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Surgical Procedures

 

Submucosal Resection (SMR) of the Inferior Turbinate

The turbinates (inferior, middle and superior) consist of three boney shelves positioned along the side wall of the nasal cavity. The turbinates function to humidify and warm air as it passes through the nose en route to the lungs. In addition, the turbinates are the primary regulators of nasal resistance. Throughout the day the turbinates swell and shrink through a process known as the nasal cycle. Patients often notice that one side of the nose is congested and several hours later the congestion shifts to the other side – this is the nasal cycle. The inferior turbinate is the largest of the three turbinates and is responsible for the nasal cycle. Congestion during a cold, allergy attack, or congestion at night are all due to inferior turbinate swelling.

The objective of SMR of the inferior turbinates is to remove the soft, spongy inner core of the turbinate while preserving the pink lining (mucosa). I liken SMR to liposuction as they are performed in a similar fashion. The procedure is performed in the office under light oral sedation or in the operating room. Oral sedation consists of valium 1 hour before the procedure and again at the beginning of the procedure. A small endoscope attached to a camera a video system provides excellent visualization. Local anesthesia is provided by application of a topical gel with cotton pledgets followed by injection of lidocaine – similar to a dental procedure. A suction device is then used to remove the spongy inner core of the inferior turbinate. Bleeding is very minimal and nasal packing is not expected.

Recovery following SMR is mild. Patients can return to work the next day. I do not advise significant exercise or straining for 1 week. Pain is typically be managed with Tylenol or Ibuprofen alone. Saline (salt water) rinses are recommended several times a day for weeks to alleviate minor crusting at the incision site. I routinely see patients back 1-2 weeks after the procedure to inspect the nose and remove residual crusts.

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Inspire Hypoglossal Nerve Stimulator

Inspire therapy consists of a breathing sensor and a stimulation lead, powered by a small battery. Implanted during a short, outpatient procedure, Inspire therapy continuously monitors your breathing while you sleep. The system delivers mild stimulation to key airway muscles, and gently moves the tongue and other soft tissues out of the airway so you can breathe during sleep. Using the small handheld sleep remote, simply turn Inspire therapy on at night before bed and off in the morning when you wake up.

You might be a candidate for Inspire therapy if:

  • you have moderate to severe Obstructive Sleep Apnea (AHI of 20 to 65)
  • you are unable to use or get consistent benefit from CPAP
  • you are not significantly overweight
  • you are over the age of 22

Post-Operative Expectations:

Recovery time after surgery will vary from patient to patient, but you can expect some pain and swelling at the small incision sites for a few days after the implant. Based on your recovery, you may be able to go home the same day of your procedure, or your Inspire therapy-trained doctor may want to keep you overnight.

Within a few days following the procedure, you should be able to return to normal non-strenuous activities. You should avoid strenuous activities for about two weeks, or as directed by your Inspire therapy-trained doctor. A week after surgery, your doctor will examine you to make sure you are healing properly. Most patients have a full recovery within a couple of weeks.

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Uvulopalatopharyngoplasty (UPPP)

Uvulopalatopharyngoplasty or UPPP is a procedure designed to open the throat to allow improved breathing in patients with obstructive sleep apnea. The procedure is often combined with tonsillectomy. This surgery requires about a one hour general anesthesia and always requires an overnight stay in the hospital.

The post operative recovery is associated with significant amount of discomfort that is treated with a combination of steroids and oral pain medication.

The surgery involves removing the tonsils if present and trimming or reconstructing the uvula and soft palate. The tissues are then sewn together in an effort to expand the back of the throat to allow a better passage of air during sleep.

Post-Operative Expectations:

  • Reflux of fluid up into the nose with swallowing also called velopharyngeal insufficiency; this is uncommon and rarely presents a long term problem.
  • Pain occurs in all patients and usually resolves over a two to four week period. Patients can typically return to work after two weeks.
  • Some patients will have an altered sense of taste that can last for weeks to months.
  • In the immediate post-operative period both ear pain and pain upon opening the jaw are common. This can be alleviated to some degree by chewing gum.

UPPP is often done in combination with surgery at the base of the tongue or the nasal cavity to correct nasal obstruction. This is all part of a multi-level approach to treatment of sleep apnea.

