaesthetic spray is placed in the nose and a flexible endoscope is passed through the nose into the throat to examine the vocal folds from the inside. This allows David to check the positioning of the implant, and to check that the correct amount of implant has been used. The sedation is also reduced so that you are able to talk. David asks you to speak and by listening to your voice (as well as looking at the vocal folds with the endoscope) he is able to optimize the positioning and the volume of the implant.
If your vocal fold is paralysed an additional procedure called an arytenoid adduction is sometimes performed at the same time as the medialisation thyroplasty. Arytenoid adduction is a procedure in which the smaller arytenoid cartilage at the back of the vocal fold is repositioned. This is achieved by creating a second window in the back part of the thyroid cartilage to allow a suture to be placed through the arytenoid cartilage.
The muscles of the neck are then brought together, and the skin incision is closed using absorbable sutures that are buried under the skin. A surgical drain is usually not required.
From the operating room you are taken to the recovery room and then to the ward for an overnight stay. You will be discharged home the next day with pain relievers and antibiotics for one week. You may eat and drink normally, although most people have mild discomfort with swallowing. No voice rest is required.
What are the risks of Medialisation Thyroplasty?
MT is a very safe procedure. The most common complication of MT is that either too little or too much implant has been placed into the vocal folds, resulting in poor voice quality. The implant can be adjusted with a second surgery, which is required in approximately 10% of people. Other complications after MT are not common, however the following complications may occur: pain, bruising or bleeding in the neck (haematoma), bleeding into the vocal fold, excessive neck scarring, shortness of breath, infection or extrusion of the implant.
Laryngeal Reinnervation
What is Laryngeal Reinnervation?
Laryngeal reinnervation (LR) is a surgical procedure to improve the voice for people with a paralysed vocal fold. In this procedure, one of the nerves from the ansa cervicalis (a collection of nerves that supplies the strap muscles in the front of the neck) is connected to the main nerve to the larynx (the recurrent laryngeal nerve). This results in new nerve signals passing into the vocal fold, improving the position, muscle tone and bulk of the paralysed vocal fold. It cannot make a paralysed vocal fold move again.
Why is Laryngeal Reinnervation Performed?
Laryngeal reinnervation (LR) is a surgical procedure to improve the voice for people who have one paralysed vocal fold (called unilateral vocal fold paralysis).
What does Laryngeal Reinnervation involve?
Laryngeal Reinnervation is performed under general anaesthetic. A breathing tube is placed through the vocal folds, into the trachea. A skin incision is made in one side of the lower neck. The ansa cervicalis is identified in the deeper part of the neck. One of its branches is cut. The thyroid gland is dissected to allow identification of the recurrent laryngeal nerve (RLN), the main nerve to the muscles of the larynx. The RLN is then cut. The cut ends of the RLN and of the ansa cervicalis branch are then joined with sutures using a microscope to visualize the suturing. The neck incision is then closed with sutures. An augmentation of the paralyzed vocal fold using an injection laryngoplasty is usually performed at the same time (through the mouth) to give some immediate vocal improvement, because it takes 3 – 12 months for the nerve to heal and to have a positive effect on the voice.
What are the risks of Laryngeal Reinnervation?
Laryngeal Reinnervation is a very safe procedure. The major risk is that the operation may not be as successful as hoped, owing to poor healing between the nerves that have been joined together. If this occurs, further surgery may be required to improve the voice.
There is a scar in the front of the neck. The scar is visible but it does fade with time. In the early postoperative period bleeding may occur in the neck, leading to a haematoma (a collection of blood under the skin causing neck swelling). A haematoma may cause narrowing of the airway and breathing problems, so early recognition and treatment is very important. If a haematoma develops, surgery to stop the bleeding and to remove the haematoma is required. Wound infection is uncommon.
Voice Feminization Surgery
For some people, the sound of their voice does is not consistent with their gender identity. This is a symptoms most commonly reported by Transgender people, however, there can be other reasons why a person’s voice may have an inappropriate quality (especially the vocal pitch) that does not fit with their gender identity, and this may include vocal fold paralysis, vocal fold paresis (weakness), vocal fold oedema (swelling) and the use of medications to treat certain types of cancer. A full evaluation, including videostroboscopy, is vital to understand the reason for the abnormal voice quality.
If there is no underlying voice disorder requiring specific surgical treatment (such as a paralysed vocal fold), then surgery to alter the pitch of the voice may be recommended to improve the voice quality. Depending on the desired outcome of the surgery, this surgery is called Vocal Feminization or Vocal Masculinization.
Voice Feminization Surgery is surgery undertaken to change the quality of the voice by raising the pitch of the voice (by making the voice sound higher).
This surgery may be undertaken for the treatment of androphonia (voicing with an abnormally low pitch) for different people: for trans women, for women with disorders that are treated with androgens (male sex hormones), and for women with ovarian cancer when the tumour is producing androgens.
There are two types of Voice Feminization Surgery: surgery performed through the mouth (transoral or endoscopic approach), and surgery performed through an incision in the front of the neck (external approach).
Anterior (or Wendler) Glottoplasty: This is the most commonly performed voice feminization surgery and is performed through the mouth. In this procedure the vocal folds are accessed via a laryngoscope (a tubular metal surgical instrument) placed through the mouth. Therefore, the procedure is often referred to as Microlaryngoscopy and Anterior Glottoplasty. Once the vocal folds are exposed, the front (or anterior) 40-50% of the lining of the two vocal folds is removed using laser. a microscope to visualize the area, usually with a laser. The anterior parts of the vocal folds are then brought together with sutures (stitches) and /or an injection of filler into each vocal fold. The aim of the surgery is to create a web between the anterior parts of the vocal folds which means that the front parts of the vocal folds have fused with each other. This shortens the length of the vocal folds that vibrate to produce voice. A reduction in the length of the vocal folds leads to an increased rate of vibration, resulting in an increase in the pitch of the voice.
Cricothyroid Approximation: This technique is performed through an incision in the front of the neck. In this procedure two of the main cartilages of the larynx – the thyroid cartilage and the cricoid cartilage – are pulled closer to each other in the front of the larynx and sutures and/or a metal plate are used to keep the cartilages closer together. This increases the tension of the vocal folds, resulting in an increase in the pitch of the voice. This was a commonly used technique in the past but has fallen out of favour because the long-term results of the surgery have been less satisfactory, with the vocal pitch decreasing again in the long term.
There are some risks associated with Voice Feminization Surgery, and these include:
- Failure to raise the vocal pitch to the level desired (persistently low voice)
- Excessive elevation of vocal pitch
- Poor voice quality in general: for example, roughness, breathiness, and/or poor projection of the voice
- Excess healing tissue on the vocal folds (granulation tissue)
- Excess scarring of the vocal folds
- Further surgery to treat abnormal healing/scarring or to adjust the vocal pitch
Voice therapy is an important part of pre- and post-operative voice care when undergoing Voice Feminization Surgery. Voice therapy is particularly important to help with aspects of voicing that surgery is not able to alter, such as vocal resonance, intonation and intensity (loudness).
Voice Masculinization Surgery
For some people, the sound of their voice does is not consistent with their gender identity. This is a symptoms most commonly reported by Transgender people, however, there can be other reasons why a person’s voice may have an inappropriate quality (especially the vocal pitch) that does not fit with their gender identity, and this may include vocal fold paralysis, vocal fold paresis (weakness), vocal fold oedema (swelling) and the use of medications to treat certain types of cancer. A full evaluation, including videostroboscopy, is vital to understand the reason for the abnormal voice quality.
