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Endoscopic Skull Base Surgery via the Endoscopic Endonasal Approach (EEA)

Endoscopic endonasal  skull-base surgery is a minimally invasive surgical technique performed through the nose in order to remove brain tumors, pituitary tumors, and other lesions at the base of the skull, through the nasal passages. This procedure often takes less than four hours to complete and patients typically go home in a few days. Patients who have this procedure done typically have shorter anesthesia times, improved outcomes, faster recovery, less pain, and no scars compared to traditional open brain surgery.

A multidisciplinary team of neurosurgeons and otolaryngologists perform these operations as combined procedures

With the endoscopic endonasal approach (EEA), surgeons reach tumors and lesions of the skull base and top of the spine directly by operating through the nose and sinuses. A specially designed endoscope provides light and a lens for viewing and transmitting internal images. Highly crafted instruments are used alongside the endoscope for dissection and tumor removal. These surgeries are performed in dedicated operating theatres  that incorporate sophisticated imaging technology.

This minimally invasive approach uses the nose and sinuses as natural corridors to access tumors and lesions in critical areas at the base of the skull or top of the spine. The Endoscopic Endonasal Approach allows surgeons to treat many hard-to-reach tumors, even those once considered “inoperable,” without disturbing the face or skull

The concept of team surgery has allowed us to expand the role of the Endoscopic Endonasal Approach (EEA) to include all pituitary tumors, regardless of size or invasiveness, and to access tumors of the skull base from the frontal sinus all the way down to the upper cervical spine and out to the cavernous sinus, Meckel’s cave, jugular foramen and beyond.

 

What is the skull base?

The skull base (or cranial base) is the part of the skull (cranium) that supports the brain and separates the brain from the rest of the head. Blood vessels to the brain and nerves from the brain (cranial nerves) run through holes in the skull base. Below the skull base are the nasal passages, sinus cavities, facial bones, and muscles associated with chewing.

 

What will happen before EEA surgery?

If surgery is recommended, additional testing is often necessary. This may include visits with additional specialists, medical clearance from your primary physician or anesthetist, and medical tests. CT and MRI scans are often obtained before surgery for use with an image guidance system akin to a GPS of the brain and skull base.

 

In recent years, the transnasal endoscopic approach to the ventral midline skull base has rapidly become a widespread procedure. In fact, this approach occupies a crucial place in the armamentarium of neurosurgeons and otorhinolaryngologists for the management of diseases of the anterior skull base, the sella, the suprasellar and parasellar regions.

NOSE BLEEDS (EPISTAXIS)

NOSE BLEEDS (EPISTAXIS)

Care and prevention

Most nose bleeds (or epistaxis) are mere nuisances; but some are quite frightening, and a few are even life threatening.  Doctors classify nose bleeds into two different types-

  1. Anterior Nose bleed: the nose bleed that comes from the front of the nose and begins with a flow of blood out of one or the other nostril if the patient is sitting up or standing
  2. Posterior Nose bleed: the nose bleed that comes from deep in the nose and flows down the back of the mouth and throat even if the patient is sitting up or standing

Obviously if the patient is lying down even the anterior nosebleeds seem to flow in both directions, especially if the patient is coughing of blowing his nose. Nevertheless, it is important to try to make the distinction since posterior nosebleeds are often quite severe and almost always require care from a doctor.  Posterior nose bleeds are more likely to occur in older people, persons with high blood pressure and in cases of injury to the nose or face.

Nosebleeds in children are almost always of the anterior type.  Anterior nose bleeds are common in dry climates and when the air is dry.  The dry air parches the nasal membranes so that they crust, crack and bleed.  This can be prevented if you will place a bit off lubricating cream or ointment (e.g. Vaseline, Bactroban ointment) about the size of a pea on the end of your fingertip and the rub it up the nose, especially on the middle portion (the septum).

Up to three applications a day may be needed, but usually every bedtime is enough.

Warfarin, Aspirin (or Aspirin containing products) and non-steroidal anti-inflammatories (e.g.Brufen, Voltaren) thin the blood and can cause bleeding, or cause the bleeding to persist.

If the nosebleeds persist you should see your doctor, who may recommend cautery to the blood vessel that is causing trouble.