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Lateral Pharyngoplasty

Lateral pharyngoplasty, also called expansion sphincteroplasty, is a variation of the traditional procedure called uvulopalatopharyngoplasty (UPPP). This procedure is often done in patients who have narrowing of the throat or webbing of the posterior arch of the palate. If the tonsils are present they are removed at the time of the procedure. Excessive tissue that forms the web is then reconfigured to expand the back of the throat. If the uvula is present it is removed or re-shaped.

Post Operative Expectations:

  • Recovery requires approximately two to four weeks. Patients can usually return to work in two to three weeks.
  • Many patients experience pain that radiates into the ear and stiffness of the jaw associated with chewing.
  • There can be an alteration in taste that may last for months.
  • Post-operative pain medications include liquid Roxicet and Lortab elixir. A topical viscous Lidocaine gel is used for pain control. To prevent thrush or a yeast infection, Nystatin swish and swallow is given. Patients are also prescribed Prednisone to help with any swelling.

This procedure is often done in conjunction with tongue base surgery. Nasal surgery, if it is performed, is usually done at the time of the sleep endoscopy.

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Lingual Tonsillectomy

Lingual tonsillectomy is performed on patients with moderate to severe obstructive sleep apnea. Patients are initially evaluated in the office and then proceed to diagnostic sleep endoscopy to confirm the site(s) of obstruction at the base of the tongue. The tissue that typically causes this collapse is called the lingual tonsil. The lingual tonsils sit on top of the base of tongue muscle and create excess volume in a tight space. The lingual tonsils are removed using the Da Vinci robot; in some cases a portion of the tongue muscle will also be removed. Patients who undergo lingual tonsillectomy have failed CPAP or other measures and are interested in surgical treatment for their problem. This procedure may be combined with tonsillectomy, uvulopalatopharyngoplasty, palatal z-plasty or lateral pharyngoplasty.

Work at the base of the tongue on a patient with obstructive sleep apnea may compromise breathing in the first 24-48 hours. Patients who undergo this procedure are admitted to the ICU overnight. The breathing tube placed at the time of surgery is typically removed in the operating room. Most patients are discharged from the hospital on the day after surgery; if a longer stay is necessary, patients are transferred to a regular hospital room where the atmosphere is more restful.

Frequent complaints after surgery include numbness of the tongue, altered taste, coated tongue and a sense of tightness at the back of the throat. These symptoms generally resolve over 3 months.

Complications can include a chipped tooth, lip abrasion, tongue weakness, and bleeding. Although very rare, compromised breathing due to swelling after surgery could require tracheostomy. The most common time for post-operative bleeding is 7-10 days after surgery; this occurs in less than 5% of patients I ask that patients not travel for 2 weeks after surgery in order to minimize the risk and allow them to receive prompt attention should they have a problem with bleeding or pain control.

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Palatal Z-Plasty

A palatal z-plasty is performed in patients with an elongated soft palate and uvula. The uvula is divided down the midline and then transferred to an area forward and laterally. This accomplishes the function of shortening the palate and eliminating the vibration of the uvula and palate. The procedure also prevents narrowing of the soft palate as it heals. It is similar in many ways to the traditional uvulopalatopharyngoplasty "UPPP". As with UPPP and lateral pharyngoplasty, this procedure is often performed in conjunction with a tonsillectomy.

Recovery typically takes two weeks. A liquid and soft diet is recommended. There is associated discomfort that is controlled with narcotic pain medications. Patients can experience ear pain which is normal. The sutures that are present will dissolve in two to three weeks.

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Partial Midline Glossectomy

Partial midline glossectomy involves the removal of a segment of muscle at the back of the tongue. When performing a lingual tonsillectomy the tongue muscle is entwined in the lingual tonsil tissue. Almost invariably, partial midline glossectomy is performed during a lingual tonsillectomy. This does not add to the post-operative recovery. The area that is being excised does not affect tongue movements or taste. The goal of removing tissue in the midline is to create a trough through which air can flow. A pre-operative x-ray helps to determine whether additional tongue muscle needs to be removed.

The side effects from partial midline glossectomy are the same as for lingual tonsillectomy. This includes pain lasting up to several weeks requiring strong pain medications.. In addition, there may be an altered sense of taste that can last for months. There may be a short period when speech may be altered. Patients also describe ear pain. Patients can expect to lose 15-20 pounds and can become dehydrated.