If there is no underlying voice disorder requiring specific surgical treatment (such as a paralysed vocal fold), then surgery to alter the pitch of the voice may be recommended to improve the voice quality. Depending on the desired outcome of the surgery, this surgery is called Vocal Feminization or Vocal Masculinization.
Voice Masculinization Surgery is surgery undertaken to change the quality of the voice by decreasing the pitch of the voice (by making the voice sound lower).
This surgery may be undertaken for people who feel that the pitch of their voice is too high, including trans men whose voice is still high despite testosterone treatment; cis men with an abnormally high pitched voice; and for men with a high pitched voice owing to abnormal vocal folds (eg. thinned and/or scarred), when previous treatment has been unsuccessful.
The surgical procedure for Voice Masculinization Surgery is called a Shortening (or Type 3) Thyroplasty. It is performed through an incision in the front of the neck (external approach). This procedure is usually performed using local anaesthetic and sedation so that the voice can be checked during the procedure, by asking the person to voice. In this procedure the cartilaginous framework of the larynx is exposed, and a vertical strip of cartilage is removed from each side of the main laryngeal cartilage, the thyroid cartilage. This shortens the thyroid cartilage, and thus also shortens the vocal folds, reducing the tension of the vocal folds and decreasing the vocal pitch. The voice is checked by asking the person to voice, and the vocal folds are also examined using an endoscope during the procedure. Once an appropriate reduction in the pitch has been achieved, the cut edges of the cartilage are then joined together on each side using either sutures or metal plates and screws. The skin incision is then sutured closed.
There are some risks associated with Voice Masculinization Surgery, and these include:
- Poor voice quality in general: for example, roughness, breathiness, and/or poor projection of the voice
- Failure to lower the vocal pitch to the level desired (persistently high voice)
- Excessive decrease of the vocal pitch
- The need for further surgery to adjust the vocal pitch
Voice therapy is an important part of pre- and post-operative voice care when undergoing any voice surgery. Voice therapy is particularly important to help with aspects of voicing that surgery is not able to alter, such as vocal resonance and intonation.
Endoscopic Airway Surgery
Microlaryngoscopy & Dilation of Laryngotracheal Stenosis
Narrowing in the upper airway may cause serious symptoms, such as shortness of breath (especially on exertion) and stridor, a high pitched sound heard during inspiration (breathing in or inhaling), or during both inspiration and expiration (taking a breathing out or exhaling). Narrowing of the larynx caused by scarring (posterior glottic stenosis or subglottic stenosis), vocal fold paralysis, throat infections and tumours in the throat are the main conditions associated with stridor.
Most people with airway stenosis (narrowing of the airway) are treated initially with dilation (stretching) of the area of narrowing. This is performed via the mouth using a laryngoscope under general anaesthetic in the operating room. Therefore, the procedure is called Microlaryngoscopy & Dilation of Stenosis.
The three most common conditions treated this way are:
Subglottic stenosis: narrowing of the part of the larynx (voicebox) that is below the vocal folds. This may be caused by trauma (from intubation), or by inflammatory conditions such as idiopathic subglottic stenosis, granulomatosis with polyangiitis, or sarcoidosis.
Posterior Glottic stenosis: narrowing of the part of the larynx (voicebox) that is between the back part of the vocal folds. This causes a restriction in the opening of the vocal folds. This is usually caused by trauma from intubation (placement of a breathing tube).
Tracheal stenosis is narrowing of part of the trachea (the windpipe). This is usually caused by trauma, from either intubation (placement of a breathing tube) or tracheostomy.
The area of narrowing is dilated (stretched) using an airway balloon dilator. David also injects steroid medication into the area that has been dilated to prolong the duration of effect, as, in most cases, these stenoses tend to recur (the narrowing forms again).
Microlaryngoscopy and Laser Cordotomy
Narrowing in the upper airway may cause serious symptoms, such as shortness of breath (especially on exertion) and stridor, a high-pitched sound heard during inspiration (breathing in or inhaling), or during both inspiration and expiration (taking a breathing out or exhaling).
Narrowing of the airway may result from paralysis of both vocal folds, leading to an inability to fully open the vocal folds to allow for an adequate intake of air. Bilateral vocal fold paralysis most commonly occurs as a complication of surgery, but may also result from intubation, neurological disorders or from cancers affecting organs near to the larynx. Bilateral vocal fold paralysis is often treated with laser surgery to one of both vocal folds to enlarge the size of the airway. This is performed via the mouth using a laryngoscope under general anaesthetic in the operating room. Therefore, the procedure is called Microlaryngoscopy & Laser Cordotomy.
The Laser is used to make an incision in one (or sometimes both) of the vocal folds to create more space in the airway to improve breathing. This is effective in improving the breathing, however there is usually a decrease in the voice quality after this procedure as the voice becomes breathier and weaker.
External Airway Surgery
Tracheal Resection
When dilation of a tracheal stenosis is not effective, or is not possible, a Tracheal Resection is performed. This is a procedure in which the narrowed part of the trachea is excised (removed) and then the trachea is rejoined to restore the trachea to its normal size. This is performed through an incision in the front of the neck under general anaesthetic in the operating room. The recovery postop requires several days in hospital afterwards, and some restriction in neck movements for six weeks after the surgery.
Combined Glottic Reconstruction
When dilation or laser treatment of posterior glottic stenosis or bilateral vocal fold paralysis is not effective, or is not possible, a Combined Glottic Reconstruction may be performed. This is a procedure in which the front of the larynx is opened to allow access to the back of the larynx (posterior glottis). The back of the larynx is then split in half, and a piece of cartilage (usually harvested from the chest wall) is inserted between the two halves to enlarge the size of the airway. Part of the lining of the throat is then advanced into the larynx to cover the cartilage to improve healing. This procedure is performed through an incision in the front of the neck under general anaesthetic in the operating room. The recovery postop requires several days in hospital afterwards, and a temporary tracheostomy for several weeks after the surgery.
Cricotracheal Resection
When dilation of a subglottic stenosis is not effective, or is not possible, a Cricotracheal Resection may be performed. This is a procedure in which the narrowed part of the subglottis is excised (removed) and then the trachea is rejoined to the larynx to restore the airway to its normal size. This is performed through an incision in the front of the neck under general anaesthetic in the operating room. The recovery postop requires several days in hospital afterwards, and some restriction in neck movements for six weeks after the surgery.
Pharyngoesophagoscopy & Dilation
Narrowing of the throat (the pharynx) or of the food pipe (the oesophagus) may cause difficulty with swallowing, which is called dysphagia. The symptoms of dysphagia include sticking of solid food, choking on fluids or solid food, slow eating, regurgitation of food, weight loss and recurrent chest infections (pneumonia).
The narrowing may be caused by scar tissue from previous trauma, previous surgery, or previous radiation therapy; or it may be caused by a failure of the muscle between the throat and the oeosphagus (the cricopharyngeus muscle) to relax during swallowing.
Most people with narrowing of the pharynx or of the oesophagus are treated initially with dilation (stretching) of the area of narrowing. This is performed via the mouth using a metal instrument (called a pharyngoscope, or a laryngoscope, or an oesophagoscope) under general anaesthetic in the operating room. Therefore, the procedure is called Pharyngoesophagoscopy & Dilation.
