Otolaryngology

Otolaryngology

Adult & Pediatric Ear, Nose, Throat & Sinus
Facial Plastic Surgery

Facial Plastic Surgery

Eyelid Surgery, Facial Surgery, Facial Liposuction & Rhinoplasty
Head and Neck Surgery

Head and Neck Surgery

Thyroid, Parathyroid & Salivary Gland Disorders
Skin Rejuvenation

Skin Rejuvenation

Injectables, Peels, Skin Care & Microdermabrasion

Ear, Nose and Throat

Head & Neck Surgery

HotButton HeadNeck

Facial Plastic Surgery

HotButton FacialPlasticSurgery

Request More Info

ItzhakBrookBookAd

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.

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.

Could Your Medication Be Affecting Your Voice?

Some medications including prescription, over-the-counter and herbal supplements can affect the function of your voice. If your doctor prescribes a medication that adversely affects your voice, make sure the benefit of taking the medicine outweighs the problems with your voice.

Most medications affect the voice by drying out the protective mucosal layer covering the vocal cords. Vocal cords must be well-lubricated to operate properly; if the mucosa becomes dry, speech will be more difficult. This is why hydration is an important component of vocal health.

Medications can also affect the voice by thinning blood in the body, which makes bruising or hemorrhaging of the vocal cord more likely if trauma occurs, and by causing fluid retention (edema), which enlarges the vocal cords. Medications from the following groups can adversely affect the voice:

  • Antidepressants
  • Muscle relaxants
  • Diuretics
  • Antihypertensives (blood pressure medication)
  • Antihistamines (allergy medications)
  • Anticholinergics (asthma medications)
  • High-dose Vitamin C (greater than five grams per day)
  • Other medications and associated conditions that may affect the voice include: Angiotensin-converting-enzyme (ACE) inhibitors (blood pressure medication) may induce a cough or excessive throat clearing in as many as 10 percent of patients. Coughing or excessive throat clearing can contribute to vocal cord lesions.
  • Oral contraceptives may cause fluid retention (edema) in the vocal cords because they contain estrogen.
  • Estrogen replacement therapy post-menopause may have a variable effect.
  • An inadequate level of thyroid replacement medication in patients with hypothyroidism.
  • Anticoagulants (blood thinners) may increase chances of vocal cord hemorrhage or polyp formation in response to trauma.
  • Herbal medications are not harmless and should be taken with caution. Many have unknown side effects that include voice disturbance.

NOTE: Contents of this page are based on information provided by The Center for Voice at Northwestern University.

The tonsils are two clusters of tissue located on both sides of the back of the throat. Adenoids sit high in the throat behind the nose and the roof of the mouth. Tonsils and adenoids are often removed when they become enlarged and block the upper airway, leading to breathing difficulty. They are also removed when recurrence of tonsil infections or strep throat cannot be successfully treated by antibiotics. The surgery is most often performed on children.

The procedure to remove the tonsils is called a tonsillectomy; excision of the adenoids is an adenoidectomy. Both procedures are often  performed at the same time; hence the surgery is known as a tonsillectomy and adenoidectomy, or T&A.

T&A is an outpatient surgical procedure lasting between 30 and 45 minutes and performed under general anesthesia. Normally, the young patient will remain at the hospital or clinic for several hours after surgery for observation. Children with severe obstructive sleep apnea and very young children are usually admitted overnight to the hospital for close monitoring of respiratory status. An overnight stay may also be required if there are complications such as excessive bleeding, severe vomiting or low oxygen saturation.

When the tonsillectomy patient comes home

Most children take seven to ten days to recover from the surgery. Some may recover more quickly; others can take up to two weeks for a full recovery. The following guidelines are recommended:

Drinking: The most important requirement for recovery is for the patient to drink plenty of fluids. Starting immediately after surgery, children may have fluids such as water or apple juice.   Some patients experience nausea and vomiting after the surgery. This usually occurs within the first 24 hours and resolves on its own after the effects of anesthesia wear off. Contact your physician if there are signs of dehydration (urination less than 2-3 times a day or crying without tears).

Eating: Generally, there are no food restrictions after surgery, but some physicians will recommend a soft diet during the recovery period. The sooner the child eats and chews, the quicker the recovery. Tonsillectomy patients may be reluctant to eat because of throat pain; consequently, some weight loss may occur, which is gained back after a normal diet is resumed.

Fever: A low-grade fever may be observed the night of the surgery and for a day or two afterward. Contact your physician if the fever is greater than 102º.

Activity: Activity may be increased slowly, with a return to school after normal eating and drinking resumes, pain medication is no longer required, and the child sleeps through the night. Travel on airplanes or far away from a medical facility is not recommended for two weeks following surgery.

Breathing: The parent may notice snoring and mouth breathing due to swelling in the throat. Breathing should return to normal when swelling subsides, 10-14 days after surgery.

Scabs: A scab will form where the tonsils and adenoids were removed. These scabs are thick, white and cause bad breath. This is normal. Most scabs fall off in small pieces five to ten days after surgery.