Patients are typically sent home with a regimen of oral liquid pain medications such as Roxicet or Roxicodone. Tablets include Percocet which can be crushed. Patients are often sent home with Dilaudid suppositories, anti-nausea medications such as Zofran and Prednisone to prevent post-operative swelling. Antibiotics are prescribed infrequently. Finally, mouth washes, such as Nystatin, are prescribed to prevent yeast infections and viscous lidocaine for topical pain management. Neurontin may be prescribed to help manage post-operative pain.

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Thyrohyoidopexy

Thyrohyoidopexy is a procedure that is performed in patients with mild to moderate obstructive sleep apnea and significant obstruction behind the tongue. This procedure pulls the tongue forward by repositioning the hyoid bone and pulling the tongue and epiglottis down and forward. The main advantage of this procedure is that it is done through an incision through the neck and can be done without operating in the throat; as a result recovery can be achieved in days rather than weeks. However, if this procedure is combined with a tonsillectomy and palatal surgery (UPPP) recovery will take 2-3 weeks

The thyrohyoidopexy does cause some swallowing difficulties, but this improves over 2-3 weeks. There is a low incidence of post-operative complications such as bleeding, wound infection, altered sense of taste or speech and swallowing problems. Done alone, this procedure allows patient to return to normal activities rapidly, however, most patients require mulit-level surgery. The extent of surgery is determined at the time of the office visit and varies depending on an individual’s anatomy.

In some cases procedures can be done in different stages; the thyrohyoidopexy is done first followed by a sleep study in three months. If there is residual sleep apnea the palate work can be done later if necessary.


The hyoid bone (above) is secured to the thyroid cartilage (voice box) with suture. This brings the tongue forward and opens the airway behind the tongue.

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Epiglottoplasty

In some cases procedures can be done in different stages; the thyrohyoidopexy is done first followed by a sleep study in three months. If there is residual sleep apnea the palate work can be done later if necessary.

In a small percentage of patients the epiglottis plays a significant role in obstructive sleep apnea. This problem is usually identified when the patient undergoes sleep endoscopy – part of the usual diagnostic workup for patients with sleep apnea. During wakefulness patients have muscle tone that prevents the epiglottis from falling in to the airway. During sleep, however, some patients will experience obstruction due to the epiglottis falling into the airway – the floppy epiglottis.

As part of Trans Oral Robotic Surgery (TORS) the epiglottis may be trimmed. It is important to preserve the protective mechanism of the epiglottis in preventing inadvertent aspiration of food, drink, and saliva. The removal of epiglottic tissue is conservative. Only the upper third of the epiglottis is removed which preserves adequate protection for the patient.

Not all patients have a "floppy" epiglottis. The problem is confirmed at the time of Sleep endoscopy. The risks of epiglottoplasty include temporary cough when eating, a sense that food sticks or hangs up at the base of the tongue that can persist for months. There is no change in voice that accompanies this procedure. In rare cases patients have experienced (food going down the wind pipe) that has required hospitalization for pneumonia and the placement of a temporary feeding tube to prevent further episodes of aspiration during the healing process.

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Drug induced sedated endoscopy (DISE) or sleep endoscopy

Sleep endoscopy was first introduced in the 1990s by Pringle et al. The technique has been slow to gain popularity in the United States, but has been practiced widely in Europe for many years. Sleep endoscopy gives surgeons the ability to directly visualize the site or sites of obstruction that contribute to airway collapse in patients with sleep apnea. Sleep endoscopy complements the overnight polysomnogram (sleep study); the overnight sleep study identifies the severity of sleep apnea, however, it fails to identify the site(s) of obstruction. For the pulmonologist who treats OSA with CPAP or BiPAP it doesn’t really matter where the obstruction occurs because PAP opens the entire airway by acting as a pneumatic splint (some would say a "leaf-blower").

For patients considering surgery, it is critical for the surgeon to know where the site of obstruction is in order to allow the surgeon in removing the correct amount of tissue.. The traditional surgery for OSA (uvulopalatopharyngoplasty –UPPP) developed in the 1980s by Fujita gained a poor reputation because it failed to address the site of obstruction at the back of the tongue. This was in the era before sleep endoscopy. Currently fewer patients undergo UPPP because sleep endoscopy identifies additional obstruction at the base of tongue or epiglottis in one third of patients. This has led to improved results for patients undergoing surgical treatment for OSA.