The area of narrowing is dilated (stretched) using an airway balloon dilator. David also often injects steroid medication into areas of scarring to prolong the duration of effect, as, in most cases, these stenoses tend to recur (the narrowing forms again).
Pharyngoesophagoscopy & Botulinum Toxin Injection
Pharyngoesophagoscopy & Botulinum Toxin Injection is a surgical procedure performed via the mouth using a metal instrument (called a pharyngoscope, or a diverticuloscope, or an oesophagoscope) under general anaesthetic in the operating room.
This surgical procedure is undertaken to treat two conditions: antegrade cricopharyngeal dysfunction (also known as simply cricopharyngeal dysfunction), and retrograde cricopharyngeal dysfunction (RCPD).
Antegrade cricopharyngeal dysfunction is a condition in which the muscle (called the cricopharyngeus muscle) at the junction between the throat and the oesophagus (the tube that connects the throat to the stomach) does not open fully during swallowing. This causes a narrowing of the junction between the throat and the oesophagus that results in difficulty with swallowing, which is called dysphagia. The symptoms of dysphagia include sticking of solid food, choking on fluids or solid food, slow eating, regurgitation of food, weight loss and recurrent chest infections (pneumonia).
Retrograde cricopharyngeal dysfunction (RCPD) is a disorder of the swallowing mechanism that has only been defined recently, in 2019. The key symptom reported by people with this condition is that they are unable to belch/burp. This causes a number of other symptoms, including chest discomfort, abdominal discomfort and abdominal bloating. In RCPD the cricopharyngeus muscle, the muscle at the junction between the throat and the oesophagus (the tube that connects the throat to the stomach), does not relax properly to allow release of the air that comes up into the oesophagus (from the stomach) into the throat, and then to the outside world. Interestingly, people with RCPD do not report difficulty with swallowing their food (ie. food does not stick as it passes through the cricopharyngeus from the throat into the oesophagus).
Antegrade cricopharyngeal dysfunction may be treated with an injection of Botulinum Toxin into the cricopharyngeus muscle, which is usually carried out in conjunction with a dilation (stretching) of the muscle at the same time. The effect of Botulinum Toxin (and the dilation) is usually temporary, lasting for 3-4 months. The definitive procedure to treat cricopharyngeal dysfunction is a cricopharyngeal myotomy, a procedure in which the cricopharyngeus muscle is cut.
The treatment of RCPD is injection of Botulinum Toxin into the cricopharyngeus muscle to relax it. Although the effect of Botulinum Toxin is only temporary (usually 3-4 months), most people with RCPD only require one treatment with Botulinum toxin. It is thought this is because the period of muscle relaxation allows the body to reset the activity of the muscle, restoring its normal function. If the symptoms of RCPD return, either further Botulinum Toxin, or surgery to cut the cricopharyngeus muscle (a cricopharyngeal myotomy), may be required.
Pharyngoesophagoscopy & Botulinum Toxin Injection is a surgical procedure performed via the mouth using a metal instrument (called a pharyngoscope, or a diverticuloscope, or an oesophagoscope) under general anaesthetic in the operating room.
This surgical procedure is undertaken to treat two conditions: antegrade cricopharyngeal dysfunction (also known as simply cricopharyngeal dysfunction), and retrograde cricopharyngeal dysfunction (RCPD).
Antegrade cricopharyngeal dysfunction is a condition in which the muscle (called the cricopharyngeus muscle) at the junction between the throat and the oesophagus (the tube that connects the throat to the stomach) does not open fully during swallowing. This causes a narrowing of the junction between the throat and the oesophagus that results in difficulty with swallowing, which is called dysphagia. The symptoms of dysphagia include sticking of solid food, choking on fluids or solid food, slow eating, regurgitation of food, weight loss and recurrent chest infections (pneumonia).
Retrograde cricopharyngeal dysfunction (RCPD) is a disorder of the swallowing mechanism that has only been defined recently, in 2019. The key symptom reported by people with this condition is that they are unable to belch/burp. This causes a number of other symptoms, including chest discomfort, abdominal discomfort and abdominal bloating. In RCPD the cricopharyngeus muscle, the muscle at the junction between the throat and the oesophagus (the tube that connects the throat to the stomach), does not relax properly to allow release of the air that comes up into the oesophagus (from the stomach) into the throat, and then to the outside world. Interestingly, people with RCPD do not report difficulty with swallowing their food (ie. food does not stick as it passes through the cricopharyngeus from the throat into the oesophagus).
Antegrade cricopharyngeal dysfunction may be treated with an injection of Botulinum Toxin into the cricopharyngeus muscle, which is usually carried out in conjunction with a dilation (stretching) of the muscle at the same time. The effect of Botulinum Toxin (and the dilation) is usually temporary, lasting for 3-4 months. The definitive procedure to treat cricopharyngeal dysfunction is a cricopharyngeal myotomy, a procedure in which the cricopharyngeus muscle is cut.
The treatment of RCPD is injection of Botulinum Toxin into the cricopharyngeus muscle to relax it. Although the effect of Botulinum Toxin is only temporary (usually 3-4 months), most people with RCPD only require one treatment with Botulinum toxin. It is thought this is because the period of muscle relaxation allows the body to reset the activity of the muscle, restoring its normal function. If the symptoms of RCPD return, either further Botulinum Toxin, or surgery to cut the cricopharyngeus muscle (a cricopharyngeal myotomy), may be required.
Cricopharyngeal Myotomy
The cricopharyngeus muscle is the muscle at the junction between the throat and the oesophagus (the tube that connects the throat to the stomach). When the cricopharyngeus does not open fully during swallowing, sticking of food in the bottom of the throat may result. This is called antegrade cricopharyngeal dysfunction, or just cricopharyngeal dysfunction. Cricopharyngeal dysfunction may also be associated with a pouch (similar to a hernia) from the bottom part of the throat, referred to as either a pharyngeal pouch or a Zenker’s Diverticulum.
Cricopharyngeal dysfunction may be treated with a Botulinum Toxin injection together with dilation (stretching) of the muscle, but the definitive procedure to treat cricopharyngeal dysfunction is a cricopharyngeal myotomy, a procedure in which the cricopharyngeus muscle is cut.
A cricopharyngeal myotomy is performed in one of two ways: either through the mouth using a laser or stapler to cut the muscle (Endoscopic Cricopharyngeal Myotomy), or via an external incision in the neck (External or Open Cricopharyngeal Myotomy). Both procedures are performed under general anaesthetic in the operating room and require two days in hospital after the surgery.
Tonsillectomy
Tonsillectomy is an operation in which the tonsils are removed. It is performed under general anesthetic in a hospital.
The tonsils (more specifically referred to as the palatine tonsils) are small oval shaped collections of lymphoid tissue located on either side of the throat at the back of the mouth. They are part of the immune system and are most active in childhood.
Tonsillitis is inflammation of the tonsils and is caused by viruses or bacteria. If acute tonsillitis occurs often, or if chronic tonsillitis develops, tonsillectomy may be required.
Tonsillectomy is one of the most common operations performed for children. Adults may also need their tonsils removed.
Tonsillectomy results in medium to large sized ulcers in the lining on each side of the throat. These will fill in with healing tissue, and then scar tissue will form to heal these areas completely. This may take up to 6 weeks. One of the main complications of tonsillectomy is bleeding that may come from the areas from where the tonsils have been removed (the tonsil beds). Bleeding occurs in up to 5% of people who have their tonsils removed. If bleeding does occur, it usually happens in the first two weeks after surgery. It is usually mild, but on occasions it may be moderate to severe.
