The following document was written by Mr Vik Veer MBBS(lond) MRCS(eng) DoHNS(eng) in Dec 2007. You may use the information here for personal use but if you intend to publish or present it, you must clearly credit the author and www.clinicaljunior.com
This site is not intended to be used by people who are not medically trained. Anyone using this site does so at their own risk and he/she assumes any and all liability. ALWAYS ASK YOUR SENIOR IF YOU ARE UNSURE ABOUT A PROCEDURE. NEVER CONDUCT A PROCEDURE YOU ARE UNSURE ABOUT.
In this section I’ll go through the information you need to give patients to consent them for common ENT operations. You shouldn’t consent someone for an operation unless you are the operating surgeon – sadly this isn’t the case everywhere and frequently juniors are being made to consent patients for operations they have not seen let alone understand.
Operation time – 8-15 minutes
Pain – the hole left after a tonsillectomy is very painful as it is like having two large ulcers in your mouth. Some departments don’t provide NSAIDs after a tonsillectomy due to the risk of altering the clotting system with these drugs.
Infection – explain to the patient that they will see a white fur or slough collecting in area where the tonsils used to be. This is normal and this is how the mouth heals after this operation. However if this fur gets infected the pain can get much worse and would need antibiotics. The worst day after a tonsillectomy is day 3 after the operation in those without an infection. Patients tend to feel better by day 5. We insist however that patients take 2 weeks off work / school and avoid seeing family and friends as much as possible, to avoid catching an infection from someone else.
“If the infection takes hold it tends to extend into the walls of the mouth and cause bleeding - this is a serious complication and so if you cough up or spit out any blood - particularly 5 to 10 days after the operation then you MUST come DIRECTLY to A&E with ENT services. do not wait for the GP to check it or even wait to phone NHS direct - just come ASAP - and call an ambulance if need be. This can be an early warning sign of a much more serious bleed to come and many people who have this require an emergency operation immediately. This occurs in about 1 – 3 % of all tonsillectomies.”
“The way to avoid these complications of infection and bleeding is to eat as much as possible to scrape off the white fur in the mouth. You will need rough food that is difficult to mash up in your mouth - ice cream and jelly will just slip past the throat - you need something like chicken or toast to really scratch this stuff off to try and avoid getting an infection. You will also notice that the more you eat the quicker you will get better and the less pain you'll feel in the long run - The muscles in the mouth tend to start to spasm if you don't eat properly and you need to eat to stretch them out again to reduce the pain.”
Particularly in young children with loose teeth there is a chance of these teeth being knocked out, but is also more common in people with caps or crowns. Obviously damage to teeth could happen to normal teeth and so should be consented for in everyone.
“During the operation your mouth is held open for about 8-15 minutes. This can make the jaw ache a lot after the operation and occasionally this can lead to dislocation of your jaw. Even though this sounds terrible in actual fact we pop it back into place any many people have no further worries about this.”
Consent also for diathermy burns of the lips, tongue, etc. They normally heal very quickly.
In the very young and those with Downs Syndrome there is a greater chance of injuring the neck with the extension used to view the tonsils during the operation. This obviously can occur in the elderly and anyone if not enough care is taken.
Operation time – 10 minutes
It’s useful to show where vaguely the adenoid lies in the post nasal space and that we remove it through the mouth either by scrapping it off or by burning it down. Its probably best to draw a picture for this operation as the anatomy isn’t obvious.
Pain – Adenoidectomy isn’t as painful as tonsillectomy but it is still quite painful. Some departments don’t provide NSAIDs after an adenoidectomy due to the risk of altering the clotting with these drugs.
Infection – We insist that patients take 2 weeks off work / school and avoid seeing family and friends as much as possible, to avoid catching an infection from someone else.
“If there is any bleeding - this is a serious complication. If you cough up or spit out any blood or have a nosebleed - particularly 5 to 10 days after the operation then you MUST come DIRECTLY to A&E with ENT services. Do not wait for the GP to check it or even wait to phone NHS direct - just come ASAP - and call an ambulance if need be. This can be an early warning sign of a much more serious bleed to come and many people who have this require an emergency operation immediately.
Velopharyngeal incompetence & Hypernasal speech – “Sometimes when we remove a large adenoid the tissue around that adenoid doesn’t completely fill up the space left behind. This gap can lead to problems such as food or water accidentally going up into the back of the nose rather than going down the normal way. In the same way instead of speaking normally through the mouth sometimes people end up talking too much through their nose because of this gap. In most people these issues resolve in time without any problems but rarely this can continue long term.”
All the other complications are exactly the same as in tonsillectomy.
Operation time for each grommet is about 2 – 5 minutes
Probably best to draw a picture for this operation as the anatomy isn’t obvious. Draw a coronal view with the pinna, external auditory canal, tympanic membrane, and vague hole for the middle ear. Explain that when the middle ear fills with fluid the ear drum can’t move as easily as before therefore there is less hearing. The myringotomy is when we make a small hole in the ear drum and suck out all the fluid to allow the ear drum to move again. We put a tube into this hole to drain out any more fluid that may collect in the middle ear after the operation. The grommet normally grows out by itself in about 9 months to a year.