To stop an anterior nosebleed 

If you or your child has an anterior nose bleed, you may be able to care for it yourself by taking the following steps:

  1. Pinch the soft (lower) parts of the nose together between your thumb and index finger.
  2. Hold it for 5 minutes (timed by the clock)
  3. Keep head higher than the level of the heart – sit up or lie with head elevated.
  4. Apply ice (crushed in a plastic bag or washcloth) to nose and cheeks
  5. Sucking ice is also useful

To prevent re-bleeding after bleeding has stopped:

  1. Do not pick or blow nose (sniffing is all right)
  2. Do not strain or bend down to lift anything heavy
  3. Keep head higher than the level of the heart

If re-bleeding occurs:

Clear nose of all blood clots by sniffing forcefully

  • Spray nose four times on both sides with decongestant nasal spray (such as Drixine or Otrivine)
  • Pinch the soft parts of the nose together between your thumb and two fingers for five minutes (to stop an anterior nose bleed)
  • Call your doctor if these measures fail.

When to call the doctor or go to the Accident and Emergency:

  • IF bleeding cannot be stopped or keeps reappearing within a short period of time
  • IF bleeding is rapid or if blood loss is large
  • IF you feel weak or faint, presumably from blood loss
  • IF bleeding begins by going down the back of the throat rather than the front of the nose

YOUR CONSULTATION

If your nose bleeds are severe and/or recurrent, please call 031 201 3118 for an appointment.

A complete history will be taken, and a thorough examination of the nasal passages will be performed (including nasal endoscopy). Further management will depend on the site and cause of the nose bleed, and will be in keeping with best ENT specialist practice guidelines.

 

 

 

 

 

REFLUX AND THROAT SYMPTOMS

REFLUX AND THROAT SYMPTOMS

At the lower end of the oesophagus (gullet) there is a one-way valve (lower oesophageal sphincter) which allows food and fluids to pass into the stomach and should prevent anything from flowing back from the stomach into the oesophagus.  In some people this one-way valve is faulty and irritating stomach acid may flow up from the stomach and into the oesophagus (gullet) and throat. This may cause indigestion and heartburn (a burning sensation behind the breastbone)

Occasionally people experience only the throat symptoms and do not experience indigestion or heartburn (this is sometimes referred to as “silent” reflux, or laryngopharyngeal reflux).

The reflux may cause throat symptoms such as irritation and burning in the throat, muscle spasm in the throat, and a feeling of a lump in the throat

Other symptoms include coughing,  hoarseness, excess mucus in the throat, and a bad taste in the throat.

The excess mucus in the throat may sometimes be mistaken for a postnasal drip.

TO AVOID THESE SYMPTOMS

  • Don’t smoke
  • Eat small meals regularly
  • Do not rush meals
  • Avoid those foods associated with your symptoms,  e.g. acidic fruit drinks, spicy meals, alcohol, coffee
  • Don’t take aspirin for headaches, colds and coughs- use Paracetamol instead
  • Avoid taking anti-inflammatory medications
  • Avoid becoming overweight- – if you are overweight, reducing your weight may be of great benefit
  • Posture- avoid bending from the waist or stooping just after meals. Try and bend from the knees. Take meals on an upright chair, rather than stooping in front of the TV
  • Avoid tight belts and underclothes as they increase pressure on the stomach
  • Eat your evening meal well before going to bed so that it has time to digest
  • Raise the head of the bed on blocks by 6 inches

MEDICATIONS

  • Antacids are available from the chemist – they neutralise any acid in the gullet. Some preparations relieve symptoms by forming a layer on top of the stomach contents, e.g. Gaviscon.
  • Other drugs actually reduce the production of acid in the stomach (e.g. Losec).
  • Medication that enhances the normal movement of the gullet may be of help, eg Motilium

YOU SHOULD SEE YOUR DOCTOR IF

  • You suffer from heartburn regularly- every day or every week
  • Your heartburn or other symptoms persist for more than 2 weeks
  • Your symptoms do not respond to antacids

THIS IS ESPECIALLY IMPORTANT IF YOU ARE

  • Over 45 years old
  • Have a family history of stomach problems
  • Drink or smoke heavily
  • Take aspirin or anti-arthritis pain killers

 

YOUR CONSULTATION

If you have symptoms suggestive of silent reflux, please call 031 201 3118 for an appointment.

A complete history will be taken, and a thorough examination conducted. This will include a flexible laryngopharyngoscopy.

Further management will depend on the clinical findings, but will be in keeping with best ENT specialist practice guidelines.