What to expect after tonsillectomy
- Pain: This is the main concern after tonsillectomy: the throat is very painful and regular pain relief is required. It usually takes about 2 days before the pain becomes significant, and the pain may continue to be moderate to severe for 10-14 days, before subsiding. Your ears may also be painful postoperatively. This is pain referred from the throat to the ear. During this time it is important to take regular pain relief.
- Nausea: After surgery nausea and vomiting may occur for two reasons: because surgery on the throat can stimulate nausea, and because some of the pain medicines may upset the stomach causing nausea.
- Difficulty Swallowing: Swallowing is usually difficult after tonsillectomy because of the pain. On rare occasions after tonsillectomy, food or fluid that is swallowed may also pass into the nose during swallowing as the function of the palate may be affected temporarily. This will resolve as the throat heals.
- Bad Breath: It is common to notice bad breath, or to have an unusual small or taste in the mouth for 2 weeks after the surgery.
- Altered Speech: Your speech may be altered temporarily after surgery because of the pain, and because the function of the palate may be affected temporarily. This will resolve as the throat heals and the palate regains its function. Your speech may also be altered if the tongue is numb or swollen.
- Tongue Numbness/Swelling and Taste Change: The tongue may be numb and/or swollen after tonsillectomy because of pressure applied to the tongue during the operation by the device (called a gag) that is used to keep the mouth open, and the tongue out of the way. A numb and/or swollen tongue may also affect your swallowing and your speech. This will improve over the first 2 weeks. The sense of taste may also be altered after tonsillectomy because of the pressure applied to the tongue, and because the taste nerves pass close to where the surgery has taken place. This will also improve with time, but this may take several weeks.
Lingual Tonsillectomy
The lingual tonsils are collections of lymphoid tissue located on the back third of the tongue, in the throat. They are not visible when looking through the mouth, unlike the palatine tonsils. The lingual tonsils are part of the immune system, but are much less active than the palatine tonsils. Lingual tonsillitis (infection of the lingual tonsils) is much less common than standard (palatine) tonsillitis. The lingual tonsils may become swollen owing to chronic low- grade infection. Swollen lingual tonsils may result in a chronic sore throat, or a sensation of a lump in the throat, or they may obstruct breathing at night when a person is asleep.
Lingual tonsillectomy is an operation in which the lingual tonsils are removed from the back of the tongue. It is performed under general anesthetic in a hospital. It is an uncommon operation, unlike standard (palatine) tonsillectomy.
Lingual tonsillectomy results in a large ulcer on the back of the tongue. After the surgery, this fills in with healing tissue, and then scar tissue will form to heal the area completely. This may take up to 6 weeks. One of the main complications of lingual tonsillectomy is bleeding that may come from the back of the tongue. If bleeding does occur, it usually happens in the first two weeks after surgery. It is usually mild, but on occasions it may be moderate to severe.
What to expect after lingual tonsillectomy
- Pain: After the surgery the tongue and throat are painful and pain relief is required. It usually takes about 2 days before the pain becomes significant, and the pain may continue to be moderate to severe for 10-14 days, before subsiding. Your ear may also be painful postoperatively. This is pain referred from the throat to the ear. During this time it is important to take regular pain relief. The type of pain relief prescribed is described below.
- Difficulty Swallowing: Swallowing is usually difficult after this surgery, not only because of pain, but also because some of the tongue has been removed. Food may stick (temporarily) in the defect, but it is easily washed out by taking a sip of fluid after a mouthful of food. This will improve as the defect heals and closes over.
- Altered Speech: The tongue may not function properly after surgery owing to postoperative swelling. This may result in an altered quality to your speech. Your speech will return to normal as the tongue heals and regains its function.
- Tongue Numbness/Swelling: The tongue may be numb and/or swollen after surgery not only because of removal of the tonsils, but also because of the pressure applied to the tongue during the operation by the laryngoscope that is used to keep the mouth open. A numb and/or swollen tongue will affect your swallowing and your speech. These will improve over the course of 2-6 weeks.
Transoral Robotic Surgery
Transoral Robotic Surgery (TORS) is a modern surgical technique to perform surgery on the upper airway via the mouth, with robotic assistance using the da Vinci System.
This minimally invasive form of surgery is mainly used to treat cancers of the throat, mouth and larynx (voicebox).
The da Vinci System is a robotic-assisted surgical device that the surgeon is in complete control of at all times. The da Vinci System allows the operating surgeon to have a three-dimensional high definition view of the operative site from inside the body. The system also allows the use of wristed instruments (that are able to bend and rotate through a greater range of motion than the human hand) inside the body. The use of this technology results in enhanced visualisation, precision and control when operating in the upper airway.
TORS is performed by a team of two surgeons: one surgeon at the system console who controls the surgical device, and one surgeon at the patient’s head who assists in the procedure. David regularly operates with his fellow TORS surgeon, Dr John Chaplin.
David completed his training in TORS in 2017 at the Hospital of the University of Pennsylvania and undertakes this type of surgery at two hospitals in Auckland: Southern Cross Brightside and Southern Cross North Harbour.
Salivary Gland Surgery: Parotidectomy
The parotid glands produce saliva which is secreted into the mouth during eating. There is a parotid gland on each side of the face, located just in front of and below the ear. A parotidectomy is a surgical procedure in which part or all of the parotid gland is removed.
What can go wrong with the parotid gland?
Swelling of the parotid gland is the most common abnormality of the parotid glands. The swelling may affect the whole gland. Causes for diffuse gland swelling include an infection of the gland, a stone in the gland blocking salivary flow, or a metabolic disorder such as diabetes. The swelling may also affect only a part of the gland (a parotid lump or mass). The most common cause of a parotid lump is a tumour (also called a neoplasm), which is an abnormal proliferation of parotid gland cells. Most parotid tumours are benign (not a cancer), but occasionally the tumours may be malignant (a cancer).
What investigations are used to evaluate parotid lumps?
A CT scan (a type of x-ray) or an ultrasound scan are sometimes used to help determine the extent of a parotid lump.
Another very important investigation is an FNA (fine needle aspirate) biopsy, a procedure in which a needle is placed into the parotid lump to collect cells from the lump. This sample is then analysed by a pathologist in the lab to help determine the cause of the lump. However even after these investigations, it is not always possible to determine what exactly the lump is.
Why are parotid lumps removed?
It is routinely recommended that all parotid lumps be removed for three main reasons:
- Even after having the investigations described above, it is not always possible to tell whether a lump is benign or malignant. Removal of the lump allows a pathologist to examine the lump and to determine exactly what it is.
- Parotid tumours (benign or malignant) may continue to grow and cause facial disfigurement.
- Some benign parotid tumours may turn into malignant tumours (cancers) if left to grow for many years.
How are parotid lumps removed?
Parotid lumps are removed by removing part or all of the parotid gland. The operation to remove part of the parotid gland is called a partial (or superficial or subtotal) parotidectomy. The operation to remove all of the parotid gland is called a total (or radical) parotidectomy.
What happens in a parotidectomy?
Removal of part or all of the parotid gland is an operation performed under general anaesthesia (the person undergoing the operation is asleep).
