What is a congenital neck mass?

A congenital neck mass is a growth that is present at birth and slowly becomes noticeable to the patient or family. Although the neck abnormality is present since birth, the resulting lump may not appear until much later in life.

What are the types of congenital neck masses?

Congenital neck masses can take many forms. The most common congenital masses that are treated by an ear, nose, and throat specialist are:

• Branchial Cleft Anomalies (abnormalities)
• Thyroglossal duct remnants (like cysts)
• Lymphangiomas (cystic hygromas)
• Hemangiomas (blood vessel abnormalities)
• Dermoid cysts

Each of these causes will be discussed in detail below as well as Deep Neck Infections.

BRANCHIAL CLEFT ANOMALY

What are Branchial Cleft Anomalies?

Branchial cleft fistulas (tracts) and cysts (called anomalies) are found in the neck and are composed of tissue trapped in the developing neck. These anomalies appear as a soft lump or draining opening on one side of the neck. They can appear in any age group yet are very common in the first decade of life. Because these anomalies develop in the growing embryo, any tract that forms in combination with a cyst follows a fairly predictable pattern. The tracts connect the cyst to the inside of the throat at a specific area. It is important to understand this relationship so that the entire tract can be excised and will not recur.

There are three kinds of branchial cleft anomalies. A first branchial cleft anomaly (Fig. 1) is more unusual and may be involved with the nerve that moves the facial muscles (Facial nerve).

Second and third branchial anomalies are common. Fig. 2 shows how they differ by location.

If your child has been diagnosed with a branchial cleft anomaly, many times the physician will order a CT scan (cat scan). This test will allow us to identify the exact location of the mass and/or tract as well as its relation to blood vessels and nerves in the neck.

Once an anomaly has been identified, treatment consists of surgically removing the cyst before it has a chance to get infected and become an abscess. Surgery is performed under general anesthesia by making an incision over the cyst or draining area. Every effort is made to place the incision in an existing skin crease so that cosmetically the child’s scar will be minimal. Plastic surgery techniques are always used to close the incision. Branchial cleft anomalies are usually removed as an outpatient procedure. These operations usually last between one and two hours. Ear, nose and throat specialists have extensive training in surgery of the neck, making them the most qualified physicians for this type of surgery.

If the cyst has become infected (or formed an abscess) prior to removal, incision and drainage of the abscess may be necessary first, followed by treatment with antibiotics. The cyst and tract can then be safely removed at a later date.

THYROGLOSSAL DUCT REMNANTS

What are Thyroglossal Duct Cyst?

Thyroglossal duct cysts are cysts that are left over when the thyroid migrates from the base of the tongue into the neck before birth. The cyst is connected to the back of the tongue by a small tract. The cyst usually lies in the middle of the neck in front of the “Adam’s Apple” (Fig. 3).

Thyroglossal duct cysts usually show up in the first ten years of life, but may be found in older children or even adults. It is a benign cyst that usually contains mucous or even pus-like fluid. Many times, these cysts will not be evident until your child has an upper respiratory infection (cold). After which, the cyst will suddenly appear in the front of the neck. The sudden appearance or rapid enlargement of these cysts can be alarming. If a cyst is infected, many times antibiotics and/or drainage may be necessary to control the infection prior to definitive removal.

However, if the cyst appears without infection, and you wish to avoid further problems with infection, surgical removal is best performed before the cyst is ever infected.

Thyroglossal duct cysts are usually in the middle of the neck and seem to move up and down during swallowing. Because thyroid tissue may be inside the cyst, it is important to make sure that the thyroid gland has developed normally (and that not all the thyroid tissue is within the cyst). Your doctor may order an ultrasound and/or a thyroid scan to make sure the “cyst” is not the only functioning thyroid gland.

Once these tests have been completed, excision of the cyst may be performed as an outpatient procedure. This operation usually takes 45 minutes to an hour. Your child may leave the same day but will require decreased activity in the first week after surgery.

LYMPHATIC DRAINAGE ABNORMALITIES
(CYSTIC HYGROMAS)

What is a lymphangioma?

A lymphangioma is the result of an abnormal collection of lymph channels in the body. These channels usually link the disease-fighting lymph nodes together. During fetal development connections may occur causing cysts made up of these channels to grow. Large extensive collections of these are known as lymphangiomas or cystic hygromas. They grow steadily with the child and usually surround normal muscles, blood vessels, and nerves. These cysts can involve the neck, oral cavity, face and airway. They can also extend into the chest.

How are lymphangiomas recognized?

Because of their size, lymphangiomas are usually visible as a large compressible (can flatten when pushed on) mass. Those not noticed at birth are recognized before most children reach their second birthday.

Why are lymphangiomas of concern?

Lymphangiomas grow around normal muscles, blood vessels, and nerves. They may become quite extensive and cause significant cosmetic (appearance) deformities and functional disabilities. They may prevent the child from swallowing normally, speaking, or even breathing. The cysts are not cancerous. However, they continue to grow and many times cannot be completely removed without sacrificing an important normal structure.

How is a lymphangioma diagnosed and treated?

DIAGNOSIS: These lesions are first evaluated by physical examination. Magnetic Resonance imaging (MRI) is the imaging study that gives the best information regarding the extent and location of the cystic hygroma. X-rays and CT scans may also be used to help fully realize the extent of the cyst.

Once the location and extent into surrounding structures has been studied, therapy best suited for the patient can be initiated.

TREATMENT: There are generally two methods used to treat lymphangiomas:

Medical – This method utilizes medications (sclerosing agents) injected into the cyst to reduce the size of the cyst. This means that the cyst is not removed, but “scars” down on itself so that growth stops.

Surgical – This approach to treatment of a lymphangioma is excision of the cyst with a surgical procedure. *If airway involvement is present, the lymphangioma is removed as soon as it is diagnosed. Sometimes, a TRACHEOTOMY may be needed to secure the airway.

Our practice’s philosophy is to surgically remove those lesions that appear to be removable with a single operation. Many times this is done in the first few months of life. If, however, the lesion is quite extensive and places the child at risk for nerve, blood vessel, or muscle damage, or, would result in significant deformity in the appearance of the child, sclerosing agents are recommended.

