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Pneumococcal Vaccination is Key to Protecting Cochlear Implant Patients

Cochlear implants bring sound to thousands of people with hearing loss worldwide. People with cochlear implants are at increased risk for pneumococcal meningitis. Despite CDC recommendations that all cochlear implant patients receive pneumococcal vaccination, many patients remain unvaccinated. The American Academy of Otolaryngology – Head and Neck Surgery (AAO-HNS), in coordination with the CDC and FDA, has begun a campaign to help raise awareness about the importance of pneumococcal vaccinations for all cochlear implant patients. Pneumococcal vaccination, the “Pneumo Shot”, is recommended by CDC for all patients who have, or will receive cochlear implants.

Brochure: Pneumococcal Vaccination for Cochlear Implant Patients

© 2016 American Academy of Otolaryngology – Head and Neck Surgery

What You Should Know

  • Children with cochlear implants are more likely to get bacterial meningitis than children without cochlear implants. In addition, some children who are candidates for cochlear implants have inner ear anatomic abnormalities that may increase their risk for meningitis.
  • Because children with cochlear implants are at increased risk for pneumococcal meningitis, the Centers for Disease Control (CDC) recommends that they receive pneumococcal vaccination on the same schedule that is recommended for other groups at increased risk for invasive pneumococcal disease. Recommendations for the timing and type of pneumococcal vaccination vary with age and vaccination history and should be discussed with a health care provider.
  • The Centers for Disease Control and Prevention (CDC) has issued pneumococcal vaccination recommendations for individuals with cochlear implants. These recommendations can be viewed in detail on the CDC website.
    • Children who have cochlear implants or are candidates for cochlear implants should receive PCV13. PCV13 is now recommended routinely for all infants and children (see Table 2 in the CDC March 12, 2010 MMWR issue located at the above website for the number of doses and dosing schedule).
    • Older children with cochlear implants (from age 2 years through age 5) should receive two doses of PCV13 if they have not received any doses of PCV7 or PCV13 previously. If they have already completed the four-dose PCV7 series, they should receive one dose of PCV13 through age 71 months.
    • Children 6 through 18 years of age with cochlear implants may receive a single dose of PCV13 regardless of whether they have previously received PCV7 or the pneumococcal polysaccharide vaccine (PPSV23) (Pneumovax®).
    • In addition to receiving PCV13, children with cochlear implants should receive one dose of PPSV23 at age 2 years or older and after completing all recommended doses of PCV13.
  • The Centers for Disease Control and Prevention (CDC) has issued pneumococcal vaccination recommendations for adults with cochlear implants. These recommendations can be viewed in detail on the CDC website.
    • Adult patients (=19 yrs of age) who are candidates for a cochlear implant and those who have received a cochlear implant should be given a single dose of PCV13 followed by a PPSV23 at least 8 weeks later. A second dose of PPSV23 is recommended for those 65 years of age and older.
    • For those adults who previously have received 1 doses of PPSV23 should be given a PCV13 dose =1 year after the last PPSV23 dose was received. For those who require additional doses of PPSV23, the first such dose should be given no sooner than 8 weeks after PCV13 and at least 5 years after the most recent dose of PPSV23.
  • For both children and adults, the vaccination schedule should be completed at two weeks or more before surgery.

Additional Facts

  • According to the Food and Drug Administration (FDA), as of April 2009, approximately 188,000 people worldwide have received cochlear implants. In the United States, roughly 41,500 adults and 25,500 children have received them. In the U.S., there are 122 known reports of meningitis in patients who have received cochlear implants with 64% of these cases having occurred in children.
  • Meningitis is an infection of the fluid that surrounds the brain and spinal cord. There are two main types of meningitis, viral and bacterial. Bacterial meningitis is the more serious type and the type that has been reported in individuals with cochlear implants. The symptoms, treatment and outcomes may differ, depending on the cause of the meningitis.
  • The vaccines available in the United States that protect against most bacteria that cause meningitis are:
    • 13-valent pneumococcal conjugate (PCV13) (Prevnar 13®)
    • 23-valent pneumococcal polysaccharide (PPSV) (Pneumovax®)
    • Haemophilus influenzae type b conjugate (Hib)
    • Tetravalent (A, C, Y, W-135) meningococcal conjugate (Menactra® and Menveo®)
    • Tetravalent (A, C, Y, W-135) meningococcal polysaccharide (Menomune®)
  • Meningitis in individuals with cochlear implants is most commonly caused by the bacterium Streptococcus pneumoniae (pneumococcus). Children with cochlear implants are more likely to get pneumococcal meningitis than children without cochlear implants.
  • There is no evidence that children with cochlear implants are more likely to get meningococcal meningitis, caused by the bacterium Neisseria meningitides, than children without cochlear implants. Health care providers should follow the CDC immunization guidelines for routine meningococcal vaccination.
  • The Haemophilus influenzae type b (Hib) vaccine is not routinely recommended for those 5 years of age or older, since most older children and adults are already immune to Hib. Available information does not suggest that older children and adults with cochlear implants require the Hib vaccine. However, the Hib vaccine can be given to older children and adults who have never received it. Children less than age 5 should receive the Hib vaccine as a routine protection, according to the CDC guidelines for childhood immunizations. Most children born after 1990 have received the Hib vaccine as infants.
  • Health care providers (family physicians, pediatricians and otolaryngologists) and families should review the vaccination records of current and prospective cochlear implant recipients to ensure that all recommended vaccinations are up to date.