 

SEPTOPLASTY

SEPTOPLASTY

Septoplasty is an operation performed to straighten the partition between the nostrils (septum) by trimming and refashioning cartilage and bone.

A septoplasty is usually performed to improve the nasal airway and can also allow for better access for nasal sprays.  It may be performed as part of a septorhinoplasty (“nose job”) or to provide access for surgery to the sinuses (endoscopic sinus surgery).  Turbinate trimming and/or cautery may also be indicated at the same time especially if you have allergies.

GENERAL POINTS – AFTER SURGERY

  • Packing of the nose is uncommonly required but if inserted may remain in for 24-48 hours.
  • There is usually mild pain only – Paracetamol should be sufficient in most cases.
  • Gentle nose blowing only to clear loose clots and mucous.
  • A bloodstained mucous discharge and nasal blockage is common for 2-3 weeks.  It is due to local reaction with swelling and production of mucous.  Sleeping with head elevated may help.  It may take 6 weeks to clear completely.
  • Use a nasal spray or drops if prescribed by your surgeon and try to breathe through your nose as much as possible.
  • Saline douche will help to clear clots and mucous.  Advice regarding saline douche will be provided.
  • Avoid strenuous activity for 3 weeks.  Lifting and straining may precipitate bleeding.
  • Clean nostrils with cotton buds gently.  Use antibiotic ointment if prescribed.
  • Take antibiotics if prescribed.
  • Black eyes are not expected with this procedure.
  • Dissolvable stitches occasionally appear from the nostrils.  Do not attempt to pull these out.

 

YOUR CONSULTATION

If you think that you may need a septoplasty, please call 031 201 3118 for an appointment. A complete history will be taken,  and a thorough examination will be conducted to determine whether a septoplasty is indicated. Best ENT specialist practice guidelines will be followed at all times.

 

 

 

TONSILLECTOMY & ADENOIDECTOMY

TONSILLECTOMY

A tonsillectomy is a procedure done to remove the tonsils

WHAT ARE TONSILS?

The tonsils are lymphoid tissue lying on either side of the back of the throat.  This tissue is similar to lymph nodes or ‘glands’ found in the neck, groin and other parts of the body.  They have a role in immune defence (defence against infection), although like the appendix their role has become less important as humans have evolved.  If they are recurrently or chronically infected they become a source of, rather than a defence against, infection.

 

WHY REMOVE TONSILS?

  • Recurrent/persistent infection causing sore throat, fever, halitosis and time lost from employment or studies.
  • Large size causing obstruction (a problem more common in children) with snoring or obstructive sleep apnoea.
  • Suspicion of tumour or malignancy (rare!).

 

GENERAL POINTS

  • Tonsillectomy is performed under General anaesthetic
  • Removal is performed through the mouth.
  • Tonsillectomy is usually a day stay procedure.

ADENOIDS

The adenoids are tonsil-like tissue in the back of the nose, up behind the roof of the mouth (palate).  They are often large in small children and are commonly also removed with the tonsils (adenotonsillectomy).  As children grow the adenoids tend to shrink and the adenoids seldom require removal in older children and adults.

AFTER SURGERY

  • Tonsillectomy is a painful operation!  Adequate pain relief is important.  A combination of paracetamol, anti-inflammatories, antibiotics and possibly other medications will be prescribed.  Pain usually “peaks” 5 – 7 days post-operatively and it is important to keep taking pain relief regularly for 10 days.  Pain is often referred to the ears, which share the same nerves as those which supply the throat.
  • There is no food restriction.  Adequate fluid intake (2-3 litres/day) is essential (avoid citrus juices as they sting).  Encourage chewing to lessen jaw muscle stiffness: chewing gum is helpful.
  • A yellow layer called slough is normal over the surgical site.  It usually separates around 5 – 7 days, sometimes with a small amount of blood.
  • At least a week and often up to 2 weeks off work or school is required to recover.
  • Avoid strenuous activity/sport for two weeks (lack of energy is common).