An incision in the skin is usually made in front of the ear and into the upper part of the neck. In some cases, the incision is made in front of the ear, then into the area behind the ear, finishing in the hairline (a facelift type incision). The skin is lifted off the parotid gland, to allow removal of the gland tissue. After the gland has been removed a plastic tube (a drain) is placed in the area where the parotid gland was found, and this tube is then passed through the skin and connected to a plastic bottle. The drain prevents the collection of blood or saliva under the skin postoperatively, and it stays in place for an average of 48 hours after the operation. Patients usually stay in hospital for 24-48 hours after the operation. The drain is often removed before discharge home, but occasionally the patient is discharged with the drain still in place, and the drain is removed at a follow up appointment.
What are the possible risks or complications of parotid surgery?
- Facial weakness: The facial nerve, which controls the muscles of facial movement, passes through the middle of the parotid gland on its way to the facial muscles. The nerve is identified during the operation and in most cases preserved, however the nerve may be injured during the surgery. If nerve injury occurs, part of the face may be weak, or the entire face may be weak (a facial palsy). If weakness does occur, in most cases it is temporary, but rarely it may be permanent.
- Numbness of the outer ear: The great auricular nerve, which provides sensation to the lower half of the ear, passes very close to, or passes over, the parotid gland. It is often affected by parotid surgery, resulting in numbness of the lower half of the ear. This numbness is often permanent.
- Bleeding: Significant blood loss during the operation is uncommon. After the operation, bleeding may occur, and a clot may collect under the skin. This is called a haematoma. If this occurs, a second brief operation is sometimes performed to remove the clot.
- Salivary drainage/collection: Sometimes the remaining parotid gland tissue may leak saliva into the tissues, which may either collect under the skin (this is called a sialocoele), or it may discharge through the incision (this is called a salivary fistula). A sialocoele is treated by placing a needle through the skin to suck out the saliva. A salivary fistula is treated with pressure dressings or with Botox injections.
- Frey’s Syndrome (also known as gustatatory sweating): After parotid surgery, some patients notice that when they eat, the cheek and temple region on the side of the operation becomes sweaty. If this sweating is troublesome, it is treated with a roll-on antiperspirant, or occasionally with Botox injections.
- Recurrence of the lump: Some tumours (even benign ones) may reappear in the parotid, sometimes many years after the original surgery. After having parotid surgery, it is important to notify your surgeon if any new lumps develop.
Salivary Gland Surgery: Submandibular Gland Excision
The submandibular glands produce saliva which is secreted into the mouth during eating. There is a submandibular gland on each side of the neck, located just below the jaw-bone (mandible).
Submandibular gland excision is a surgical procedure in which the submandibular gland is removed.
What can go wrong with the submandibular gland?
Swelling of the submandibular gland is the most common abnormality of the submandibular glands.
The swelling may affect the whole gland. Causes for diffuse gland swelling include an infection of the gland, or a stone in the gland blocking salivary flow. The swelling may also affect only a part of the gland (a submandibular lump or mass). The most common cause of a submandibular lump is a tumour (also called a neoplasm), which is an abnormal proliferation of submandibular gland cells. Submandibular tumours may be benign (not a cancer), or malignant (a cancer).
What investigations are used to evaluate submandibular lumps?
A CT scan (a type of x-ray) or an ultrasound scan are sometimes used to help determine the extent of a submandibular lump.
Another very important investigation is an FNA (fine needle aspirate) biopsy, a procedure in which a needle is placed into the submandibular lump to collect cells from the lump. This sample is then analysed by a pathologist in the lab to help determine the cause of the lump. However even after these investigations, it is not always possible to determine what exactly the lump is.
Why are submandibular lumps removed?
It is routinely recommended that all parotid lumps be removed for three main reasons:
- Even after having the investigations described above, it is not always possible to tell whether a lump is benign or malignant. Removal of the lump allows a pathologist to examine the lump and to determine exactly what it is.
- Submandibular tumours (benign or malignant) may continue to grow and cause compression of the neck.
- Some benign submandibular tumours may turn into malignant tumours (cancers) if left to grow for many years.
How are submandibular lumps removed?
Submandibular lumps are removed by removing the affected submandibular gland. This is called submandibular gland excision.
What happens in a submandibular gland excision?
Removal of the submandibular gland is an operation performed under general anaesthesia (the person undergoing the operation is asleep).
An incision in the skin is made below the submandibular gland, approximately 5cm below the lower border of the jaw-bone (mandible). The skin is lifted off the submandibular gland, to allow removal of the gland. After the gland has been removed a plastic tube (a drain) is sometimes placed in the area where the submandibular gland was found, and this tube is then passed through the skin and connected to a plastic bottle. The drain prevents the collection of blood or saliva under the skin postoperatively, and it stays in place for only one night after the operation. Patients usually stay in hospital for 24 hours after the operation. The drain is removed before discharge home.
What are the possible risks or complications of submandibular gland surgery?
- Lip weakness/asymmetry: The marginal mandibular nerve, a branch of the facial nerve, which controls the muscles moving the lip, passes over the submandibular gland on its way to the facial muscles around the lip. The nerve is identified during the operation and in most cases preserved, however the nerve may be injured during the surgery. If nerve injury occurs, the lip movements may be weak, and there may be asymmetry of the appearance of the lips. If weakness does occur, in most cases it is temporary, but rarely it may be permanent.
- Tongue numbness: The lingual nerve passes through the floor of the mouth close to the submandibular gland, to which it has a connection. The nerve is identified and preserved during surgery, but it may be injured during surgery. If nerve injury occurs the tongue will be numb on one side. If numbness does occur, in most cases it is temporary, but rarely it may be permanent.
- Tongue weakness: The hypoglossal nerve travels to the tongue muscles close to the submandibular gland. The nerve is preserved during surgery, but very rarely it may be injured during surgery. If nerve injury occurs the tongue will be weak on one side. If weakness does occur, in most cases it is temporary, but rarely it may be permanent.
- Bleeding: Significant blood loss during the operation is uncommon. After the operation, bleeding may occur, and a clot may collect under the skin. This is called a haematoma. If this occurs, a second brief operation is sometimes performed to remove the clot.
- Recurrence of the lump: Some tumours (even benign ones) may reappear in the submandibular region, sometimes many years after the original surgery. After having submandibular gland surgery, it is important to notify your surgeon if any new lumps develop.
Salivary Gland Surgery: Sublingual Gland Excision
The sublingual glands produce saliva which is secreted into the mouth during eating. There is a sublingual gland on each side of the mouth, located just inside the jaw-bone (mandible), under the tongue in the front part of the floor of the mouth.
Sublingual gland excision is a surgical procedure in which the sublingual gland is removed.
What can go wrong with the sublingual gland?
Leaking of saliva from the sublingual gland is the most common abnormality of the sublingual glands. The saliva that leaks from the gland may accumulate in the floor of the mouth under the tongue (this is called a ranula); or it may leak into the neck and accumulate below the jawline in the upper part of the side of the neck or under the chin (this is called a plunging ranula).
A lump or mass within the sublingual gland may also occur: this is usually caused by a tumour (also called a neoplasm), which is an abnormal proliferation of sublingual gland cells. Sublingual tumours may be benign (not a cancer), or malignant (a cancer).
What investigations are used to evaluate sublingual lumps?
A CT scan (a type of x-ray) or an ultrasound scan are sometimes used to help determine the extent of a sublingual lump.