HEMANGIOMA

What is a hemangioma?

A hemangioma is an abnormal growth of blood vessels that are formed before or shortly after birth. They can be very small (pinpoint) or grow to be quite large. They need to be distinguished from vascular malformations (abnormal connections between blood vessels) because treatment is different.

What do hemangiomas look like?

Hemangiomas may look like small red pimples on the skin, large bulging bluish-red masses protruding from the forehead or eyelid, or soft compressible bluish masses in the neck. Hemangiomas may also involve the breathing tube just below the voice box (subglottic area) causing noticeable breathing problems.

Hemangiomas usually start to grow larger shortly after birth (proliferative stage) reaching a peak at 18 months to 2 years of age. At that point, most hemangiomas will start to shrink (involute). This process may take several years.

How are hemangiomas diagnosed and treated?

DIAGNOSIS: Magnetic resonance imaging (MRI) is used to diagnose hemangiomas. Sometimes, a biopsy (a small amount of tissue from the lesion) is required to confirm the diagnosis.

TREATMENT: If hemangiomas are located in areas that cause the patient breathing problems (in the airway) or problems seeing (covers part of the eye), steroids may be given to shrink the mass. However, steroids only give temporary relief and therefore need to be given over long periods of time. In addition, this form of treatment has its own risks due to side effects of steroids. Should this treatment option be recommended, your physician will discuss these issues in detail with you.

If steroids are not advised, then surgical therapy is an alternative to remove or reduce the size of the hemangioma more permanently. Surgical therapy using laser has been very helpful in shrinking or excising (removing) hemangiomas.
Both the CO2 (carbon dioxide) and YAG laser are used in our practice.

DERMOID CYST

What is a dermoid cyst?

A dermoid cyst is a mass containing skin, hair, and skin glands that are trapped under the skin, usually located in a line drawn from the middle of the forehead to the bottom of the neck. An ear, nose, and throat specialist is commonly consulted to evaluate a congenital dermoid cyst located on the scalp, face, in the nose or on the neck.

How is a congenital dermoid cyst recognized?

A dermoid cyst is recognized as a small, painless swelling on the face, scalp, nose, or neck. They can range in size from 1 to 4 centimeters (about 1/2 to 3 inches) across. These cysts may need to be differentiated from other congenital neck masses, which can be done with careful physical exam. Sometimes, imaging (picture type) studies such as CT scans or MRI’s are needed. CT scans are also useful to look for any part of the dermoid cyst that may extend into the skull bone. This is especially true of nasal dermoid cysts, which look like a small hole on top of the nose, usually with a hair sticking out.

How are dermoid cysts treated?

Dermoid cysts need to be surgically removed and this is usually a simple surgical procedure. Nasal dermoid cysts, however, require more extensive evaluation looking for invasion into the skull, and may require surgical removal by an ear, nose, and throat surgeon, working with a neurosurgeon.

DEEP NECK INFECTIONS

What is a “deep neck” infection?

A “deep neck” infection refers to an infection or abscess (collection of pus) located deep under the skin near blood vessels, nerves, and muscles.

Where is the “deep neck” located?

There is a band of tissue in the neck called the cervical fascia, which divides the neck into superficial (just under the skin) and deep layers. The deep layer of the neck is then further subdivided into various spaces. A deep neck infection is an infection that is located in one of these spaces in the deep layer of the neck. Ear, Nose, and Throat surgeons are experts in the anatomy of the neck including these spaces.

Although a deep neck infection can be seen in any of the deep neck spaces, the most common spaces in which deep neck infections are found in children are:

• RETROPHARYNGEAL SPACE
  This space is located directly behind the mouth.
  The lymph nodes (infection fighting structures) that drain the ADENOIDS, SINUSES, nose, and pharynx (back of throat) are located in this space. Infections in any of these areas can result in spread of infection to these lymph nodes, resulting in lymphadenitis (infection of the lymph nodes) and abscess formation (collection of pus). The retropharyngeal lymph nodes become significantly smaller after five years of age; therefore, this infection is usually seen only in younger children.
• PERITONSILLAR SPACE
  Located in the tissue around the tonsil in the back of the throat.
  Infection in this space usually results from an untreated infection of the tonsils (TONSILLITIS). This type of infection is known as a peritonsillar abscess or quinsy (a collection of pus in the peritonsillar space) and is probably the most common type of deep neck infection. This infection can occur at any age.
• PARAPHARYNGEAL SPACE
  It is located just behind the carotid artery (delivers blood to the head), just to the side of the throat. Infections in this area are due to common upper respiratory infections that spread to the lymph nodes located in this space. If an infection in this area remains untreated, the neck swells and the child stops moving the neck, indicating pain.
• SUBMANDIBULAR SPACE
  This space is located under the jaw on each side. Infection in this space is usually the result of a dental infection and is known as Ludwig’s angina. It is more commonly seen in adolescents, but can also occur in younger children.

What causes a deep neck infection?

In children, deep neck space infections are usually caused by more common infections, such as dental abscesses, tonsillitis, or respiratory infections that are located “above” these spaces that spread into these deep spaces by the lymphatic system (system that drains fluid in the body).

Lymph nodes (contain disease fighting cells) in these spaces then become infected (lymphadenitis).

Additionally, bacteria can be directly introduced to a deep neck space by trauma affecting the area (more commonly seen in adults).
Finally, an infection from one deep space may spread to another deep space directly.

What are the symptoms of a deep neck infection?

Some of the more common symptoms of a deep neck infection include: Decreased ability to move the neck, asymmetry of the neck and back of the throat, difficulty or pain when swallowing, drooling, sick appearance, fever, and swelling in the neck, under the jaw, or on the face. Difficult or fast breathing may also be noted if airway involvement has occurred.

What are the complications of a deep neck infection?