© 2016 American Academy of Otolaryngology – Head and Neck Surgery

The Importance of Vaccinations in Cochlear Implant Users

Bacterial meningitis is a serious infection of the brain and the fluid that surrounds the brain. Bacterial meningitis is a life-threatening infection. Individuals who have a cochlear implant are at increased risk for bacterial meningitis. Although this risk is small, it is important for children and adults with a cochlear implant to be vaccinated against the bacteria that can gain entry into the brain and commonly cause bacterial meningitis. Two types of bacteria have produced the vast majority of cases of meningitis after cochlear implantation. Steptococcus pneumoniae (“Pneumococcus”) and Haemophilus influenzae type b (“Hib”).

Cochlear implant users and their families should be aware that vaccines against pneumococcus (“pneumo” vaccine) and Hib are widely available. These vaccines strengthen the body’s defenses to protect against the common causes of bacterial meningitis. This is another reason for being sure to get vaccinated.

Follow-up Care

Cochlear implant users and their families should also be aware that vaccinations do not eliminate the risk of meningitis. Children and adults with cochlear implants who develop a middle ear infection (otitis media) or a fever of uncertain cause should seek medical treatment and monitoring until the infection resolves. Infections in a child or an adult with a cochlear implant should be taken seriously. Untreated middle ear and other infections may spread to produce meningitis.
In addition, if an ear with a cochlear implant develops a discharge from the ear canal, or produces unusual ear symptoms or a watery nasal discharge, it is important to have that ear examined by the surgeon who performed the surgery or another suitable experienced cochlear implant surgeon.

Patient Education Materials

  • Brochure: Pneumococcal Vaccination for Cochlear Implant Patients

© 2016 American Academy of Otolaryngology – Head and Neck Surgery

Snoring is a sound produced by vibration of the soft tissues of the upper airway during sleep and is indicative of increased upper airway resistance. Studies estimate that 45% of men and 30% of women snore on a regular basis. It can affect not only the snorer’s sleep but also the sleep of a spouse or other family members nearby. In fact, snoring causes many couples to sleep in separate rooms and often places strain on marriages and relationships. Recent evidence suggests that snoring may even cause thickening of the carotid arteries over time and potentially increase risk of stroke.

Snoring also may be a sign of a more serious health condition known as obstructive sleep apnea (OSA), characterized by a repetitive stopping or slowing of breathing that can occur hundreds of times through the night. Most patients who snore should receive a comprehensive sleep evaluation, by a trained physician, that often includes sleep testing either done in the home or sleep laboratory.

1) Palatal stiffening procedures

  • Palatial Implants: – Palatal implant therapy, also known as the Pillar procedure, involves the placement of three polyester implants into the soft palate under local anesthesia in the office. The implants, in conjunction with the body’s scarring response, result in stiffening of the palate, and subsequently, less vibration and flutter that causes snoring. Potential benefits of this method include ease of application, minimal discomfort, fast recovery and potentially more long-term benefit. Complications are rare but include implant extrusion requiring replacement. The primary drawback for many patients considering this option is the relatively high cost of the implants.
  • Injection Snoreplasty: – In this method, also done under local anesthesia in the office, a chemical is injected into the soft palate. The subsequent inflammation and scar tissue stiffen the palate, therefore decreasing vibration and snoring. The most commonly used agent is Sodium tetradecyl sulfate which has been used in the treatment of varicose veins. Injection snoreplasty has the advantage of lower cost than other methods but is associated with more pain and recovery time. Some patients may also require additional injection treatments to achieve optimal results.
  • Radiofrequency: – Radiofrequency treatment, also an office-based procedure performed under local anesthesia, uses heat to stiffen portions of the soft palate. Multiple treatment sessions may be required to achieve the desired results. Discomfort and recovery are generally less than injection snoreplasty but more than palatal implants. Cost of radiofrequency also usually falls in between the other two options.

2) Tonsillectomy/Adenoidectomy

Enlarged tonsils and adenoids are a common cause of snoring and sleep disruption in children. The tonsils are clusters of lymphoid tissue in the back of the throat while the adenoids are a similar mound of tissue in the back of the nose. Although less commonly a problem in adults, some adults can receive excellent resolution of snoring through removal of enlarged tonsils and/or adenoids.