 

POSSIBLE COMPLICATIONS

  • Bleeding may occur for up to 2 weeks after the operation (most commonly after 5 – 7 days).  Most bleeding is brief and settles with bed-rest and sucking ice.  About 5% of patients will experience bleeding severe enough to be readmitted to hospital.  If bleeding is more than a cupful or lasts longer than 10 minutes, contact your family doctor, local A & E clinic or Hospital Emergency Department.
  • Occasionally patients complain of an unpleasant or decreased taste when eating.  This usually resolves but may take weeks or months.
  • Vomiting is quite common in the first few hours.  If it fails to settle it may require further treatment.
  • Jaw damage which can restrict jaw opening is rare, unless there are pre-existing problems.  Please tell your surgeon & Anaesthetist if you have problems with your jaw.
  • There may be a change in the pitch of the voice.  This is rarely more than mild, and is usually temporary.
  • Damage to teeth may occur: please draw attention to caps on the front teeth.

YOUR APPOINTMENT

If you think that you or your child may required tonsillectomy and / or adenoidectomy, please call 031 201 3118 for an appointment.

A complete history will be taken, and a thorough examination completed. Further management will be in keeping with best ENT specialist practice guidelines.

 

 

ADENOIDECTOMY

ADENOIDECTOMY

 

WHAT ARE ADENOIDS?

Adenoids are tonsil-like lymphoid tissue located behind the nose.

The Eustachian tube opens near the adenoids.  If adenoids are enlarged or chronically infected they can block this opening or be a source of infection travelling up the Eustachian tube into the middle ear.  The result may be recurrent ear infections.

If the adenoids are enlarged or chronically infected, they can also block the back of the nose, leading to nasal obstruction, mouth breathing, chronic nasal discharge, snoring and obstructive sleep apnoea.

Removal is indicated to relieve nasal obstruction, snoring, sinusitis and ear infections.

NOTE: adenoids usually shrink in size as children grow older: adenoid removal is less commonly done in patients over the age of 8 years.

GENERAL

  • Adenoid removal is always under general anaesthetic
  • Removal is done with an instrument passed through the mouth
  • It is usually a day case procedure

POST SURGERY

-Quiet activity for a few days – about 1 – 2 days off school

-Mild pain – relieved with Paracetamol

-A blocked nose may persist for immediately after surgery- this will clear over 1-2 weeks

 

POSSIBLE COMPLICATIONS

-Bleeding –this is a rare complication. If it does occur, it is usually mild and controlled with Otrivine nose drops. Contact me if lasts for more than 10 minutes or if bleeding is heavy, i.e. with blood clots.

-Occasionally there can be re-growth after removal (usually when removed at a young age- <18 months).

-Altered speech – mild, usually settles.  Very rarely, a congenital weakness of the soft palate may become apparent after adenoidectomy, causing ‘cleft palate’ like speech and nasal regurgitation of swallowed fluids.

-Damage to teeth may occur (rarely).  Please draw attention to caps on the front teeth.

 

SUMMARY

 

Adenoidectomy in children, either alone or in combination with a tonsillectomy or grommet insertion, may be extremely beneficial in treating nasal obstructive symptoms and middle ear problems.

 

 

YOUR CONSULTATION

 

If your child has a persistently blocked nose, is a mouth breather, and/or snores, he/she may have enlarged adenoids.

Please call 031 201 3118 or 031 581 2534 for an appointment. A full history will be taken, a complete ear, nose and throat examination will be performed, and if necessary, X-Rays will be requested.

Thereafter, a decision regarding the need for adenoidectomy will be taken in keeping with best ENT specialist practice guidelines.

 

 

 

FUNCTIONAL ENDOSCOPIC SINUS SURGERY (FESS)

Most people who undergo endoscopic sinus surgery do so as part of the treatment of chronic sinus problems that have not responded to maximal medical therapy.

Symptoms of sinus disease include facial pain or pressure, a blocked nose, a decreased sense of smell, a persistent foul smell in the nose or nasal discharge.  Less commonly sinus problems cause headaches, hoarseness, cough and a variety of other symptoms.  For this reason sinus problems are frequently confused with other medical conditions.

Most people with sinus problems can be successfully treated medically, without the need for surgery.  Prolonged courses of antibiotics, often in association with Prednisone, nasal sprays, and saline irrigations, are frequently effective.

Treatment of underlying allergies and avoidance of exposure to environmental triggers such as cigarette smoking may also be helpful.  The medical treatment chosen will depend on my assessment of the cause.

If the above medical therapy fails or you have a problem which is clearly not amenable to medical therapy, then surgery may be required.

The operation

The operation will usually be performed under general anaesthetic.  General anaesthetic carries minimal risk in otherwise healthy patients.  You will have the chance to discuss this with your anaesthetist pre-operatively.