Bleeding: With the exception of small specks of blood from the nose or in the saliva, bright red blood should not be seen. If such bleeding occurs, contact your physician immediately or take your child to the emergency room.

Pain: Nearly all children undergoing a tonsillectomy/adenoidectomy will have mild to severe pain in the throat after surgery. Some may complain of an earache (so called referred pain) and a few may have pain in the jaw and neck .

Pain control: Your physician will prescribe pain medication for the young patient such as acetaminophen, ibuprofen, acetaminophen with codeine, or acetaminophen with hydrocodone. The pain medication will be in a liquid form or sometimes a rectal suppository will be recommended. Pain medication should be given as prescribed.  Contact your physician if side effects are suspected or if pain is not well-controlled. If you are troubled about any phase of your child’s recovery, contact your physician immediately.

What is laryngopharyngeal reflux (LPR)?

Food or liquids that are swallowed travel through the esophagus and into the stomach where acids help digestion. Each end of the esophagus has a sphincter, a ring of muscle, that helps keep the acidic contents of the stomach in the stomach or out of the throat. When these rings of muscle do not work properly, you may get heartburn or gastroesophageal reflux (GER). Chronic GER is often diagnosed as gastroesophageal reflux disease or GERD.

Sometimes, acidic stomach contents will reflux all the way up to the esophagus, past the ring of muscle at the top (upper esophageal sphincter or UES) and into the throat. When this happens, acidic material contacts the sensitive tissue at back of the throat and even the back of the nasal airway. This is known as laryngopharyngeal reflux or LPR.

During the first year, infants frequently spit up. This is essentially LPR because the stomach contents are refluxing into the back of the throat. However, in most infants, it is a normal occurrence caused by the immaturity of both the upper and lower esophageal sphincters, the shorter distance from the stomach to the throat, and the greater amount of time infants spend in the horizontal position. Only infants who have associated airway (breathing) or feeding problems require evaluation by a specialist. This is most critical when breathing-related symptoms are present.

What are symptoms of LPR?

There are various symptoms of LPR. Adults may be able to identify LPR as a bitter taste in the back of the throat, more commonly in the morning upon awakening, and the sensation of a “lump” or something “stuck” in the throat, which does not go away despite multiple swallowing attempts to clear the lump. Some adults may also experience a burning sensation in the throat. A more uncommon symptom is difficulty breathing, which occurs because the acidic, refluxed material comes in contact with the voice box (larynx) and causes the vocal cords to close to prevent aspiration of the material into the windpipe (trachea). This event is known as laryngospasm.

Infants and children are unable to describe sensations like adults can. Therefore, LPR is only successfully diagnosed if parents are suspicious and the child undergoes a full evaluation by a specialist such as an otolaryngologist. Airway or breathing-related problems are the most commonly seen symptoms of LPR in infants and children and can be serious. If your infant or child experiences any of the following symptoms, timely evaluation is critical.

  • Chronic cough
  • Hoarseness
  • Noisy breathing (stridor)
  • Croup
  • Reactive airway disease (asthma)
  • Sleep disordered breathing (SDB)
  • Spit up
  • Feeding difficulty
  • Turning blue (cyanosis)
  • Aspiration
  • Pauses in breathing (apnea)
  • Apparent life threatening event (ALTE)
  • Failure to thrive (a severe deficiency in growth such that an infant or child is less than five percentile compared to the expected norm)

What are the complications of LPR?

In infants and children, chronic exposure of the laryngeal structures to acidic contents may cause long term airway problems such as a narrowing of the area below the vocal cords (subglottic stenosis), hoarseness, and possibly eustachian tube dysfunction causing recurrent ear infections, or persistent middle ear fluid, and even symptoms of “sinusitis’. The direct relationship between LPR and the latter mentioned problems are currently under research investigation.

How is LPR diagnosed?

Currently, there is no good standardized test to identify LPR. If parents notice any symptoms of LPR in their child, they may wish to discuss with their pediatrician a referral to see an otolaryngologist for evaluation. An otolaryngologist may perform a flexible fiber-optic nasopharyngoscopy/laryngoscopy, which involves sliding a 2 mm scope through the infant or child’s nostril, to look directly at the voice box and related structures or a 24-hour pH monitoring of the esophagus. He or she may also decide to perform further evaluation of the child under general anesthesia. This would include looking directly at the voice box and related structures (direct laryngoscopy), a full endoscopic look at the trachea and bronchi (bronchoscopy), and an endoscopic look at the esophagus (esophagoscopy) with a possible biopsy of the esophagus to determine if esophagitis is present. LPR in infants and children remains a diagnosis of clinical judgment based on history given by the parents, the physical exam and endoscopic evaluations.

How is LPR treated?

Since LPR is an extension of GER, successful treatment of LPR is based on successful treatment of GER. In infants and children, basic recommendations may include smaller and more frequent feedings and keeping an infant in a vertical position after feeding for at least 30 minutes. A trial of medications including H2 blockers or proton pump inhibitors may be necessary. Similar to adults, those who fail medical treatment, or have diagnostic evaluations demonstrating anatomical abnormalities may require surgical intervention.