Another very important investigation is an FNA (fine needle aspirate) biopsy, a procedure in which a needle is placed into the sublingual lump to collect cells from the lump. This sample is then analysed by a pathologist in the lab to help determine the cause of the lump. However even after these investigations, it is not always possible to determine what exactly the lump is.
Why are sublingual lumps removed?
It is routinely recommended that all parotid lumps be removed for three main reasons:
- Even after having the investigations described above, it is not always possible to tell whether a lump is benign or malignant. Removal of the lump allows a pathologist to examine the lump and to determine exactly what it is.
- Sublingual tumours (benign or malignant) may continue to grow and cause difficulty with swallowing or speaking.
- Some benign sublingual tumours may turn into malignant tumours (cancers) if left to grow for many years.
How are sublingual lumps removed?
Sublingual lumps are removed by removing the affected sublingual gland. This is called sublingual gland excision.
What happens in a sublingual gland excision?
Removal of the sublingual gland is an operation performed under general anaesthesia (the person undergoing the operation is asleep). This is performed through the mouth.
An incision is made in the lining of the floor of the mouth under the tongue. The lining of the mouth (called mucosa) is lifted off the sublingual gland, to allow removal of the gland.
What are the possible risks or complications of sublingual gland surgery?
Tongue numbness: The lingual nerve passes through the floor of the mouth alongside the sublingual gland. The nerve is identified and preserved during surgery, but it may be injured during surgery. If nerve injury occurs the tongue will be numb on one side. If numbness does occur, in most cases it is temporary, but rarely it may be permanent.
Submandibular gland swelling: The submandibular duct passes through the floor of the mouth alongside the sublingual gland. The duct is identified and preserved during surgery, but it may be injured during surgery. If duct injury occurs, the submandibular gland may become swollen and painful, and in some cases it may need to be removed in a separate surgery.
Bleeding: Significant blood loss during the operation is uncommon. After the operation, bleeding may occur, and a clot may collect under the tongue. This is called a haematoma. If this occurs, a second brief operation is sometimes performed to remove the clot.
Recurrence of the lump: Some tumours (even benign ones) may reappear in the sublingual region, sometimes many years after the original surgery. After having sublingual gland surgery, it is important to notify your surgeon if any new lumps develop.
The sublingual glands produce saliva which is secreted into the mouth during eating. There is a sublingual gland on each side of the mouth, located just inside the jaw-bone (mandible), under the tongue in the front part of the floor of the mouth.
Sublingual gland excision is a surgical procedure in which the sublingual gland is removed.
What can go wrong with the sublingual gland?
Leaking of saliva from the sublingual gland is the most common abnormality of the sublingual glands. The saliva that leaks from the gland may accumulate in the floor of the mouth under the tongue (this is called a ranula); or it may leak into the neck and accumulate below the jawline in the upper part of the side of the neck or under the chin (this is called a plunging ranula).
A lump or mass within the sublingual gland may also occur: this is usually caused by a tumour (also called a neoplasm), which is an abnormal proliferation of sublingual gland cells. Sublingual tumours may be benign (not a cancer), or malignant (a cancer).
What investigations are used to evaluate sublingual lumps?
A CT scan (a type of x-ray) or an ultrasound scan are sometimes used to help determine the extent of a sublingual lump.
Another very important investigation is an FNA (fine needle aspirate) biopsy, a procedure in which a needle is placed into the sublingual lump to collect cells from the lump. This sample is then analysed by a pathologist in the lab to help determine the cause of the lump. However even after these investigations, it is not always possible to determine what exactly the lump is.
Why are sublingual lumps removed?
It is routinely recommended that all parotid lumps be removed for three main reasons:
- Even after having the investigations described above, it is not always possible to tell whether a lump is benign or malignant. Removal of the lump allows a pathologist to examine the lump and to determine exactly what it is.
- Sublingual tumours (benign or malignant) may continue to grow and cause difficulty with swallowing or speaking.
- Some benign sublingual tumours may turn into malignant tumours (cancers) if left to grow for many years.
How are sublingual lumps removed?
Sublingual lumps are removed by removing the affected sublingual gland. This is called sublingual gland excision.
What happens in a sublingual gland excision?
Removal of the sublingual gland is an operation performed under general anaesthesia (the person undergoing the operation is asleep). This is performed through the mouth.
An incision is made in the lining of the floor of the mouth under the tongue. The lining of the mouth (called mucosa) is lifted off the sublingual gland, to allow removal of the gland.
What are the possible risks or complications of sublingual gland surgery?
- Tongue numbness: The lingual nerve passes through the floor of the mouth alongside the sublingual gland. The nerve is identified and preserved during surgery, but it may be injured during surgery. If nerve injury occurs the tongue will be numb on one side. If numbness does occur, in most cases it is temporary, but rarely it may be permanent.
- Submandibular gland swelling: The submandibular duct passes through the floor of the mouth alongside the sublingual gland. The duct is identified and preserved during surgery, but it may be injured during surgery. If duct injury occurs, the submandibular gland may become swollen and painful, and in some cases it may need to be removed in a separate surgery.
- Bleeding: Significant blood loss during the operation is uncommon. After the operation, bleeding may occur, and a clot may collect under the tongue. This is called a haematoma. If this occurs, a second brief operation is sometimes performed to remove the clot.
- Recurrence of the lump: Some tumours (even benign ones) may reappear in the sublingual region, sometimes many years after the original surgery. After having sublingual gland surgery, it is important to notify your surgeon if any new lumps develop.
Neck Dissection
A neck dissection is a surgical procedure in which groups (or levels) of lymph nodes are removed from one side of the neck. If lymph nodes are removed from both sides of the neck, the procedure is called a bilateral neck dissection. A neck dissection is performed to treat people with cancer in the head and neck region.
There are approximately 150 lymph nodes in each side of the neck. These lymph nodes are part of the immune system, and they filter lymphatic fluid draining from regions and organs in the head and neck. Cancer cells from a malignant tumour in the head and neck may spread through lymphatic vessels, and then become lodged in a lymph node. When cancer cells grows in a lymph node it is called a metastasis, and it has spread there from the primary (or original) tumour.
What happen in neck dissection surgery?
A neck dissection is an operation carried out under general anaesthetic. N incision is made on one (or both) side(s) of the neck. The position of the incision depends on which groups (or levels) of lymph nodes are being removed. The groups of lymph nodes that are removed depend on the location of the primary (or original) cancer in the head and neck region.
The lymph nodes are removed, taking care to preserve as many, if not all, the other structures inside the neck. However, in some cases it is necessary to remove other structures in the neck when the lymph nodes are removed, such as the internal jugular vein, the sternocleidomastoid muscle and the accessory nerve.
After the lymph nodes have been removed a plastic tube (a drain) is placed in the neck from where the nodes have been removed, and this tube is then passed through the skin and connected to a plastic bottle. The drain prevents the collection of fluid under the skin postoperatively. The drain is often removed before discharge home, but occasionally the patient is discharged with the drain still in place, and the drain is removed at a follow up appointment. Patients usually stay in hospital for 2-3 days after the operation.
What are the possible risks or complications of neck dissection surgery?
There are several risks and complications of neck dissection, and these will depend on the specific location and extent of the neck dissection surgery undertaken. The risks and complications include:
Bleeding: Significant blood loss during the operation is uncommon. After the operation, bleeding may occur, and a clot may collect under the skin in the neck. This is called a haematoma. If this occurs, a brief second operation is sometimes performed to remove the clot.
