Surgical Procedures
Surgery may be an option if your healthcare
provider finds an obstruction in your airway or if more conservative
treatments have not worked. Whatever type of surgery is recommended, be sure
you are aware of all possible risks and side effects ahead of time. While
surgery can be an effective treatment for some patients, it doesn't benefit
everyone.
Nasal operations
Nasal surgery is used to remove blockages in
the nose (such as growths and polyps) or to repair a deviated septum ( a
displacement of the wall that divides the nose into halves). These
operations may be one part of an overall plan to treat apnea and are
generally used along with other forms of treatment, like nasal sprays and
other surgeries.
Laser-assisted uvulopalatoplasty (LAUP)
This procedure is used mainly to treat
snoring. With the LAUP (pronounced "lay up"), the surgeon uses a laser to
remove part of the uvula and soft palate. The procedure takes place in
several sessions in a doctor's office. This procedure has an undetermined
degree of effectiveness on apnea, varying from person to person.
Uvulopalatopharyngoplasty (UPPP)
This surgery involves removing the uvula (the
soft, fleshy projection that hangs in the back of the throat), the tonsils,
and part of the soft palate. Approximately 50% of patients who undergo this
operation do see improvement. Side effects, such as severe throat pain,
nasal sounding speech and the regurgitation of liquids into the nose while
swallowing, are sometimes reported.
Inferior sagittal mandibular osteotomy
(ISO) and geniohyoied advancement
with hyoid myotomy (GAHM)
The ISO and GAHM are procedures that enlarge
the airway. ISO is an operation that includes bringing the lower bone of the
jaw forward. The GAHM operation includes attaching the hyoid (the u-shaped
bone where your bottom teeth are located) to the windpipe. The effectiveness
of these operations often depends on a person's weight and lower jaw
structure.
Maxillomandibular advancement (MMO)
This reconstructive surgery involves cutting
the bone that connects the jaw to the face and moving the upper and lower
jaws forward. This operation is done under general anesthesia and requires a
hospital stay of a few days. After the operation, the jaw is wired shut to
hold it in place for about 4 weeks. A liquid diet is required and weight
loss often results. Once the wires are removed, orthodontic work may be
necessary for realignment of the teeth so they fit together properly. This
treatment is time-consuming and expensive, but it's results are positive for
some patients. The best candidates for this type of treatment are those born
with smaller-than-normal jaw or jaw that is set too far back.
Laser midline glossectomy (LMG) and
ligualplasty
These surgeries involve enlarging the area
behind the tongue by removing a portion of the back half of the tongue.
These procedures are rarely done, but may be effective for some patients.
Tracheosotomy
This surgery is rarely used to treat
sleep apnea, and is only applicable
to an immediate life threatening sleep apnea condition. It involves the
making a small surgical opening in the windpipe. The tracheostomy bypasses
any obstructions in the throat and allows air to flow freely into the lungs
while the patient is sleeping. The opening is covered during the day and
normal breathing and speech resume.
There actually are several types of tonsils. The tonsils
that are usually responsible for tonsillitis and therefore removed in a
tonsillectomy are called the palatine tonsils. These tonsils are collections
of lymph tissue on the right and left side of the lateral upper throat (also
called the oropharynx). A second set of tonsils, known as the lingual
tonsils, are located at the base of the tongue. And a third set of tonsillar
tissue, known as the pharyngeal tonsils or, more commonly, the adenoids, are
located along the back wall of the uppermost part of the throat (in a region
called the nasopharynx).
It is felt that the tonsils play a role in fighting
disease during early life. Studies have shown that the tonsils contains
disease-killing cells called natural killer cells. Moreover, the tonsillar
tissue can express surface immunoglobulins known as IgA, and white blood
cells within the tonsils can also differentiate into antibody secreting
cells.
Tonsillitis is the term for an infection of the tonsils.
Pharyngitis is an infection of the surrounding throat (called the pharynx).
These two infections often occur at the same time. Symptoms of tonsillitis
are fever, chills, sore throat and pain on swallowing.
Acute tonsillitis can be caused by both
viruses and bacteria. Generally, younger preschool children tend to get
viral tonsillitis, and older children and adults get bacterial infections.
Also, viral infections can lead to later infection by bacteria. Many of the
viruses that commonly infect the upper respiratory tract (influenza,
parainfluenza, rhinovirus) are also responsible for viral tonsillitis. The
most common bacterial infections are beta-hemolytic streptocci,
staphylococci, pneumococci and Hemophilus.