The complications of deep neck infections can be life threatening; therefore, early detection and treatment are of extreme importance.
Some of these complications include:

• Airway obstruction -probably the most serious initial complication; a deep neck infection can create swelling that pushes in on the airway causing partial or complete obstruction (blockage)
• Spread of the infection – deep neck infections can spread to other deep neck spaces, as well as the mediastinum (middle chest cavity), lungs (empyema-pus in the lungs), bloodstream (sepsis), and bones (osteomyelitis)
• Thrombus (clot) formation in arteries and veins of the neck
• Nerve involvement - the nerves which affect vocal cord movement, eyelid closure, sweating, and pupil constriction may also be pressed upon causing nerve dysfunction

How is a deep neck infection evaluated?

Because the infection is only noted by swelling in the neck a careful history and physical examination is important when suspecting a deep neck infection.

Blood tests useful in the evaluation of a deep neck infection include blood counts (for signs of infection), chemistry profiles (to check for lack of fluid intake), and blood cultures (to check if the infection has spread to the blood).

X-rays of the neck, teeth, and chest may also be indicated depending on the type of deep neck infection suspected.

CT scans are the standard of care (test of choice) when evaluating the extent of a deep neck space infection. They give very accurate pictures of the infection’s location, which is especially useful if surgical drainage of the infection is required.

How is a deep neck infection treated?

Because of the immediate threat of airway obstruction, most deep neck infections require hospitalization. When the airway is narrowed, an endotracheal (breathing tube passed through the mouth) or nasotracheal (breathing tube passed through the nose) tube may be placed to hold open the airway until the infection can be treated. In severe cases, when a breathing tube cannot be inserted, a TRACHEOTOMY may be temporarily required.

Most patients will have a history of decreased fluid and food intake, therefore fluids given by vein will usually be required.

All patients with deep neck infections are started on antibiotics given by vein. In a select group of patients, careful hospital observation and antibiotics may be enough to treat the infection. However, surgical drainage is required in some cases. Please see DRAINAGE OF NECK ABSCESSES for details.

When is an ear, nose, and throat specialist involved in the treatment of a deep neck abscess?

Because airway obstruction is always a concern with a deep neck infection, an ear, nose and throat specialist is usually consulted immediately to help manage the airway and determine whether surgical therapy is needed.

Video stroboscopy involves looking at the voice box (larynx) using a rapidly flashing light (strobe light) that, in effect, allows us to view the VOCAL CORDS moving in “slow motion”. In this way, the shape, vibration, and movement of the vocal cords in the voice box can be observed and recorded.

What are the indications for video stroboscopy?

Video stroboscopy is indicated in the evaluation of problems of the voice, such as HOARSENESS. The slow motion effect allows us to see problems in the motion of the vocal cords or how nodules or other growths are affecting the way the vocal cords move together (to make sound). Because the results can be recorded, it is also useful to evaluate progress during treatment of voice disorders. Evaluation of the voice box is also usually necessary prior to voice or speech therapy.

What is involved with video stroboscopy?

Video stroboscopy is a painless procedure; therefore, it requires no sedation (sleepy medication). A nasal spray and gel-like medicine is placed in the nose to allow a flexible tube (scope) with a camera to be placed without pain. You will notice however, that your child will probably find that the procedure feels “weird”. A machine makes a flashing light (strobe) match your child’s voice frequency while the doctor looks through the flexible camera. This rapidly flashing light creates the effect of the vocal cords opening and closing in “slow motion”; the vocal cords are actually still moving normally. The patient is then instructed to say different sounds.

Specialized treatment can then be designed based on any abnormalities seen with vocal cord movement. As these pictures can be stored on a computer database, they are useful to compare to later videos to document improvement during treatment.

The entire procedure is done in an office setting and is completed in about 1/2 hour.

Vocal cord surgery is a general name for many different types of procedures that can be performed on the vocal cords.

What are the indications for vocal cord surgery?

Vocal Cord surgery is performed when the vocal cords have growths, such as, polyps, tumors, or other masses that need to be removed for biopsy or to improve function. The child will usually exhibit a hoarse or raspy voice.

Vocal Cord surgery is also indicated to normalize vocal cord functioning when the vocal cords are scarred from various causes, paralyzed, or are otherwise abnormal. These conditions may interfere with the complete opening and/or closing of the vocal cords, which is necessary for normal speech and breathing.

Please see HOARSENESS and VOCAL CORD DISORDERS for more information.

How is vocal cord surgery performed?

Surgery on the vocal cords can be performed either directly in an open surgical approach (making an incision in the neck) or indirectly through an endoscopic approach (through a tube inserted into the mouth and throat).
Either procedure is performed under general anesthesia (the patient is fully asleep).

An open surgical approach is most often performed after trauma or fracture of the larynx (upper front of neck) has occurred. Please see REPAIR OF FACIAL AND NECK TRAUMATIC INJURIES in “Surgeries We Perform”.

Although the open surgical approach allows somewhat better control of the vocal cords during the procedure, the endoscopic approach may be more successful in restoring more normal voice sound. The endoscopic approach also has the advantage of allowing extremely close observation of the vocal cords, therefore resulting in a precise and accurate cut or removal of tissue. However, not all surgeries can be performed endoscopically. Be sure to discuss this option with your doctor.

Recovery after either an open or endoscopic approach includes minimizing damage to the larynx during surgery, as well as reducing inflammation after the surgery. Therefore, your surgeon will recommend the procedure he/she feels will minimize these complications.

What is involved with endoscopic vocal cord surgery?

Endoscopic vocal cord surgery is basically MICROLARYNGOSCOPY (magnified examination of the vocal cords) in addition to a corrective procedure performed on the vocal cords.

As mentioned above, this surgery is performed with the patient under general anesthesia (fully asleep). The patient is lying on the back and a laryngoscope is inserted in the mouth to hold down the tongue and visualize the vocal cords. A special telescope or operating microscope is used to get very close and detailed views of the vocal cords and surrounding areas.

There are many different methods used to correct vocal cord abnormalities. These can include using forceps (like tweezers) to hold a bump or nodule and small scissors or the CO2 laser (see below) may be used to remove it. Powered instruments may also be used to remove lesions. These rotating blades remove growths such as papillomas with very little damage to normal tissue.