As opposed to the above office-based procedures, tonsillectomy/adenoidectomy is an outpatient surgery performed in the operating room under general anesthesia. Most patients require a recovery time at home of approximately one week but may continue to experience a sore throat for two weeks. The most common complication is bleeding, often occurring over a week after the surgery. Serious bleeding is rare.

3) Nasal Surgery

Increased nasal congestion has been shown to cause or contribute to snoring. Nasal obstruction may result from many causes, including allergies, polyps, septal deviation and turbinate hypertrophy. Medical treatment options, such as a nasal steroid spray or allergy management may be helpful in some patients. Structural problems, such as a deviated septum, often benefit from surgical treatment.

One surgical option, known as radiofrequency turbinate reduction (RFTR), can often be performed in the office setting under local anesthesia. RFTR uses radiofrequency heat to shrink swollen tissues in each side of the nose. Other nasal surgeries, including septoplasty and polyp removal, are usually performed in the operating room under general anesthesia. In select patients, treatment of nasal congestion can result in improvement or resolution of snoring.

What else should I know?

There are also other available treatments such as oral appliances, nasal devices, positional therapy and a variety of over-the-counter products. Careful patient and procedure selection is critical to successful management of snoring. Talk to your ear, nose and throat doctor for a complete evaluation and to learn what treatment may be best for you.

© 2016 American Academy of Otolaryngology – Head and Neck Surgery

Tonsils and adenoids are the body’s first line of defense as part of the immune system. They “sample” bacteria and viruses that enter the body through the mouth or nose, but they sometimes become infected. At times, they become more of a liability than an asset and may even cause airway obstruction or repeated bacterial infections. Your ear, nose and throat (ENT) specialist can suggest the best treatment options.

What are tonsils and adenoids?

Tonsils and adenoids are similar to the lymph nodes or “glands” found in the neck, groin and armpits. Tonsils are the two round lumps in the back of the throat. Adenoids are high in the throat behind the nose and the roof of the mouth (soft palate) and are not visible through the mouth or nose without special instruments.

What affects tonsils and adenoids?

The two most common problems affecting the tonsils and adenoids are recurrent infections of the nose and throat, and significant enlargement that causes nasal obstruction and/or breathing, swallowing and sleep problems.

Abscesses around the tonsils, chronic tonsillitis and infections of small pockets within the tonsils that produce foul-smelling white deposits can also affect the tonsils and adenoids, making them sore and swollen. Cancers of the tonsil, while uncommon, require early diagnosis and aggressive treatment.

When should I see a doctor?

You should see your doctor when you or your child experience the common symptoms of infected or enlarged tonsils or adenoids.

Your physician will ask about problems of the ear, nose and throat and examine the head and neck. He or she may use a small mirror or a flexible lighted instrument to see these areas.

Other methods used to check tonsils and adenoids are:

  • Medical history
  • Physical examination
  • Throat cultures/Strep tests – helpful in determining infections in the throat
  • X-rays – helpful in determining the size and shape of the adenoids
  • Blood tests – helpful in diagnosing infections such as mononucleosis
  • Sleep study, or polysomnogram – helpful in determining whether sleep disturbance is occurring because of large tonsils and adenoids.

Tonsillitis and its symptoms

Tonsillitis is an infection of the tonsils. One sign is swelling of the tonsils. Other symptoms are:

  • Redder than normal tonsils
  • A white or yellow coating on the tonsils
  • A slight voice change due to swelling
  • Sore throat, sometimes accompanied by ear pain
  • Uncomfortable or painful swallowing
  • Swollen lymph nodes (glands) in the neck
  • Fever
  • Bad breath

Enlarged tonsils and/or adenoids and their symptoms

If your or your child’s adenoids are enlarged, it may be hard to breathe through the nose. If the tonsils and adenoids are enlarged, breathing during sleep may be disturbed. Other signs of adenoid and or tonsil enlargement are:

  • Breathing through the mouth instead of the nose most of the time
  • Nose sounds “blocked” when the person speaks
  • Chronic runny nose
  • Noisy breathing during the day
  • Recurrent ear infections
  • Snoring at night
  • Restlessness during sleep, pauses in breathing for a few seconds at night (may indicate sleep apnea).

How are tonsil and adenoid diseases treated?

Bacterial infections of the tonsils, especially those caused by streptococcus, are first treated with antibiotics. Removal of the tonsils (tonsillectomy) and/or adenoids (adenoidectomy) may be recommended if there are recurrent infections despite antibiotic therapy, and/or difficulty breathing due to enlarged tonsils and/or adenoids. Such obstruction to breathing causes snoring and disturbed sleep that leads to daytime sleepiness, and may even cause behavioral or school performance problems in some children.