In the past, more serious bacterial
infections also caused tonsillitis. These include diphtheria and scarlet
fever. Immunizations and improved antibiotics have reduced the role of these
bacteria. The tonsils can also become enlarged in infectious mononucleosis
("mono")
Tonsillitis is treated by a combination of
supportive measures to relieve the symptoms and medicine against the
organisms causing the infection. Supportive measures include increased fluid
intake, anti-inflammatory medications and gentle salt water gargles.
Antibiotics are effective against bacterial
infections. Penicillin is still effective against many of the infectious
organisms, though some bacteria have developed resistance to this medicine
and stronger antibiotics must be used.
Viral infections are not affected by
antibiotics, and unnecessary use of antibiotics can actually make the
situation worse. These infections are best treated by supportive measures
alone.
Very severe infections require
hospitalization. Inability to swallow can lead to dehydration that is best
treated with intravenous fluid. Antibiotics are also more effective when
given intravenously.
Tonsillitis can lead to a very severe
condition called a peritonsillar abscess. An abscess is a collection of pus
caused by tissue death and breakdown of the white blood cells fighting the
infection. The swelling from an abscess can be so great that it blocks the
airway and interferes with breathing. The infection can also spread out of
the tonsil and into the neck and chest, which can be rapidly fatal. *For
these reasons it is important that tonsillitis be treated under the guidance
of a health care professional.
A persistent tonsillar infections can lead to
enlargement of tonsils and a condition known as chronic tonsillitis. Despite
antibiotic treatment, the tonsils can remain infected. The tonsils can also
trap food particles in small infoldings called crypts, producing small white
stone-like particles called tonsilliths. These can produce inflammation and
prolong the infection.
Tonsillectomy is the surgical procedure for
removal of the tonsils. As a treatment for chronic tonsillitis,
tonsillectomy is done when medicine, supportive measures, and other
non-surgical treatments are no longer effective. Each individual is
different and it is not possible to give an exact number of infections
needed before tonsillectomy should be considered. However, general
guidelines based on past research have shown that individuals with 6-7
infections in one year or 2-3 infections per year for more than a few years
would probably benefit from tonsillectomy.
In some cases tonsillectomy is a necessary
operation and sometimes must be done on a near-emergency basis. This occurs
if the tonsils are so large that they block breathing. Enlarged tonsils can
also cause obstructive sleep apnea and are removed in those cases. Patients
who are carriers of diphtheria (rare in these days) should undergo
tonsillectomy. Tonsillectomy is also recommended in individuals with just
one enlarged tonsil in order to biopsy the tissue.
A peritonsillar abscess must be drained in
some way. Relatively small or contained abscesses can be drained by
aspirating the pus with a needle, using a local anesthetic. More severe
infections require a general anesthetic and drainage in the operating room.
A tonsillectomy is a surgical procedure done
under a general anesthetic. The tonsil is surrounded by a capsule of tissue.
The surgeon uses special instruments to remove the tonsil by dissecting
between this capsule and the adjacent throat tissue. Different surgeons have
different techniques, but the most commonly-used methods are with
electrocautery or with a cutting instrument (scalpel or scissors) For
otherwise healthy individuals, tonsillectomy can in most cases the be done
on an out-patient basis. The site where the tonsils were taken out heals on
its own over a period of 7-10 days. Research has shown that removal of the
tonsils does not hinder the bodies immune system.
Tonsillectomy is done using a general
anesthetic, and there always is a small risk of complications from the
anesthesia. The major complication associated with the tonsillectomy itself
is bleeding at the site where the tonsils were removed. This can occur right
after the operation or up to seven to ten days afterwards when the scar
covering the operative site falls off. Roughly 1-2% of patients who have
tonsillectomy will have bleeding severe enough to require a trip to the
emergency room. About one-half of these people will need to go back to the
operating room to control the bleeding, and the other half will stop
bleeding on their own. As with any surgical procedure, there are rare risks
of other complications.
Post-operatively, a tonsillectomy results in
a very sore throat. The physician will prescribe pain medications and
antibiotics to help relieve these symptoms. Some individuals cannot swallow
enough fluids after the operation to prevent dehydration and must return to
the hospital for intravenous fluids. The pain medications are also powerful
and must be taken with care.
A child snoring is a problem needing medical
attention. The snoring could be related to apnea. Sleep apnea has been
linked to some cases of sudden infant death syndrome (SIDS), although the
exact relationship is still uncertain. Sleep apnea may be present in
children who are overweight and those who have enlarged tonsils and
adenoids. Children with sleep apnea may snore, squeak, have difficulty
breathing and sleep fitfully. Since it is not normal for a child to snore,
parents should report their child's snoring to a healthcare provider. Older
children who have sleep apnea may seem sluggish and may perform poorly in
school. Sometimes they are labeled "slow" or "lazy."