I will usually prescribe Prednisone and antibiotics around the time of the surgery as this improves the results.  In some cases the surgery can be performed on an outpatient basis without the need for nasal packing.

The surgery is done with the use of an endoscope. The principle of the surgery is to unblock the obstructed openings (ostia) of the sinuses, to allow drainage of secretions, and to allow air to enter the sinuses (i.e. for ventilation of the sinuses)- this returns the sinuses to normal health

General points – after surgery

  • There is usually mild pain only – Paracetamol and an anti- inflammatory should be sufficient in most cases.
  • Packing of the nose is usually required for the first night  postoperatively- the packing is removed the next morning.
  • A blocked nose is common for 2-4 weeks due to swelling and crusts, which improves after cleaning at the postoperative visit(s).
  • Healing takes approximately 6-12 weeks to be complete, longer if there is postoperative infection.
  • There is usually some bleeding for several days after surgery,  and after each cleaning.
  • Thick brown mucus may drain from the nose for 3-4 weeks or more.
  • Avoid hard nose blowing for 4-7 days following the surgery.
  • Saline irrigations will help to clear clots and mucous.  A syringe or saline squeeze bottle and advice regarding saline irrigations will be provided.
  • Take antibiotics and/or Prednisone as prescribed.
  • Usually patients require 7-10 days off work.
  • Avoid bending, lifting and straining for 3 weeks after surgery.  Exertion may precipitate bleeding.

 

A follow-up visit is arranged one to two weeks after the surgery to clean crusts from the surgical site.  Further follow-up visits are arranged at approximately weekly or fortnightly intervals until the area is healed at around 6 – 8 weeks.  At each of these visits and at subsequent follow-up examinations, any persistent scar tissue may be removed under local anaesthetic.

Results of Surgery

Sinus disease is usually due to a complex combination of structural, mucosal (lining) and environmental factors.  In general, FESS is successful in up to 80% of patients.

In some patients, there will be persisting disease, which requires ongoing medical treatment.  Allergic mucosa may require the permanent use of nasal corticosteroid sprays.  Severe polyposis with sinusitis has a high rate of recurrence (>50%).

Risks of Surgery

Although there are potentially very serious risks from surgery in this area, the incidence is very low.

 

Bleeding – Bleeding is a potential risk in all forms of sinus surgery.  Although the risk of bleeding appears to be reduced with the endoscopic technique, on occasion significant bleeding may require stopping of the procedure and placement of nasal packing.  Bleeding following surgery may also require the placement of packing and hospital admission.  Blood transfusion is very rarely required.

 

Post-operative discharge – Blood-stained nasal discharge may occur for approximately three weeks after the procedure.  This is normal and slowly improves.

Cerebrospinal fluid leak – This is a rare complication (<1% of all sinus surgery patients).All operations on the sinuses carry a risk of intra-cranial penetration, which may result in a leak of cerebrospinal fluid (or CSF, the fluid that surrounds the brain).  Should this rare complication occur, it creates a potential pathway for infection which could result in meningitis.  This would extend your hospitalisation as further surgery would be required for closure of the leak.

Visual problems– these complications are extremely rare, though double-vision and loss of vision have been reported in the literature

Other risks – Watering of the eye can occasionally result from sinus surgery or from sinus inflammation.  This is usually temporary but can be persistent and may require surgery to correct it.  Swelling or bruising around the eye may occur and blowing the nose in the post-operative period may result in a temporary collection of air under the skin causing facial swelling for a period of time.

 

Septoplasty – In some cases, it may be necessary to straighten the nasal septum at the time of surgery.  This is usually done to allow access to the sinuses during the operation.  A separate blog is available regarding this procedure.

A follow-up visit is arranged one to two weeks after the surgery to clean crusts from the surgical site.  Further follow-up visits are arranged at approximately weekly or fortnightly intervals until the area is healed at around 6 – 8 weeks.  At each of these visits and at subsequent follow-up examinations, any persistent scar tissue may be removed under local anaesthetic.

 

YOUR CONSULTATION

If you have troublesome sinusitis which has been resistant to medication, please call 031 201 3118 for an appointment.

A complete history of your problem will be taken, followed by a thorough examination of the nasal passages (including nasal endoscopy). A CT scan of the sinuses may be required for further information.

Further management will depend on the clinical findings, and will be in keeping with best ENT specialist practice guidelines.