Haemorrhage and pain – minimal and tends to stop within a few hours.
Infection – this is normally an operation for young children and you need to explain to the parents that the reason we are doing this operation is to improve the hearing.
“After this operation however we are creating a artificial communication between the outside world and the inside which will allow bugs to enter the normally sterile environment of the middle ear. So your child will be more likely to get ear infections than before. The way to stop infections is to ensure that no water gets into the ear at all. Every shower / bath etc the parents will need to get some cotton wool and mix with Vaseline and use that to plug the ear water tight. Swimming will be more difficult and the child will have to wear a head band to stop water from entering the ear.”
“The reason we are doing this is that children need their hearing more as they are developing language skills and being a year behind at school is terrible for children who may find it difficult to catch up once the glue ear has got better. That is why we accept the extra risk of infection. The other good thing is that the infections won’t be as bad as normal as there shouldn’t be so much pain as all the pus will just drain out through the grommet rather than causing pressure on the ear drum”
“Rarely the grommet doesn’t grow out like normal and just stays there. If this happens we may have to perform another very quick operation to remove the grommet under another anaesthetic in a few years time. “
“Rarely also the grommet can leave a hole in the ear drum that doesn’t heal up. This will require another much bigger operation to patch this hole up in the future.”
“The more times we do this operation, the more scarring occurs on the ear drum. This is normally not a problem however it can in very severe cases make the ear drum stiffer and worsen the hearing. Any operation on the ear has a risk of damaging the hearing. The chance of this happening is minuscule in this operation but I’m afraid can’t guarantee that there will be no problems with this.”
Operation time 30 - 45 mins
“There will always be a little bleeding from the nose after this operation however sometimes there is more than we can manage before waking you up. We simply stop the bleeding by putting a small tampon in your nose to stem the flow. This will probably stay in for a few hours before we take it out and allow you to go home. “
“The chance of an infection is quite low especially if you remember to clean your nose out with the salt water douches you’ll be provided with after the operation. If you have any problems we can start antibiotics after the operation.”
“This is not an operation to remove your polyps, it is an operation to allow the nasal sprays to get to the areas where polyps are formed so that they can work effectively. You will still need nasal sprays after this operation and if you stop using them they will probably come back.”
“Very rarely there are other complications that I need to inform you about. We are working on very delicate structures between your eyes and just below the base of your brain. There is a chance that we can damage a thin bone near your eye that can lead to a black eye. This in itself is normally not a problem however there have been cases in the world where there can be permanent visual damage after this operation. Also if we damage the thin bones beneath the brain some of the fluid surrounding the brain could drip through the nose. Again this isn’t in itself a serious problem but there is a chance that now there is a connection between the outside environment and your brain you could get meningitis from infections going up this route. These complications are extremely rare but I cant promise you that they won’t happen.”
“Sometimes there are occasions where we need to perform a septoplasty so that we can gain access to the areas that we are concerned about (see complications below).”
Operation time – 20-45 minutes.
“There will always be a little bleeding from the nose after this operation however sometimes there is more than we can manage before waking you up. We simply stop the bleeding by putting a small tampon in your nose to stem the flow. This will probably stay in for a few hours before we take it out and allow you to go home. “
“The chance of an infection is quite low especially if you remember to clean your nose out with the salt water douches you’ll be provided with after the operation. If you have any problems we can start antibiotics after the operation.”
“We are going to be removing cartilage and bone from the middle part of your nose which normally has no major consequences. If however, you were to repeatedly have this operation and we kept taking away the support for the nose then there is a chance that the nose shape will change because of this. In extreme cases boxers can lose all the support for their nose and it just collapses. The chances of this happening for you on your first operation is very low, but there still is a chance and I need to inform you about this. Specifically also you could have a hole in the septum which is the separator between the two sides of the nose. All of these problems can be corrected but they would require a much better operation if they did happen.”
Normally takes about 5-10 minutes to perform.
"We are going to be looking around your nose, mouth, throat, voice box, and gullet / oesophagus. We have probably already done this in clinic with a flexible scope but now we need to have a much better look at the areas we can’t see with the flexible scope."
"The risks are very small, there is a risk of scratching the lining of the throat which can cause some bleeding which generally is only specks of blood. If there is something that doesn’t look right however, we will take a biopsy which will be sent to the lab. If we take this biopsy there is a chance that you could experience some more bleeding after that. With these scratches you might also get an infection, a bit like a sore throat. This can be treated with anitbiotics."
"Very rarely there is a chance that we could puncture or damage any part of the areas we are looking at. This is very rare but it would require us to fix this immediately with another operation. (they might push you here – so the worse case scenario would be that there is a perforation of the oesophagus requiring a exploration of the chest)"
"There is also a chance of damaging your teeth during this operation, especially if you have caps or crowns. If we damage them we will fix them for you at a later date."