Chronic infections of the adenoids can affect other areas such as the eustachian tube – the passage between the back of the nose and the inside of the ear. This can lead to frequent ear infections and buildup of fluid in the middle ear that may cause temporary hearing loss. Studies also find that removal of the adenoids may help some children with chronic earaches accompanied by fluid in the middle ear (otitis media with effusion).

In adults, the possibility of cancer or a tumor may be another reason for removing the tonsils and adenoids. In some patients, especially those with infectious mononucleosis, severe enlargement may obstruct the airway. For those patients, treatment with steroids (e.g., prednisone) is sometimes helpful.

How to prepare for surgery

Children

  • Talk to your child about his/her feelings and provide strong reassurance and support
  • Encourage the idea that the procedure will make him/her healthier.
  • Be with your child as much as possible before and after the surgery.
  • Tell him/her to expect a sore throat after surgery, and that medicines will be used to help the soreness.
  • Reassure your child that the operation does not remove any important parts of the body, and that he/she will not look any different afterward.
  • It may be helpful to talk about the surgery with a friend who has had a tonsillectomy or adenoidectomy.
  • Your otolaryngologist can answer questions about the surgical procedure.

Adults and children

For at least two weeks before any surgery, the patient should refrain from taking aspirin or other medications containing aspirin. (WARNING: Children should never be given aspirin because of the risk of developing Reye’s syndrome). Your doctor may ask to you to stop taking other medications that may interfere with clotting.

  • Tell your surgeon if the patient or patient’s family has had any problems with anesthesia or clotting of blood. If the patient is taking medications, has sickle cell anemia, has a bleeding disorder, is pregnant, or has concerns about the transfusion of blood, the surgeon should be informed.
  • A blood test may be required prior to surgery.
  • •A visit to the primary care doctor may be needed to make sure the patient is in good health at surgery.
  • You will be given specific instructions on when to stop eating food and drinking liquids before surgery. These instructions are extremely important, as anything in the stomach may be vomited when anesthesia is induced.

When the patient arrives at the hospital or surgery center, the anesthesiologist and nursing staff may meet with the patient and family to review the patient’s history. The patient will then be taken to the operating room and given an anesthetic. Intravenous fluids are usually given during and after surgery.

After the operation, the patient will be taken to the recovery area. Recovery room staff will observe the patient closely until discharge. Every patient is unique, and recovery time may vary.

Your ENT specialist will provide you with the details of pre-operative and post-operative care and answer your questions.

After surgery

There are several post-operative problems that may arise. These include swallowing problems, vomiting, fever, throat pain and ear pain. Occasionally, bleeding from the mouth or nose may occur after surgery. If the patient has any bleeding, your surgeon should be notified immediately. It is also important to drink liquids after surgery to avoid dehydration.

Any questions or concerns you have should be discussed openly with your surgeon.

© 2016 American Academy of Otolaryngology – Head and Neck Surgery

Obstructive sleep apnea (OSA) is a serious health condition characterized by a repetitive stopping or slowing of breathing that can occur hundreds of times during the night. This often leads to poor quality sleep and excessive daytime sleepiness. Risks of untreated sleep apnea include high blood pressure, stroke, heart disease and motor vehicle accidents. It is estimated that 1 in 5 Americans have at least mild OSA.

A variety of surgical and non-surgical options are available for the treatment of snoring and sleep apnea. Medical options include positive pressure (i.e. CPAP), oral appliances and weight loss. Many of these treatment options depend on regular, long-term adherence to be effective. In patients having difficulty with other treatments, surgical procedures for the nose and throat can be a beneficial alternative. Surgical therapy can also be effective when used as an adjunct to improve tolerance and success with CPAP or an oral appliance.

Surgical Treatments

Nose

Increased nasal congestion has been shown to cause or contribute to snoring, disrupted sleep and even sleep apnea. It is also a leading cause of failure of medical treatments for OSA, such as CPAP or an oral appliance. Nasal obstruction may result from many causes including allergies, polyps, deviated septum, enlarged adenoids and enlarged turbinates.

Medical treatment options, such as a nasal steroid spray or allergy management, may be helpful in some patients. Structural problems, such as a deviated septum, often benefit from surgical treatment. One surgical option, known as radiofrequency turbinate reduction (RFTR), can be performed in the office under local anesthesia. RFTR uses radiofrequency to shrink swollen tissues in each side of the nose.

Upper throat (palate, tonsils, uvula)

In many patients with OSA, airway narrowing and collapse occurs in the area of the soft palate (back part of the roof of the mouth), tonsils and uvula. The specific type and combination of procedures that are indicated depend on each individual’s unique anatomy and pattern of collapse. Therefore the procedure selection and surgical plan must be customized to each patient. In general, these procedures aim to enlarge and stabilize the airway in the upper portion of the throat.