Defects on the vocal cords or surrounding areas may be repaired by injections, flaps of tissue, or grafts depending on the size of the defect.

The surgery itself usually lasts about an hour, but is highly variable. Removal of nodules or bumps or more simple reconstructive procedures may not require an overnight stay in the hospital. More complex procedures may require a hospital stay.

What is the CO2 laser?

Laser stands for “light amplification by stimulated emission of radiation”. The CO2 laser device increases the intensity of light waves using CO2 (carbon dioxide) and concentrates them in an intense, penetrating beam of light. This is similar in a way to using a magnifying glass to concentrate the sun’s rays; the “concentrated” sun rays underneath the magnifying glass get hot enough to burn paper for example. Similarly, the CO2 laser beam can be used to very accurately “burn off” areas of tissue that need to be removed, (vaporized).

Why is the CO2 laser used in vocal cord surgery?

The CO2 laser can be passed through the glass of the operating microscope, allowing for very accurate placement of the laser beam on the vocal cords. This method of tissue removal is much more precise than surgical scissors, and results in less bleeding and inflammation to the surrounding tissues. As mentioned previously, the less traumatic the surgical procedure, the more favorable the outcome, including faster recovery.

What are the risks of using the CO2 laser?

Although the laser can precisely vaporize the desired tissue, it can also accidentally burn basically anything else it may come in contact with. Therefore, safety precautions have been made to avoid this complication. These safety precautions include protective eye gear for both the patient and the operating team. A wet cloth may also be placed over the patient’s face and eyes. Also, as the breathing tube can catch on fire, these surgeries are usually performed without a breathing tube in place while the laser is in use. In addition, the lowest amount of oxygen needed is used during the procedure.

What are the risks and complications of vocal cord surgery?

The risks with the use of the CO2 laser are described above. The short-term risks of vocal cord surgery in general include chipped teeth (protective teeth guards are used during surgery to help prevent this), bleeding, breathing difficulties, hoarseness, change in voice quality, or infection.

Long term risks include a less than desired outcome in regaining normal voice or scarring from the surgery that may need additional surgical repair in the future.
Your surgeon will discuss these with you in detail.

What is involved with recovery after vocal cord surgery?

Recovery after vocal cord surgery is dependent on the surgical procedure, as well as how well inflammation and swelling are controlled after the surgery. Your surgeon will give you guidelines on how to start reusing your voice. It is important to follow to these guidelines and keep all recommended follow up appointments to regain optimal vocal cord function.

What are Tympanostomy Tubes (“Tubes”)?

Tympanostomy tubes are small plastic or silastic tubes that are inserted into the ear drum (tympanic membrane) to help ventilate the ear and prevent fluid from building up (OTITIS MEDIA WITH EFFUSION). In this way, tubes help prevent infections in the ear (OTITIS MEDIA). These tubes allow the pressure in the middle ear to be equal to the pressure outside the ear. This is why they are sometimes called PE tubes or “pressure equalization” tubes.

When are tubes a consideration?

Tympanostomy tubes may be suggested when your child’s ear infection has failed to improve with antibiotics or has fluid which will not clear after an appropriate length of time. Tubes are especially helpful in reversing the hearing loss due to fluid trapped behind the ear drum.

What is involved with Tympanostomy tube placement?

Placement of tubes occurs through the ear canal under a brief (five to ten minutes) general anesthetic, and rarely requires a blood test or IV. A tiny hole (myringotomy) is made in the eardrum, through which fluid is suctioned. Then a tiny tube (the pressure equalizing or PE tube) is placed in the hole allowing air to enter the middle ear. The procedure is painless and allows your child to resume normal activity upon leaving the hospital.

Tubes usually fall out of the ear (as the ear drum grows) within one to two years unless specified by your doctor.

Frequently Asked Questions

1. Do tubes cause scarring of the ear drum?The tubes selected for use in this practice are unlikely to cause changes in the ear drum. However, if ear drum scarring occurs due to tubes or repeated infection, this rarely causes hearing loss.
2. Do the tubes ever fall in the ear instead of out?Very rarely, tubes migrate into the middle ear instead of out and into the ear canal. They can be easily retrieved under a brief anesthetic and the ear drum patched. In some instances, your physician may recommend leaving the tube alone.
3. Can my child reach the tube?No, the ear drum (and tube) cannot be reached without a long narrow instrument.
4. When the tube falls out, is there a hole left in the ear drum?The ear drum heals as the tube is pushed out. Very rarely, the ear drum does not heal completely, leaving a hole. This can be repaired by “patching” the ear drum, a common and highly successful procedure.
5. Do tubes cause drainage?No. Once tubes are placed, the ear should not drain except in the first three days after surgery. If drainage occurs, this is usually the result of a cold, sinus infection, adenoid infection, or rarely, a mastoid infection.
6. Will my child need a second set of tubes?Generally, no. About 20 percent of all children who get tympanostomy tubes in the first place need a second set. Risk factors include: infection starting before six months of age, adenoid disease, immune system problems, cleft palate and sinusitis.
7. Are there any restrictions involved after the tubes are placed in my child?Diving should be avoided while the tubes remain in the ears. In addition, ear plugs or ear putty will be recommended if the child lies with ears submerged in bath water, swims deeper than 18 inches, or swims in the Gulf or lake water.

A tympanoplasty is a surgical procedure that repairs or reconstructs the eardrum (tympanic membrane) to help restore normal hearing. This procedure may also involve repair or reconstruction of the small bones behind the tympanic membrane (ossiculoplasty) if needed. Both the eardrum and middle ear bones (ossicles) need to function well together for normal hearing to occur.

What are the indications for a tympanoplasty?

This procedure is usually not performed (or needed) in children under four years of age. A tympanoplasty is recommended when the eardrum is torn (perforated), sunken in (atelectatic), or otherwise abnormal and associated with hearing loss. Abnormalities of the ear drum and middle ear bones can occur through injury, OTITIS MEDIA, congenital (at birth) deformities, or chronic ear conditions such as a CHOLESTEATOMA.