Sleep endoscopy is performed under twilight anesthesia in an ambulatory surgery center operating room. An anesthetist carefully monitors your breathing while the surgeon examines your airway with a fiber-optic scope very similar to the scope used during your office examination. The scope is first inserted with the patient awake; it is possible to observe the exam during this part of the procedure while the surgeon explains the findings. The patient is then made sleepy using i.v. Propofol. The exam is then repeated with the patient sedated. The findings are recorded for later review and planning for surgery. After the examination the surgeon will discuss the results with the patient and his or her family.

Associated Procedures

Many patients also complain of nasal obstruction. Nasal obstruction contributes to sleep apnea and also makes it difficult to use CPAP effectively. If indicated, correction of nasal obstruction is performed during sleep endoscopy; this may include septoplasty or radiofrequency of the turbinates.

Complications

Sleep endoscopy is a minimally invasive procedure. It involves both an awake portion, which is similar to the office exam, and a sedated portion. The patient is monitored by an anesthetist in an operating room to ensure optimal safety throughout the procedure. Complications could include nose bleed or mild sore throat; these are extremely rare. The need for intubation (breathing tube) is exceedingly rare.

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Tonsillectomy

When the tonsils are removed sutures are usually not used to close the raw area. These raw surfaces are allowed to heal from the edges. During the healing period a small amount of blood tinged mucous may be coughed or spit up. If the adenoids have been removed, there may be a small amount of bloody nasal discharge as well.

You can diminish the chances of post-operative bleeding by remaining relatively inactive for the first two post-operative weeks. Specifically, you should avoid heavy lifting, bending over, straining and any form of vigorous exercise. Adults should plan on remaining home from work for ten to fourteen days until they feel well. Children should remain home from 7-10 days. They may return to school after this period of time but are not allowed to participate in any physical activity for an additional week. For adults, it is helpful to gargle with a solution of equal parts hydrogen peroxide and water every four to six hours while awake for the first two days. This cleanses the throat and helps to prevent bleeding.

There can be a considerable amount of discomfort associated with the removal of the tonsils. Tylenol will help children through this period. Aspirin and Advil tend to promote bleeding after surgery and should be avoided. Adults may require stronger medication as may children. Your physician may prescribe a pain medication for you. Sometimes the pain from the removal of the tonsils is felt mostly in the ears. This does not mean that you are developing an ear infection. For the first few days there may be a slight to moderately elevated temperature. This is normal. A cold washcloth around the neck may help some of the discomfort. There is often a bad odor to the breath for one to two weeks following surgery. This is due to germ growth in the raw, healing surfaces.

Initially, liquids are better tolerated than solid foods. It is very important to maintain adequate intake of fluids during the post-operative period. This will keep you both well hydrated and keep the tonsil area clean. Avoid hot liquids and soups for the first few days. Cold substances are generally better tolerated and help to prevent bleeding. You may eat solid foods whenever you feel ready but the sooner you eat the better your recovery will be. For the first week after surgery we encourage patients to chew gum between meals. This helps to keep the muscles of the throat relaxed and promotes greater ease of swallowing.

As the tonsil heals, a gray, sometime white membrane forms over the raw surfaces. This later turns red. This is part of the normal healing process and does not mean that any infection exists. Sometimes, a scab will dislodge from the healing surface 2-3 weeks after surgery causing some bleeding. If this occurs gargling with peroxide solution and remaining quiet with the head elevated will help.

Should the bleeding seem excessive or persist (2 tablespoons), you should contact the operating surgeon through the office. Should the problem occur after office hours, please come to the St. Joseph Mercy Hospital emergency room where the physician in charge will evaluate you and contact our physician on call.

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Thermal Control Radio Frequency Ablation (TCRFA)

Temperature controlled radio frequency is a minimally invasive surgical procedure used to reduce tissue volume in a precise, targeted manner. Nasal TCFRA is generally recommended for patients with nasal congestion due to a mildly deviated septum and enlarged nasal turbinates, patients who experience sleep apnea but have difficulty wearing a CPAP mask, or patients requiring sinus surgery who have enlarged nasal turbinates.

You have chosen a procedure that is performed either in the office using a local anesthetic or in an operating room setting in conjunction with sleep endoscopy. If the procedure is performed in the office you may experience some mild discomfort during the procedure; however, this should be minimal. The procedure takes about 15 minutes and you will be in the office for approximately 30 minutes. This procedure is done under local anesthetic so you do not need to be accompanied by anyone to your appointment.