The surgery is performed in an operating room under general anesthesia, either as an outpatient or with an overnight hospital stay. The recovery varies depending on the patient and the specific procedures performed. Many patients return to school/work in approximately one week and return to normal diet and activity at two weeks. Throat discomfort, particularly with swallowing, is common in the first two weeks and usually managed with medications for pain and inflammation. Risks include bleeding, swallowing problems and anesthesia complications, although serious complications are uncommon.

The tonsils and adenoids may be the sole cause of snoring and sleep apnea in some patients, particularly children. In children and in select adults with OSA and enlarged tonsils/adenoids, tonsillectomy/adenoidectomy alone can provide excellent resolution of snoring, sleep apnea and associated symptoms.

Lower throat (back of tongue and upper part of voice box)

The lower part of the throat is also a common area of airway collapse in patients with OSA. The tongue base may be larger than normal, especially in obese patients, contributing to blockage in this area. The tongue may also collapse backward during sleep as the muscles of the throat relax, particularly when some patients sleep on their back. The epiglottis, or upper part of the voice box, may also collapse and contribute to airway obstruction.

Multiple procedures are available to reduce the size of the tongue base or advance it forward out of the airway. Other procedures aim to advance and stabilize the hyoid bone which is connected to the tongue base and epiglottis. A more recent technology involves implantation of a pacemaker for the tongue (“hypoglossal nerve stimulator”) which stimulates forward contraction of the tongue during sleep. As with palatal surgery, the most appropriate type of procedure varies from one individual to another, and is primarily determined by each patient’s anatomy and pattern of obstruction.

The procedures are done under general anesthesia, often with overnight hospital observation. Recovery and risks vary depending on the procedure(s) performed, but are generally similar to procedures in the upper throat.

Skeletal procedures

For the most part, the above procedures involve surgical enlargement and stabilization inside the airway. For some patients, particularly those with developmental or structural changes of the jaw or other facial bones, surgical or orthodontic procedures on the bones of the face, jaw or hard palate (roof of the mouth) may be beneficial.

Orthodontic procedures to widen the palate (palatal or maxillary expansion) may be useful treatment options in some pediatric patients. Maxillomandibular advancement surgery includes a number of procedures designed to move the upper jaw (maxilla) and/or lower jaw (mandible) forward, thus opening the upper and/or lower airway, respectively. Although full maxillomandibular advancement surgery can provide effective enlargement and stabilization of the airway, the potential benefits must be cautiously weighed against the potential increased risks of complications, longer recovery and changes in the cosmetic appearance of the face.

What should I know before considering surgery?

Surgery is an effective and safe treatment option for many patients with snoring and sleep apnea, particularly those who are unable to use or tolerate CPAP. Proper patient and procedure selection is critical to successful surgical management of obstructive sleep apnea. Talk to your ear, nose and throat doctor for a complete evaluation and to learn what treatment may be best for you.

© 2016 American Academy of Otolaryngology – Head and Neck Surgery

What Is FNA?

Fine needle aspiration (FNA), also called fine needle biopsy, is a technique that allows a biopsy of various bumps and lumps. It allows your otolaryngologist to retrieve enough tissue for microscopic analysis and thus make an accurate diagnosis of a number of problems, such as inflammation or even cancer.

FNA is used for diagnosis in:

  • Thyroid gland
  • Neck lymph nodes
  • Neck cysts
  • Salivary glands (i.e. parotid gland, submandibular gland)
  • Inside the mouth
  • Any lump that can be felt
  • Lumps that are found on imaging tests (such as ultrasound) even if they can’t be felt

Why Is FNA Important?

A mass or lump sometimes indicates a serious problem, such as a growth or cancer*. While this is not always the case, the presence of a mass may require FNA for diagnosis. Your age, sex and habits, such as smoking and drinking, are also important factors that help in the diagnosis of a mass. Symptoms of ear pain, increased difficulty swallowing, weight loss or a history of familial thyroid disorder or of previous skin cancer (squamous cell carcinoma) may be important as well.

* When found early, most cancers in the head and neck can be cured with relatively little difficulty. Cure rates for these cancers are greatly improved if people seek medical advice as soon as possible. So play it safe. If you have a lump in your head and neck area, see your otolaryngologist right away.

What are some areas that can be biopsied in this fashion?

FNA is generally used for diagnosis in areas such as neck lymph nodes or for cysts in the neck. FNA is the most commonly performed test to determine whether thyroid nodules are benign or suspicious for malignancy. The parotid gland (the mumps gland), submandibular gland, and other areas in the neck and inside the mouth or throat can be biopsied as well. Virtually any lump or bump that can be felt (palpated) or identified by ultrasound can be biopsied using the FNA technique. Tests for infection and certain chemical substances can also be done on the material that is obtained.