How successful is tympanoplasty in restoring normal hearing?

Return to a normal range of hearing after tympanoplasty is dependent upon the extent of the abnormality. Surgeries that involve repair of the eardrum only usually have a success rate of 85-90%. A second operation may be necessary in some cases if the hearing is not restored to an acceptable level.

Are there any other options aside from tympanoplasty?

Tympanoplasty in most cases is an elective procedure, meaning that it can be scheduled whenever the patient is ready to have it done. Another option instead of this procedure includes the use of a hearing aid. When the tympanic membrane has a hole (perforation) in it, earplugs are usually recommended to protect the middle ear from infection. In a few cases, such as a significant infection or a CHOLESTEATOMA, this procedure may prevent more significant damage to the ear and the surgery may need to be performed more urgently.

What is done in preparation for a tympanoplasty?

Usually other ear, nose, and throat conditions are treated before a tympanoplasty is considered. For example, if an ADENOIDECTOMY is indicated, this surgery is usually completed before tympanoplasty.

OTITIS MEDIA of any type should not be present at the time of surgery, as infections in the ear makes the operation much more difficult and may ruin the reconstruction. If your surgeon has suggested certain medications prior to surgery, these should be done without exception to ensure a successful outcome.

A hearing test is performed to document any hearing deficiency. The more significant the hearing loss, the sooner the procedure should be performed. The eardrum will also be examined before surgery using a special operating microscope.

What is involved with a tympanoplasty?

A tympanoplasty is performed with the patient fully asleep (under general anesthesia). A surgical cut (incision) is usually made behind the ear, the ear is moved forward, and the eardrum is then carefully exposed. The eardrum is then lifted up (tympanotomy) so that the inside of the ear (middle ear) can be examined. If there is a hole in the eardrum, it is cleaned (debrided) and the abnormal area can be cut away. A piece of fascia (tissue under the skin) from the temporalis muscle (behind the ear) is then cut and placed under the hole in the ear drum to create a new intact ear drum. This tissue is called a graft. The graft allows your child’s normal eardrum skin to grow across the hole.

If needed, reconstruction of the middle ear bones (ossiculoplasty) or CHOLESTEATOMA removal may also be performed at this time.

This surgery usually requires an overnight hospital stay. The child has a dressing (large bandage) over the surgical site. This is removed the next morning and the patient is discharged home. Occasionally, in older children, or those undergoing a less involved procedure, same-day surgery is possible. Eardrops may be prescribed after discharge.

The most important part of this surgery for the parent is your part in restricting activity as outlined by your surgeon. By following these instructions very closely, you can make sure your child’s result is the best it can be. Please refer to written post-operative instructions in your surgical packet or on this web site.

What are the risks and complications of a tympanoplasty?

Because this surgery takes place in and around the ear, there are special risks for this surgery in addition to the usual risks of infection and bleeding. Because each child’s situation is different, your surgeon will relate to you just how likely these complications are to occur.

HEARING LOSS – A tympanoplasty is performed to help restore normal hearing. However, some hearing loss (more common with ossiculoplasty) may still be present after the procedure. An operation is termed successful if the hearing is restored within 10-15 decibels of normal.

FACIAL NERVE INJURY AND PARALYSIS - Because the facial nerve runs close to the surgical site, injury although uncommon, can occur. This may result in temporary facial muscle weakness and/or loss of taste on one side of the tongue.

DIZZINESS – This complication after surgery is rare and is more likely to occur when MASTOIDECTOMY is performed for CHOLESTEATOMA when the cholesteatoma has eroded the balance system.

LOSS OF GRAFT – Because this operation involves grafting using your child’s own tissue, very rarely this tissue will not survive long enough for the hole in the eardrum to heal completely. In this case, another operation may be necessary. Because the success rate of this surgery is so high, re-operation also has a very high success rate.

Your surgeon will schedule follow up visits after surgery to look at the eardrum, to check hearing and to ensure normal healing. It is important to keep these appointments, as they will help to maximize the success of the procedure.

This topic will present in more detail the types of procedures most commonly performed by an ear, nose and throat surgeon that aid in the repair of facial and neck injuries.

NOSE

One of the most common injuries to the nose is a nasal fracture (“broken nose”). This usually is caused by blunt trauma to the nose (e.g. a baseball, elbow, etc.). Swelling, bruising and bleeding may occur. A nasal fracture is usually repaired by a closed reduction. This means that the nose is relocated into a normal position without an incision. IMPORTANT: Often times it is difficult to evaluate a nasal fracture immediately after the injury due to the swelling that is present. Therefore, an ear, nose and throat specialist should do an evaluation about 4 to 5 days after the injury. Repair is best done within seven to ten days of injury.

It is important to have the nose evaluated immediately after the injury to make sure a septal hematoma is not present. A septal hematoma is a collection of blood in the septum (partition in the nose) that needs to be drained (blood removed) or an abscess (infection) and a loss of cartilage in the nose may result.

If your child has an older injury or was born with an abnormally shaped septum, then septoplasty or septorhinoplasty will be necessary. (Please see SEPTOPLASTY for more information on these procedures.

FACIAL NERVE INJURIES (please see this topic for more information)

Trauma to the face and neck including cuts, hits, stabs or jaw fractures may result in trapping or separation of the facial nerve. The ear, nose, and throat specialist is the surgeon of choice for repairing a damaged facial nerve.

EAR

The ear drum (tympanic membrane) can “tear” as a result of an explosion or a slap to the ear. In areas popular for water sports, such as Florida, this injury is more commonly seen as a result of water-skiing or wake boarding. The eardrum can also be cut (perforated) because of insertion of an object, such as a Q-tip, stick, or pen. Most of the time (90%), the holes heal without surgical treatment. However, in those cases that do not, TYMPANOPLASTY may be required.