You may experience some but not all of these side effects:

  • Mild crusting
  • Some bleeding
  • Mild pain
  • Nasal congestion
  • Nasal drainage

Symptoms generally resolve within 7-10 days after treatment. Non-narcotic analgesic medication is generally adequate to control any pain that may result from this procedure.

You may be asked to follow up with Dr. Hoff in our office within 1-14 days for a recheck. Final results may take 6-8 weeks.

Use of saline nasal sprays may be helpful for congestion. Generally, there is no contradiction to gentle nose blowing and normal physical activity. Please follow specific post-operative instructions given to you by the doctor at the time of your visit.

If you experience increased pain, fever or unspecified bleeding, please contact the office.

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Nasal Surgery

After some nasal operations, dissolvable packing may be placed to help prevent bleeding. It is common to drain mucous and a small amount of blood for a few days. You can diminish the chances of bleeding by avoiding vigorous activity for 2 weeks. Specifically, you should avoid heavy lifting, strenuous exercise, straining, swimming, vigorous sports, airplane or traveling out of the area.

Nausea and fatigue after the operation is common. Reducing your pain medication sometimes will help. Wearing gauze squares under the front of the nose to collect drainage is recommended the first few days. They are not only convenient but reduce the need to wipe your nose repeatedly, which can make it sore. The gauze squares are not necessary after the drainage stops.

Do not blow your nose the first week. If you have to sneeze, keep your mouth open so there is not pressure through your nose. Do not drink alcohol during the healing period. Do NOT use aspirin, ibuprofen or any other medications containing these products, (Example: Motrin, Advil, Ascriptin, Panadol), as these can lead to bleeding. Use only Tylenol/Tylenol combination products or prescription pain medications. Do not take any antihistamines or decongestants.

The next day, obtain saline nasal spray from any drug store (Ocean and AYR are common brands). Spray each nostril with 4 squirts at breakfast, lunch, supper and bedtime. This cleanses the nose. Use the spray for three weeks or until no benefit. The 2nd week after surgery, you may gently blow your nose after the use of the saline spray.

You may wash your nose even though it is tender. If the front of your nose crusts, you may keep the openings lubricated with antibiotic (Bacitracin or Neosporin) ointment. There may be a temporary numbness of the front teeth after surgery. The nose contains sutures which will dissolve or fall out spontaneously. Do not be alarmed if the nose does not breathe freely for 2-3 weeks. It takes 2-6 weeks to completely heal. For several days it runs, plugs and behaves like it has a cold. Afterwards it sometimes becomes dry and filled with scabs. All of this is part of the normal healing process. If you have had cosmetic correction of a nasal deformity, there will be black and blue discoloration which will clear up over a 2 week period.

One complication is a nosebleed. It does not commonly happen but if it should, please go to the emergency room to be evaluated. Another important complication (but rare) is called septal hematoma. Bleeding into the operated tissues swells the septum until breathing is nearly totally blocked. This should be reported to your physician should you suspect this complication.

Post-operative visits are usually 2 weeks following surgery. Please call the office as soon as possible to arrange this. If you have any questions or concerns in the interim period, we will be happy to answer them for you.

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Septoplasty

Patients with chronic nasal obstruction may suffer from a deviated septum. The septum is the divider of the nose separating the right and left nasal passage; it is made of cartilage and bone. The septum can become deviated (bent) due to nasal injuries or some people can have natural curvature of the septum. It is estimated that over 25% of people have a deviated septum but only a small fraction complain of nasal obstruction.

Correction of a deviated septum is called septoplasty. Septoplastyis performed under general anesthesia. A small incision is made inside the nose allowing the surgeon to remove or reshape bent cartilage and bone. After the abnormal tissue is removed a dissolvable suture is used to close the incision. Packing of the nose is rarely necessary. Unlike cosmetic nasal surgery (rhinoplasty), septoplasty does not cause external bruising. Patients typically are discharged to home one hour after surgery is complete and follow up in the office in one to two weeks.

Care after surgery includes nasal saline rinses and analgesics such as Norco or Vicodin. Most patients return to work in one week. Final results are expected after three months, however most patients experience significant improvement after 2-3 weeks.

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