How Is FNA done?

Your doctor will insert a small needle into the mass. A small amount of tissue can be drawn back into the needle using negative pressure on the syringe. Under a microscope, this tissue can be identified leading to a diagnosis. This procedure is generally accurate and frequently prevents the patient from having an open, surgical biopsy, which is more painful and costly. Local anesthesia (numbing medicine) may be used but is frequently not required. If the mass is small or difficult to feel, an ultrasound device can be used to help direct the needle into the mass. FNA is about as painful as drawing blood from the arm for laboratory testing (venipuncture). In fact, the needle used for FNA is smaller than that used for venipuncture. Although not painless, any discomfort associated with FNA is usually minimal.

What are the complications of the FNA procedure?

No medical procedure is without risks. Due to the small size of the needle, the chance of spreading a cancer or finding cancer in the needle path is very small. Other complications are rare; the most common is bleeding. If bleeding occurs at all, it is generally seen as a small bruise. Patients who take aspirin, Advil®, or blood thinners, such as Coumadin®, are more at risk to bleed. However, the risk is minimal. Infection is rarely seen. Sometimes the results of an FNA are indeterminate, leading to the need to repeat the FNA or use alternative tissue sampling techniques.

© 2016 American Academy of Otolaryngology – Head and Neck Surgery

Facial expressions allow us to interact and communicate with each other. Our appearance also has an impact on how others perceive us, so many people try to always put their “best face forward.”

Some individuals would like to improve certain aspects about their face. Others are born with facial abnormalities such as a cleft lip, a birthmark or other birth defects and desire correction. Many of us notice the effects of aging, sun damage or previous facial trauma on the face. Fortunately, many of these conditions can be corrected through procedures performed by a surgeon.

Why consider facial plastic surgery?

The range of conditions that otolaryngologists diagnose and treat are widely varied and can involve the whole face, nose, lips, ears and neck. Facial plastic surgery is a component of otolaryngology that can be divided into two categories – reconstructive and cosmetic.

Reconstructive plastic surgery is performed for patients with conditions that may be present from birth, such as birthmarks on the face, cleft lip and palate, protruding ears, and a crooked smile. Other conditions that are the result of accidents, trauma, burns or previous surgery are also corrected with this type of surgery. In addition, some reconstructive procedures are required to treat existing diseases like skin cancer.

Cosmetic facial plastic surgery is surgery performed to enhance visual appearance of the facial structures and features. Common procedures include facelifts, eye lifts, rhinoplasty, chin and cheek implants, liposuction and procedures to correct facial wrinkles. An otolaryngologist surgeon is well trained to address all of these problems.

What training is necessary?

An otolaryngologist can receive up to 15 years of college and post-graduate training in plastic surgery, concentrating on procedures that reconstruct the elements of the face.

Post-graduate training includes a year of general surgery, four years of residency in otolaryngology (disorders of the ears, nose and throat), and may also include one to two years in a fellowship dedicated to facial plastic surgery.

After passing a rigorous set of exams given by the American Board of Otolaryngology, otolaryngologists may become board-certified in the specialty of Otolaryngology – Head and Neck Surgery. Because they study the complex anatomy, physiology and pathology of the entire head and neck, these specialists (sometimes called ENTs) are uniquely qualified to perform the procedures that affect the whole face.

What kinds of problems are treated?

The following are examples of procedures:

Rhinoplasty/Septoplasty Surgery of the external and internal nose in which cartilage and bone are restructured and reshaped to improve the appearance and function of the nose.

Blepharoplasty Surgery of the upper and/or lower eyelids to improve the function and/or look of the eyes.

Rhytidectomy Surgery of the skin of the face and neck to tighten the skin and remove excess wrinkles.

Browlift Surgery to improve forehead wrinkles and droopy eyebrows.

Liposuction Surgery to remove excess fat under the chin or in the neck.

Facial implants Surgery to make certain structures of the face (cheek, lips, chin) more prominent and well defined.

Otoplasty Surgery to reshape the cartilage of the ears so they protrude less.

Skin surface procedures Surgery using lasers, chemical peels, or derma-abrasion to improve the smoothness of the skin.

Facial reconstruction Surgery to reconstruct defects in facial skin as a result of prior surgery, injury or disease. This includes reconstruction of defects resulting from cancer surgery, scar revision, repair of lacerations to the face from prior trauma, removal of birth marks, and correction of congenital abnormalities of the skull, palate or lips.

Non-surgical procedures Techniques such as chemical peels, microdermabrasion, and injectables. Injectables are medications that can be placed under the skin to improve the appearance of the face, such as BOTOX® Cosmetic, Dysport®, Restylane®, Juvéderm®, Radiesse®, Sculptra® and other fillers.