It is important to have an ear, nose, and throat specialist examine the ear and evaluate the hearing as trauma to the ear can cause hemotympanum (blood behind the ear) or a disconnection of the ear bones causing hearing loss. Trauma to the ear may cause a fracture through the ear and hearing organ resulting in hearing loss, disruption of the ear bones, spinal fluid leak or facial nerve injury. These types of injuries would usually be the result of significant head trauma, such as a motor vehicle accident, with loss of consciousness.

ORAL (in the mouth)

Traumatic injuries also occur within the mouth, especially in children. One of the most common is a soft palate (roof of mouth) laceration. These are cuts or punctures on the roof of the mouth caused by pencils, pens, and toothbrushes that get suddenly jammed against something firm and hopefully can be prevented with the “don’t run with that in your mouth” warning. Cuts on the tongue may also occur as a result of a fall or a motor vehicle accident. Most injuries that occur within the mouth heal on their own without stitches. However, blood vessel injuries can occur, so every injury needs to be carefully evaluated. Those that do not heal on their own require surgery.

NECK TRAUMA

The neck has many vital structures enclosed in a small space. Therefore, trauma to the neck is one of the more common causes of death in an injured patient. These vital structures include the airway (larynx and trachea), large blood vessels (carotid arteries and jugular veins, among others), the esophagus (tube that goes from the mouth to the stomach), the spinal cord, and many other nerves that are important for breathing, swallowing, arm movement, voice and sensation. The neck also contains glands (thyroid, parathyroid, and salivary) and other structures that are also critical for normal body functioning.

How is trauma to the neck evaluated?

Evaluation starts with the basic ABC’s (airway evaluation, check for breathing, check circulation) of resuscitation. Any patient with trauma to the neck will need to be evaluated to make sure the airway is able to deliver air to the lungs.

If the airway is compromised, a “by-pass” airway must be created either through an endotracheal tube (tube through the mouth), emergency cricothyroidotomy (temporary hole in the neck under the voice box), or a TRACHEOTOMY (a temporary tube through the neck into the breathing tube). Air (oxygen) is then delivered to the patient. Once adequate breathing is assured, any visible bleeding is controlled.

Once the patient is stabilized, the damage to the neck can be assessed.

The mechanism of the neck injury (how the injury occurred) will need to be determined. This is important because different mechanisms can result in different patterns of damage to the neck tissue. Trauma to the neck can be divided into penetrating injury (for example, a gun shot or stab wound) or through blunt injury (a hit or blow to the neck with a fist or foot, for example).

The severity of the neck injury can be assessed by assigning the injury to areas of the neck or zones created by the surgeon. This helps to determine what structures located in the neck are most likely to be damaged. Additionally, with penetrating wounds, a muscle at the front of the neck (platysma) is examined to see if it has been cut. If this muscle has not been cut, serious neck injury is much less likely.

A thorough head to toe evaluation of the patient is necessary to assess for other injuries, and find evidence of nerve, blood vessel, or airway injury associated with the neck injury.

Blood tests, x-rays, blood vessel studies (angiography), swallowing tube imaging (esophogram) or visualization (esophagoscopy), and CT scans are routinely performed to help assess the degree of damage. MRI’s (magnetic resonance imaging) are not routinely used to evaluate trauma patients. MICROLARYNGOSCOPY and BRONCHOSCOPY is commonly used by the ear, nose, and throat specialist to evaluate the airway.

The trauma surgeon usually is involved with the initial surgical management of trauma patients. However, other surgical specialists are consulted depending on the types of injuries found.

In neck trauma, the ear, nose, and throat specialist is consulted to repair laryngotracheal injuries. These injuries can include laryngeal (voice box) fracture, a crush injury to the airway or loss of function (VOCAL CORD PARALYSIS). Rarely, the airway can be completely separated necessitating immediate life-saving repair. Most of these injuries require a TRACHEOTOMY. Also, an ear, nose and throat surgeon will be asked to evaluate penetrating (stab or shot) injuries, due to the high level of expertise in neck anatomy (We know where things are!)

What are complications that can occur after neck trauma?

There are many complications that can occur after neck trauma depending on the extent and type of structures damaged.

Some of the complications primarily managed by the ear nose and throat specialist include short term, long term and post-operative complications.

Short term airway complications that need to be watched for include a slow obstruction of the airway that may occur with air leaking in between skin layers (subcutaneous emphysema), continued bleeding, or swelling of damaged tissues that press on the airway.

Long-term complications of the airway after neck trauma include narrowing (stenosis) of the airway because of scarring related to the injury. This may necessitate AIRWAY RECONSTRUCTION at a later date to reopen the narrowed area.
Fistula formation (abnormal connections between the airway and other structures) may also occur.

Post-operative complications are related to the specific surgical procedures performed by the ear, nose, and throat specialist to help repair the traumatic neck injury. Among these include breakdown of the surgical site, wound infection, bleeding, fistula formation, and airway stenosis (narrowing). Please see the various surgical procedures listed under SURGERIES WE PERFORM for more detail.

What is a tracheotomy?

The TRACHEA is the part of the AIRWAY (or breathing passage) commonly known as the “windpipe”. A tracheotomy is a surgical procedure that creates a temporary opening in the trachea. The hole itself is called a tracheotomy. The tube that is placed through this hole is called a tracheotomy tube.

What are the indications for a tracheotomy?

A tracheotomy is a temporary or permanent treatment for a variety of causes of BREATHING DIFFICULTIES in which the creation of a new breathing pathway is required, by-passing the nose, mouth, and throat. A tracheotomy is usually considered when an endotracheal (ET) tube (a tube that goes in the throat through the mouth) either will not be effective (in some emergency situations for example), or would be required for a long time. Sometimes, a tracheotomy is performed when an ET tube cannot be placed due to narrowing of the windpipe or blockage of the voice box (larynx).

The reasons for performing a tracheotomy in children generally fall into three major categories:

1. To bypass an obstruction in the airway (most common reason)
2. To help with long term ventilation in patients who cannot do this on their own (patients with respiratory muscle problems or lung problems)
3. To provide a temporary airway while reconstructive surgery is performed that may cause breathing problems

Who can perform a tracheotomy?