Infection: As with any surgery, infections may occur following neck dissection surgery, although these are uncommon.
Nerve injury: There are several important nerves in the neck that may be affected by neck dissection surgery. Every effort is made to identify and preserve these nerves, but they are at risk of injury during surgery. The nerves that may be affected are:
- The marginal mandibular nerve, a branch of the facial nerve, which controls the muscles moving the lip. If nerve injury occurs, the lip movements may be weak, and there may be asymmetry of the appearance of the lips. If weakness does occur, in most cases it is temporary, but rarely it may be permanent.
- The accessory nerve, which controls shoulder function and allows the arm to be raised above the shoulder and behind the back. If this nerve is injured the arm loses some range of motion, the shoulder drops lower and the shoulder may become painful.
- The hypoglossal nerve, which controls movement of the tongue. If nerve injury occurs the tongue will be weak on one side, and swallowing and speech may be affected.
- The lingual nerve, which carries sensory information from the tongue to the brain. If nerve injury occurs the tongue will be numb on one side.
- The vagus nerve, which controls the movement of the vocal cord on the same side, as well as the activity of the organs of swallowing. If nerve injury occurs, the voice may be weak and breathy after the surgery, and there may be difficulties swallowing.
Lymphatic/Chyle leak: During removal of the lymph nodes, the lymphatic vessels in the neck are disrupted. Occasionally after neck dissection surgery lymphatic fluid may leak from transected lymphatic vessels, more often from the left side of the neck. The lymphatic fluid turns a milky white colour when the patient eats normal food, owing to the presence of fats in the fluid, and is called chyle. This complication is usually managed with dietary modification and medications.
Scar: The incision used for neck dissection surgery usually heals well, especially if the incision can be placed in a pre-existing skin crease. However, in some people the scar is more obvious and may result in concerns regarding its appearance.
Numbness of the skin: There is usually some numbness of the skin of the neck and/or face after a neck dissection. Some of the numbness improves with time, but some residual numbness should be expected.
Neck stiffness or pain: Scar tissue from neck dissection surgery and/or nerve injury may cause stiffness and/or pain in the neck.
Chronic swelling of the neck (Lymphoedema): During removal of the lymph nodes, the lymphatic vessels in the neck are disrupted. This may lead to accumulation of fluid in the tissues of the neck, especially in the part of the neck above the incision, leading to swelling of the neck and a feeling of discomfort and pressure. This fluid accumulation is worsened if the person has also been treated with radiation therapy.
Poor wound healing: On rare occasions wound healing after a neck dissection may be delayed. This is more common if the person had had radiation therapy to the neck previously.
Recurrence of the cancer: Some cancers may reappear in the neck the original surgery. After having neck dissection surgery, it is important to notify the surgeon if any new lumps develop.
Thyroidectomy
The thyroid gland is a butterfly shaped gland in the bottom of the neck adjacent to the trachea and the larynx. It is composed of two halves, called lobes, which are connected by an isthmus. The thyroid gland is part of the endocrine system, and it plays a crucial role in the regulation of the body’s metabolism through the action of the thyroid hormones that the gland secretes into the bloodstream.
Thyroidectomy is a surgical procedure in which part or all of the thyroid gland is removed. If just one thyroid lobe is removed, the operation is called a hemithyroidectomy or thyroid lobectomy. If the entire thyroid gland is removed, the operation is called a total thyroidectomy.
What can go wrong with the thyroid gland?
The most common disorders of the thyroid gland that require surgery are swellings of the thyroid gland.
The swelling may affect only a part of the gland – a thyroid lump or mass, usually referred to as a thyroid nodule. The most common cause of a thyroid nodule is a benign proliferation of thyroid cells (called a benign follicular nodule). However thyroid tumours may occur, and these may be benign (not a cancer), or malignant (a cancer).
The swelling may affect the whole gland. This is called a goitre. Causes for diffuse gland enlargement include multiple thyroid nodules, caused by the abnormal growth of thyroid cells, and referred to as a multinodular goitre; inflammation of the gland; or a metabolic disorder such iodine deficiency.
What investigations are used to evaluate the thyroid gland?
An ultrasound scan, and sometimes a CT scan (a type of x-ray) too, are used to help determine the nature and extent of a thyroid swelling.
Another very important investigation is an FNA (fine needle aspirate) biopsy, a procedure in which a needle is placed into the thyroid lump using an ultrasound scan to guide the needle, to collect cells from the lump. This sample is then analysed by a pathologist in the lab to help determine the cause of the lump. However even after these investigations, it is not always possible to determine what exactly the lump is.
Why is thyroid surgery performed?
Thyroid surgery is performed for several reasons:
- A diffusely enlarged glad may cause compression of the neck causing discomfort, disfigurement, and /or difficulty with breathing and/or swallowing.
- Even after having the investigations described above, it is not always possible to tell whether a thyroid lump is benign or malignant. Removal of the lump allows a pathologist to examine the lump and to determine exactly what it is.
- Benign tumours and benign follicular nodules may continue to grow and cause difficulty with breathing or swallowing.
- Thyroid cancer is treated with surgical removal of the thyroid.
What happens in thyroidectomy?
Removal of half or all of the thyroid gland is an operation performed under general anaesthesia (the person undergoing the operation is asleep). This is performed through an incision in the lower part of the front of the neck.
The skin and strap muscles in the front part of the neck are lifted off the thyroid gland, to allow removal of one half, or the whole gland. During the surgery, care is taken to identify and preserve important structures adjacent to the thyroid gland, including the nerves to the larynx (voicebox) that control voice production and swallowing; and the small parathyroid glands that regulate the levels of calcium in the bloodstream; the trachea; and the larynx.
What are the possible risks or complications of thyroidectomy?
Voice change: It is common for the voice to be mildly hoarse or weak after the surgery, because the breathing tube that is inserted for the surgery often irritates the vocal cords. This usually improves after 1-2 weeks. However sometimes the voice may be moderately or very hoarse. This may occur if the nerves to the voice box have been injured by the surgery. Nerve injury may result in weakness or paralysis of one of both of the vocal cords. If one vocal cord is affected, then the voice is weak. If both vocal cords are affected, the voice may be weak, but more importantly, the airway may be narrowed causing breathing difficulties.
Low blood calcium levels (Hypocalcaemia): The parathyroid glands are four small glands (two on each side) that are usually located around the outside of the thyroid gland. These glands regulate the levels of calcium in the bloodstream. During thyroidectomy, care is taken to preserve the glands so that they function normally. Sometimes, following total thyroidectomy (or completion total thyroidectomy), the blood calcium levels may decrease below the normal range resulting in symptoms such as tingling sensations, cramping of the muscles and an abnormal heart rhythm. Blood tests are performed after total thyroidectomy to monitor calcium levels and if the calcium is too low, medications (calcium and Vitamin D) are prescribed to maintain the level of calcium in the blood. The parathyroids may recover their function after surgery, but occasionally medications are needed permanently to maintain the calcium levels.
Bleeding: Significant blood loss during the operation is uncommon. After the operation, bleeding may occur, and a clot may collect in the neck. This is called a haematoma. If this occurs, a second brief operation is sometimes performed to remove the clot.
Recurrence of the lump: Some tumours (even benign ones) may reappear in the neck, sometimes many years after the original surgery. After having thyroidectomy, it is important to notify your surgeon if any new lumps develop.