How do I find a surgeon?

The Academy can recommend a board-certified otolaryngologist in your area who has a specific interest in facial plastic surgery. A reputable surgeon will take a thorough patient history and advise you on the best procedure for you. Patients should also be cautious not to be swayed by doctors who have the latest equipment, but should instead focus on finding the provider who possesses the skills, expertise and experience necessary to choose the right treatment method for each individual.

What should you know prior to facial plastic surgery?

Your surgeon should discuss the procedure, risks, benefits, alternatives and recovery with you. Knowing what to expect will put you more at ease. You should ask how many of the particular type of procedures the surgeon has performed, and how often. You should also know what sort of preparation plans you need to make, how long the procedure will take, and any associated risks. Your surgeon should advise you about any medications you should avoid before your surgery.

Some risks might include: nausea, numbness, bleeding, blood clots, infection and adverse reactions to the anesthesia. Additionally, if you smoke, you should avoid doing so for two weeks before your surgery in order to optimize healing following your procedure.
You will also want to understand all associated costs and payment options before undergoing any procedure. Insurance will usually cover reconstructive plastic surgery, but check with your provider. If you will be paying for the procedure, find out what payment options are available and if there is a payment plan.

What will recovery be like?

Most plastic surgery will not require a long hospital stay. Depending on the extent of your surgery, some procedures can be completed on an outpatient basis, meaning you would not require a hospital stay. Other procedures may require a hospital stay overnight or for a day or two. Either way, before you are released from the hospital, your surgeon will discuss with you any special care to take while you’re recovering at home. You will be provided instructions regarding how to tend to your incision area. Permanent sutures and surgical staples will be removed in the office about a week after the procedure. Your surgeon should also explain any special diet you should follow, medications you should take or avoid, and any restriction on activities.

Following your surgery, you should generally:

  • Avoid aerobic exercise for two weeks.
  • Refrain from weight lifting and contact sports for one month.
  • Talk with your surgeon about medication to manage pain and swelling.
  • Avoid aspirin because it can cause bleeding and make bruising worse.

Most patients feel comfortable returning to work one to two weeks following their surgery, when swelling and bruising are reduced and their appearance has improved.

© 2016 American Academy of Otolaryngology – Head and Neck Surgery

By Itzhak Brook, MD, MSc

The Laryngectomee Guide has been made available on www.entnet.org for patients and physicians by author and laryngectomee, Itzhak Brook, MD, MSc. The guide provides practical information to assist laryngectomees and their caregivers in dealing with medical, dental and psychological challenges. Topics covered include the diagnosis and treatment of laryngeal cancer, side effects of radiation and chemotherapy, methods of speaking after laryngectomy, and how to care for the airway, stoma, heat and moisture exchange filter, and voice prosthesis. Also addressed are eating and swallowing issues, preventive care, use of CT and PET scans, emergency situations, anesthesia and traveling as a laryngectomee.

Itzhak Brook, MD, MSc, is an Adjunct Professor of Pediatrics at Georgetown University in Washington, DC. He earned his medical degree and completed his residency at Hebrew University, Hadassah School of Medicine, in Jerusalem and obtained his master’s degree in pediatrics from the University of Tel Aviv in Israel. He completed a fellowship in adult and pediatric infectious diseases at the University of California, Los Angeles. For 27 years, he served in the Medical Corps of the U.S. Navy. Dr. Brook is the past chairman of the Anti-infective Drug Advisory Committee of the Food and Drug Administration. He has done extensive research on anaerobic and respiratory tract infections, anthrax and infections following exposure to ionizing radiation. Dr. Brook was diagnosed with throat cancer in 2006. Two years later he had his larynx removed and currently speaks with a tracheoesophageal prosthesis. He is also the author of My Voice, a Physician’s Personal Experience with Throat Cancer.

DISCLAIMER: The American Academy of Otolaryngology – Head and Neck Surgery and its Foundation (AAO-HNS/F) is providing The Laryngectomee Guide (the Guide) for educational and informational purposes only. The guide is written from a patient’s perspective, not by an otolaryngologist, and it is not intended to provide medical or legal advice and should not be treated as such. AAO-HNS/F provides no warranty or guaranty as to the accuracy or completeness of the information provided in the Guide and is in no way responsible for its content. The book is being provided for free, and AAO-HNS/F is receiving no remuneration for making this book available. Patients should consult with their personal physicians before making any decisions about their medical care relating to laryngeal cancer or their pre- or post-surgical activities. Physicians and other providers reading this book should make independent, informed decisions about the care of their patients based on the individual facts and circumstances of each case.