You may have heard of situations in which a tracheotomy was performed in an emergency, outside of the hospital. This procedure is actually called a cricothyroidotomy and is strongly discouraged even when the person performing it has some experience. It is a difficult procedure to perform in an adult, and even more dangerous on a child, as the child’s airway is much smaller and more difficult to locate than in adults. If a patient is choking and unable to breathe, the Heimlich maneuver (hands pushing in and up on the abdomen) should usually be the first option considered.

A tracheotomy is traditionally performed in a hospital setting by a physician who has extensive experience in this procedure. With advances in airway management, the number of tracheotomies required has been reduced.
This procedure is usually performed by an ear, nose, and throat specialist, especially in children.

What is involved with a tracheotomy in a pediatric patient?

The airway anatomy is different in a child compared to an adult; therefore, the surgical technique used is different for pediatric (child) patient.

In the child, a tracheotomy is almost always performed under general anesthesia (patient fully asleep). Because of the small size (like a straw) of the airway, this procedure may be performed with a BRONCHOSCOPE or endotracheal tube in place during the procedure to help localize the trachea. The patient is placed on the back and a rolled towel is placed under the shoulders and neck to put the trachea in its most accessible position. A cut is carefully made in a specific location in the trachea and sutures (stitches) are placed on each side of the cut to help easily locate the new hole (tracheotomy). A tracheotomy tube is placed into this hole and tied securely in place. After the tracheotomy tube has been tested to make sure airflow is adequate, the bronchoscope or endotracheal tube is removed. Sometimes, a chest x-ray is taken to check for proper placement.

The tracheotomy tube will be changed 3 to 4 days after surgery. After this, parents are thoroughly educated in the care of the tracheotomy tube prior to the child going home.

How long does the tracheotomy tube need to remain in place?

The length of time a tracheotomy tube needs to remain in place depends on the exact reason the tube was needed. For a temporary breathing problem, the tracheotomy tube may be removed after just a few months. Home health nursing is usually arranged for a period of time after discharge. The ear, nose, and throat surgeon and other health care providers perform close follow-up. Speech/language pathologists are usually involved with your child as well. They will help with swallowing and speech while the tracheotomy tube is present.

How is a tracheotomy tube removed?

The name for tracheotomy tube removal is decannulation. Decannulation is always performed in the hospital setting. First the patient’s airway is re-examined by MICROLARYNGOSCOPY AND BRONCHOSCOPY to make sure there are no reasons the tracheotomy tube should not be removed.
Depending on the situation, there are several different ways decannulation may be carried out. Among these are:

• Simply remove the tube and allow the tracheotomy site to heal
• Put in a smaller tracheotomy tube in and plug over the hole of the tube during awake hours only until the child can tolerate plugging comfortably for one month
• If the airway is being reconstructed (a small airway being enlarged for example), the tracheotomy tube may be removed along with this procedure or after the surgical site heals.
• Remove the tracheotomy tube during a surgical procedure with surgical closure of the opening

What are the risks and complications involved with a tracheotomy?

Early Complications that may arise during the tracheotomy procedure or soon thereafter include:

• Bleeding
• Air trapped underneath the skin around the tracheotomy (subcutaneous emphysema) or in deeper layers of skin in the chest (pneumomediastinum)
  that may leak around the lungs (pneumothorax)
• Damage to the tube going to the stomach (esophagus)
• Injury to the nerve that moves the vocal cords (recurrent laryngeal nerve)

However, many of these early complications can be avoided or dealt with appropriately with an experienced surgeon in a hospital setting.

Later Complications that may occur while the tracheotomy tube is in place include:

• Accidental removal of the tracheotomy tube (accidental decannulation)
• Infection in the trachea and around the tracheotomy tube

These complications can usually be either prevented or quickly dealt with if the caregiver has proper knowledge of how to care for the tracheotomy site.

Delayed Complications that may result after longer-term presence of a tracheotomy include:

• Thinning (erosion) of the trachea from the tube rubbing against it
• Development of a small connection from the trachea to the esophagus
• Development of bumps (granulomas) that may need to be surgically removed before decannulation can occur
• Narrowing or collapse of the airway above the site of the tracheotomy, possibly requiring an additional surgical procedure to repair it
• Once the tracheotomy tube is removed, there may remain a small hole between the trachea and the skin, which may need surgical closure

A clean tracheotomy site, good tracheotomy tube care, and regular examination of the airway by an otolaryngologist should minimize the occurrence any of these complications.

What is a tonsillectomy?

A tonsillectomy is a surgical procedure performed to remove the TONSILS

What are some of the reasons a tonsillectomy is performed?

1. A patient with four or more infections of the tonsils per year despite adequate medical therapy (antibiotics)
2. Tonsillar hypertrophy (enlargement) causing snoring, pauses in breathing, restless sleep, difficulty swallowing or wetting the bed
3. Chronic or recurrent TONSILLITIS associated with a “strep” carrier state, not responding to medical treatment.
4. Persistent foul taste or bad breath due to chronic tonsillitis that is not responding to medical treatment.
5. Peritonsillar abscess (collection of pus around the tonsil) that does not respond to medical treatment.
6. One sided enlargement of the tonsil that is suspicious for malignancy (cancer)

What is involved with removing the tonsils?

This surgery is performed through the mouth with the patient under general anesthesia. The tongue is depressed and the tonsils are separated from the back of the throat using cautery. This technique allows the surgery to be performed with little or no bleeding.

This surgery is performed on an outpatient basis, although your child may spend about three to four hours in the hospital following the surgery for observation. If your child is under 3 years of age, they may stay in the hospital overnight. The surgery itself lasts about 20 minutes, and the doctor will talk to you immediately following the surgery.

A thyroidectomy is the removal of all or part of the THYROID GLAND. The thyroid gland consists of two lobes, one on each side of the throat, connected by a narrow band of thyroid tissue called the isthmus. The term thyroidectomy can apply to a total removal of the gland (total thyroidectomy), removal of one or part of one of the lobes (lobectomy), or the isthmus (isthmusectomy).