Is thyroid medicine needed after thyroidectomy?
After a hemithyroidectomy, thyroid medicine (thyroxine) is usually not required because the remaining half of the thyroid gland is able to maintain the appropriate levels of thyroid hormones in the blood. However, after a total thyroidectomy, there is no thyroid tissue to produce the thyroid hormones, and so it is necessary to take thyroid medicine everyday.
Thyroglossal Duct Cyst Excision
A thyroglossal duct cyst is a type of neck lump that people are born with (a congenital neck lump). These lumps are benign, contain fluid, and are usually found in the middle of the upper part of the neck near the hyoid bone which is just above the thyroid notch (Adam’s apple).
When these lumps are discovered, surgical removal (excision) is recommended to confirm the diagnosis, and to avoid complications arising from them, such as disfigurement, infection, and enlargement that may lead to compression of the airway.
What happens in Thyroglossal duct cyst excision surgery?
The operation to excise a thyroglossal duct cyst is also known as a Sistrunk procedure. In this procedure the cyst is removed as well as the middle third of the adjacent hyoid bone. Part of the hyoid bone is removed to reduce the risk of recurrence (return) of the cyst. If the hyoid bone is not removed the risk of recurrence is approximately 50%, but the risk of recurrence is only 5% when part of the hyoid bone is removed.
The operation is performed under general anaesthetic. An incision is made in the midline of the upper part of the neck over or very near to the cyst. The skin is lifted of the cyst and the cyst is removed with part of the hyoid. The muscles of the neck in this area are then sutured together before the incision is closed. Patients usually stay in hospital for 24 hours after the operation.
What are the possible risks and complications of Thyroglossal duct cyst excision surgery?
This surgery is usually a very straightforward surgery, and complications are uncommon.
Bleeding: Significant blood loss during the operation is very rare. After the operation, bleeding may occur, and a clot may collect in the neck. This is called a haematoma. If this occurs, a second brief operation is sometimes performed to remove the clot.
Recurrence of the lump: Sometimes the cysts may reappear in the neck. This is very uncommon if part of the hyoid has been removed.
Swallowing difficulties: It is common for swallowing to be uncomfortable following this surgery, but the discomfort resolves after a short period of recovery. It is very rare for this surgery to affect the swallowing long term, however this may occur owing to removal of part the hyoid and dissection of the muscles of the neck. Swallowing rehabilitation is helpful to improve this rare side effect of surgery.
Scar: The incision used for this surgery usually heals very well. However, in some people the scar is more obvious and may result in concerns regarding its appearance.
Branchial Cyst Excision
A branchial cyst is a type of neck lump that people are born with (a congenital neck lump). These lumps are benign, contain fluid, and are usually found on the side of the upper part of the neck below the angle of the jaw.
When these lumps are discovered, surgical removal (excision) is recommended to confirm the diagnosis, and to avoid complications arising from them, such as disfigurement, infection, and enlargement that may lead to compression of the airway.
What happens in Branchial cyst excision surgery?
The operation to excise a branchial cyst is performed under general anaesthetic. An incision is made in the side of the upper part of the neck over or very near to the cyst. The skin is lifted of the cyst and the cyst is removed.
After the cyst has been removed a plastic tube (a drain) is sometimes placed in the area where the branchial cyst was found, and this tube is then passed through the skin and connected to a plastic bottle. The drain prevents the collection of fluid under the skin postoperatively, and it stays in place for only one night after the operation. Patients usually stay in hospital for 24 hours after the operation. The drain is removed before discharge home.
What are the possible risks and complications of Branchial cyst excision surgery?
This surgery is usually a very straightforward surgery, and complications are uncommon.
Bleeding: Significant blood loss during the operation is very rare. After the operation, bleeding may occur, and a clot may collect in the neck. This is called a haematoma. If this occurs, a second brief operation is sometimes performed to remove the clot.
Nerve injury: Nerve injuries after branchial cyst excision surgery are rare, however, the following nerves may be affected by such surgery. If they are affected, the nerves usually recover.
- The marginal mandibular nerve, a branch of the facial nerve, which controls the muscles moving the lip. If nerve injury occurs, the lip movements may be weak, and there may be asymmetry of the appearance of the lips. If weakness does occur, in most cases it is temporary, but rarely it may be permanent.
- The accessory nerve, which controls shoulder function and allows the arm to be raised above the shoulder and behind the back. If this nerve is injured the arm loses some range of motion, the shoulder drops lower and the shoulder may become painful.
- The hypoglossal nerve, which controls movement of the tongue. If nerve injury occurs the tongue will be weak on one side, and swallowing and speech may be affected.
Scar: The incision used for this surgery usually heals very well. However, in some people the scar is more obvious and may result in concerns regarding its appearance.
Nasal Septoplasty
The nasal septum is the central supporting strut of the nose, and is composed of cartilage and bone, covered in a lining called mucosa. The septum divides the inside of the nose into two nasal cavities.
Septoplasty is an operation in which the septum is straightened. It is performed in the hospital under general anaesthetic. The most common approach for a septoplasty is a closed septoplasty, in which an incision is made in the front part of the septum on one side, just inside the nostril. Through this incision, the lining of the septum is lifted away from the septum to allow the bone and cartilage of the septum to be repositioned. Usually, a small amount of cartilage and bone is removed prior to the repositioning.
After the septum has been straightened, sutures are placed in the incision and in the deeper part of the nose, through the lining of the septum. Two small thin sheets of plastic (called splints) are then placed in each nasal cavity to support the septum as it heals. These are held in place by a single suture for two weeks, when they are removed at the first postoperative visit.
Inferior turbinate reduction surgery is usually performed at the same time as the septoplasty.
This surgery is usually performed as a day stay procedure, provided that the person having the surgery is in good general health and does not live too far away from the hospital. Regular rinsing of the nose with saline (salt water) solution is commenced two days after the surgery and the first postoperative visit occurs two weeks after the surgery.
Inferior Turbinate Reduction
The inferior turbinates are sausage shaped structures that run along the bottom part of the nasal cavity from front to back. Each turbinate is attached to the outer (or side) wall of the nasal cavity. There is one inferior turbinate in each nasal cavity. Each inferior turbinate is composed of a central bone covered by a lining (mucosa) on each side.
When the inferior turbinates became enlarged they cause nasal obstruction. Nasal sprays containing steroid may be used to reduce the size of the lining of the turbinates. However, if the nasal sprays are ineffective, then surgery may be required.
Inferior turbinate reduction is an operation in which the inferior turbinates are surgically reduced in size. It is performed in the hospital under general anaesthetic. There are two major techniques used in turbinate reduction surgery: turbinoplasty, in which the turbinate bone and the outer layer of turbinate mucosa is removed, leaving the inner layer of mucosa to cover the area from which the bone was removed; or turbinectomy, in which the entire lower part of the turbinate (bone, and both the outer and inner layers of mucosa) is removed. Both techniques have a similar effect on improving nasal airflow, but it often takes longer for the nose to heal after a partial turbinectomy.
Inferior turbinate reduction surgery may be undertaken as a sole procedure, or it may be undertaken at the same time as septoplasty surgery.
This surgery is usually performed as a day stay procedure, provided that the person having the surgery is in good general health and does not live too far away from the hospital. Regular rinsing of the nose with saline (salt water) solution is commenced two days after the surgery and the first postoperative visit occurs two weeks after the surgery.