© 2016 American Academy of Otolaryngology – Head and Neck Surgery

Obstructive sleep apnea (OSA) is a serious health condition characterized by a repetitive stopping or slowing of breathing that can occur hundreds of times during the night. This often leads to poor quality sleep and excessive daytime sleepiness. Risks of untreated sleep apnea include high blood pressure, stroke, heart disease and motor vehicle accidents. It is estimated that 1 in 5 Americans have at least mild OSA.

A variety of surgical and non-surgical options are available for the treatment of snoring and sleep apnea. Medical options include positive pressure (i.e. CPAP), oral appliances and weight loss. Many of these treatment options depend on regular, long-term adherence to be effective. In patients having difficulty with other treatments, surgical procedures for the nose and throat can be a beneficial alternative. Surgical therapy can also be effective when used as an adjunct to improve tolerance and success with CPAP or an oral appliance.

Surgical Treatments

Nose

Increased nasal congestion has been shown to cause or contribute to snoring, disrupted sleep and even sleep apnea. It is also a leading cause of failure of medical treatments for OSA, such as CPAP or an oral appliance. Nasal obstruction may result from many causes including allergies, polyps, deviated septum, enlarged adenoids and enlarged turbinates.

Medical treatment options, such as a nasal steroid spray or allergy management, may be helpful in some patients. Structural problems, such as a deviated septum, often benefit from surgical treatment. One surgical option, known as radiofrequency turbinate reduction (RFTR), can be performed in the office under local anesthesia. RFTR uses radiofrequency to shrink swollen tissues in each side of the nose.

Upper throat (palate, tonsils, uvula)

In many patients with OSA, airway narrowing and collapse occurs in the area of the soft palate (back part of the roof of the mouth), tonsils and uvula. The specific type and combination of procedures that are indicated depend on each individual’s unique anatomy and pattern of collapse. Therefore the procedure selection and surgical plan must be customized to each patient. In general, these procedures aim to enlarge and stabilize the airway in the upper portion of the throat.

The surgery is performed in an operating room under general anesthesia, either as an outpatient or with an overnight hospital stay. The recovery varies depending on the patient and the specific procedures performed. Many patients return to school/work in approximately one week and return to normal diet and activity at two weeks. Throat discomfort, particularly with swallowing, is common in the first two weeks and usually managed with medications for pain and inflammation. Risks include bleeding, swallowing problems and anesthesia complications, although serious complications are uncommon.

The tonsils and adenoids may be the sole cause of snoring and sleep apnea in some patients, particularly children. In children and in select adults with OSA and enlarged tonsils/adenoids, tonsillectomy/adenoidectomy alone can provide excellent resolution of snoring, sleep apnea and associated symptoms.

Lower throat (back of tongue and upper part of voice box)

The lower part of the throat is also a common area of airway collapse in patients with OSA. The tongue base may be larger than normal, especially in obese patients, contributing to blockage in this area. The tongue may also collapse backward during sleep as the muscles of the throat relax, particularly when some patients sleep on their back. The epiglottis, or upper part of the voice box, may also collapse and contribute to airway obstruction.

Multiple procedures are available to reduce the size of the tongue base or advance it forward out of the airway. Other procedures aim to advance and stabilize the hyoid bone which is connected to the tongue base and epiglottis. A more recent technology involves implantation of a pacemaker for the tongue (“hypoglossal nerve stimulator”) which stimulates forward contraction of the tongue during sleep. As with palatal surgery, the most appropriate type of procedure varies from one individual to another, and is primarily determined by each patient’s anatomy and pattern of obstruction.

The procedures are done under general anesthesia, often with overnight hospital observation. Recovery and risks vary depending on the procedure(s) performed, but are generally similar to procedures in the upper throat.

Skeletal procedures

For the most part, the above procedures involve surgical enlargement and stabilization inside the airway. For some patients, particularly those with developmental or structural changes of the jaw or other facial bones, surgical or orthodontic procedures on the bones of the face, jaw or hard palate (roof of the mouth) may be beneficial.

Orthodontic procedures to widen the palate (palatal or maxillary expansion) may be useful treatment options in some pediatric patients. Maxillomandibular advancement surgery includes a number of procedures designed to move the upper jaw (maxilla) and/or lower jaw (mandible) forward, thus opening the upper and/or lower airway, respectively. Although full maxillomandibular advancement surgery can provide effective enlargement and stabilization of the airway, the potential benefits must be cautiously weighed against the potential increased risks of complications, longer recovery and changes in the cosmetic appearance of the face.

What should I know before considering surgery?

Surgery is an effective and safe treatment option for many patients with snoring and sleep apnea, particularly those who are unable to use or tolerate CPAP. Proper patient and procedure selection is critical to successful surgical management of obstructive sleep apnea. Talk to your ear, nose and throat doctor for a complete evaluation and to learn what treatment may be best for you.

© 2016 American Academy of Otolaryngology – Head and Neck Surgery