What are the indications for a thyroidectomy?

A thyroidectomy is performed to assist in treatment of various thyroid diseases.
These include thyroid nodules, HYPERTHYROIDISM (overactive thyroid gland), cancer of the thyroid gland, or an enlarged thyroid (goiter) that may cause breathing or swallowing difficulties.

How does the surgeon know how much thyroid tissue to remove during a thyroidectomy?

The amount of thyroid tissue that needs to be removed is determined prior to the surgical procedure. The surgeon works closely with an endocrinologist (a doctor specializing in gland tissue disorders) to determine what areas of the thyroid gland are not functioning normally. Usually thyroid function tests (blood tests) and thyroid scanning are involved to aid in this decision. For cases in which thyroid cancer is suspected, a fine needle aspiration biopsy (a needle is inserted through the skin to get suspected cancer cells to examine under a microscope) may also be performed.

What is involved with a thyroidectomy?

The patient is fully asleep (under general anesthesia) during this procedure.
An incision (a precise surgical cut) is made across the lower part of the central neck and layers of skin and muscle are lifted up to expose the thyroid gland underneath.

The thyroid tissue to be removed is then exposed, separated from its blood supply, and removed.

Drains are sometimes placed under the skin after the surgery to help drain any blood or fluid that might accumulate after the procedure. The muscle and skin layers are replaced and the surgical incision is then closed with sutures (stitches) or clips (like staples).

A hospital stay of about two to three days is required. During this time, thyroid hormone levels will be checked to make sure they are in the normal range.

Depending on the reason for the surgery and the amount of thyroid tissue removed, thyroid hormone medications may also be started at this time. Once the wound starts to heal and the stitches and drainage tubes can be removed, the patient may leave the hospital.

What are the risks and complications of a thyroidectomy?

A usually expected condition is HYPOTHYROIDISM – Depending on the amount of thyroid tissue that needs to be removed, there may not be enough thyroid tissue left to produce the amount of thyroid hormones needed for the body to function. In these cases thyroid hormone medications are given. Taking the medications as prescribed, as well as checking thyroid hormone levels periodically can avoid hypothyroidism. An endocrinologist usually coordinates this.

Because of the location of the thyroid gland in the neck, damage to close lying structures might occur during a thyroidectomy. These complications, though uncommon with an experienced surgeon, include:

HOARSENESS – The nerve that supplies the VOCAL CORDS (recurrent laryngeal nerve) lies in this area. Damage to this nerve can result in temporary or permanent hoarseness of the voice.

HYPOPARATHYROIDISM – The four PARATHYROID GLANDS are located within the thyroid tissue. It is important for the surgeon to identify the blood vessels supplying the parathyroid glands, so these are not cut during the thyroidectomy procedure. If all of the parathyroid glands cannot be saved (may occur with a total thyroidectomy), then hypoparathyroidism would result. However, in most cases, the surgeon can implant the parathyroid gland into another location in the neck to avoid this complication.

HEMATOMA – If blood collects under the skin after the operation, this is called a hematoma. This fluid collection has a significant chance of becoming infected. Therefore, drains may be inserted at the time of surgery to prevent this complication.

WOUND INFECTION – Bacteria can sometimes infect the incision causing a wound infection. Treating the skin with special medicine before surgery and giving antibiotics during surgery helps to prevent this condition.

Functional endoscopic sinus surgery (FESS) is a surgical technique used to help open the SINUS drainage pathways and remove mucus from the sinuses, which helps to eliminate or decrease the number of infections in the future. Because this technique opens the natural sinus openings, FESS has been shown to produce better results than procedures used in the past.

When is sinus surgery necessary?

If your child has had 6 episodes of ACUTE SINUSITIS in the past year or has long-standing CHRONIC SINUSITIS which does not seem to go away completely with antibiotics, sinus surgery may be recommended.

What is involved with FESS?

Before endoscopic sinus surgery, a computed tomography (CAT) scan will be performed to see how your child’s sinuses are formed and how big they are. It is important to have the CAT scan taken while your child is on antibiotics so that we can see how effective the medicine has been in clearing up the sinus infection. If the CAT scan is taken at a children’s hospital or facility, sedation use is rare. However, your child may need to receive sedation (a calming medicine) through an IV (catheter in a vein) in order to have the CAT scan taken.

These pictures can be used to show the amount of infection in the sinuses, as well as help your doctor know exactly what kind of surgery your child will need.

The surgery is performed using small telescopes which are placed through the nose allowing the doctor to open the natural drainage pathways of your child’s sinuses under direct vision. This allows for drainage of mucus from the sinuses and helps prevent future infections.

FESS is performed under general anesthesia. This procedure does not require an overnight stay in the hospital, and the length of surgery depends on the amount of disease and blockage in the sinuses. However, surgery usually does not last more than an hour.

About 2-3 weeks after surgery, your child may be scheduled to return to the operating room for another examination under anesthesia. This will allow the doctor to clean out any crusting and evaluate the area where the surgery was performed to make sure it is healing properly.

Is endoscopic sinus surgery dangerous?

Endoscopic sinus surgery as described above involves operating on your child’s sinuses through the nose using small telescopes. As the sinuses are located near the eyes and directly under the brain, there is always a risk that damage may occur to those areas. However, because the surgery is performed under direct vision and because of the experience of the surgeons, these complications are very rare.

These risks and possible complications will be described for you prior to your child’s surgery.

Sinus Cultures

Sinus cultures are becoming more important with the emergence of bacteria resistant to common antibiotics. Sinus cultures are indicated when your child has had several sinus infections treated with appropriate antibiotics that have not completely resolved the infection.

A culture is performed under a brief (5-10 minute) general anesthetic as an outpatient procedure. Once the child is asleep, a small catheter is placed into the sinus behind the cheek through the natural opening in the nose. This is done under direct vision using a small telescope. Once the culture is obtained, your child is awakened. There are no restrictions necessary after this type of surgery. The culture results are returned in about 3-5 days and include the type of bacteria and the list of antibiotics that will effectively treat the infection.