General ENT, FAQs

What is sinusitis and endoscopic sinus surgery?
What is snoring and obstructive sleep apnea?
What is a thyroid nodule and how is it evaluated?
What does the evaluation of a neck lump entail?

What is sinusitis and endoscopic sinus surgery?

The sinuses are bony hollows in the head. When the lining of the nose and sinuses becomes swollen with allergies or infections, the sinuses can become obstructed. If they stay obstructed long enough, the mucus in the sinuses can become infected. When this occurs, patients typically experience facial pain in the distribution of the sinuses, as well as thickened, often yellow or green, nasal discharge, as well as nasal congestion.

A variety of other symptoms can occur with sinusitis, including runny itchy eyes, cough, ear symptoms including discomfort or a sense of fullness in the ears, hoarseness, and a bad smell in the nose. Sinus swelling can lead to the formation of nasal polyps. Nasal polyps, in turn, tend to obstruct sinuses and lead to sinusitis.

Facial pain, in isolation, can have other causes, including temporomandibular joint syndrome (TMJ), dental disease and non-sinus headache.

Since infection can block the sinus chambers, initial treatment generally includes antibiotics to fight infection and medicines to encourage the sinuses to open and drain. Typically these include oral and/or topical decongestants. Other treatments may include steroid nasal sprays and antihistamines. Patients who smoke will benefit from suspending smoking, permanently if possible – but at minimum during medical treatment.

When medical management is ineffective and sinusitis becomes recurrent, a thorough ENT evaluation is warranted. The initial evaluation includes a thorough history and physical exam, which often involves a telescopic exam of the nasal cavity. This provides the otolaryngologist (ENT doctor) with detailed intranasal information regarding septal deviations, nasal turbinate abnormalities and areas of abnormal drainage or polyp formation.

CT scanning of the sinuses after medical management may be recommended for patients with chronic symptoms to allow documentation of chronic sinusitis. CT is also a valuable tool for planning when surgery is warranted.

Patients may require sinus surgery if all medical management has failed – typically endoscopic sinus surgery. With endoscopic surgery, the doctor can examine and make repairs to the nasal cavity through a nasal telescope, without external incisions.

Occasionally this surgery will be performed with a state-of-the-art CT guidance system, which allows the surgeons a whole new level of information for safe sinus surgery. The surgery is typically performed under general anesthesia, but can be performed under local anesthesia and usually takes about 90 minutes. Patients may go home the same day or may stay overnight. Patients post-operatively will have generally mild discomfort and some nasal congestion. Surgery patients are directed to limit strenuous activity for about a week or two after surgery.

One or two post-operative visits are required within the first two weeks after surgery, during which the nasal cavity and sinuses are cleaned. The endoscopic sinus surgery philosophy used at the Mass. Eye and Ear is that limited surgery in key areas of the sinuses allows improved aeration and drainage, often giving dramatic improvement. This sinus surgery is generally very well tolerated.

What is snoring and obstructive sleep apnea?

Often regarded humorously, snoring can be a difficult problem – both for patients and their bed partners. It is the sound made by the soft palate and uvula during inhalation. It occurs during sleep because of the way the throat muscles relax. Although snoring does come from the mouth, it can be made worse with nasal obstruction as this limits inward airflow. Patients are at risk if their oral cavity is small and crowded, if their uvula and palate are long, if they have large tonsils, or are obese.

Depending on the amount of redundant tissue, the throat may actually close during sleep, rather than just reverberate with snoring. We call this obstructive sleep apnea. In obstructive sleep apnea, oxygen levels fall. This can lead to significant strain on the lungs and heart, and may generate heart arrhythmias.

The evaluation of snoring related to obstructive sleep apnea starts with a full office otolaryngology head and neck exam with focus on the upper airway and digestive tract. Usually formal sleep study is recommended, which can offer definitive diagnosis of obstructive sleep apnea a measure of its intensity.

The treatment of snoring and obstructive sleep apnea includes a variety of interventions. Weight loss is generally recommended. In addition, there are a variety of nasal and oral airflow devices, including CPAP, BI-PAP masks to reduce obstruction during sleep.

A variety of surgical options are available for snoring and obstructive sleep apnea, all of which either scar or shorten the palate and uvula. These include radiofrequency treatment, CO2 laser palate and uvula treatment (LAUP), or standard surgical uvulopalatopharyngoplasty (UPP).

Typically, during surgery for snoring and obstructive sleep apnea, any areas of nasal obstruction are corrected at the same time. In select patients, mandibular procedures may be included to increase the chance of surgical cure. Generally these procedures are well tolerated, but involve a sore throat that lasts for typically seven to 10 days after surgery.

What is a thyroid nodule and how is it evaluated?

Nodules within the thyroid gland are very frequent in the adult population. Some studies suggest up to 50 percent of the adult population have thyroid nodules. They are commonly benign but may represent thyroid cancers. The risk of thyroid cancer is higher in the elderly, and is higher with a past history of radiation therapy. The larger the nodule, the higher the risk of cancer.

Thyroid nodules may be identified during routine physical exams by general medical physicians, or may be identified by the patient during a shower or during shaving. When large enough they can also be sensed as a lump in the neck, especially noticeable during swallowing.

The evaluation of the thyroid nodule involves a complete history and head and neck physical exam, including evaluation of vocal cord function. The nerve to the vocal cord travels in close proximity to the thyroid and can occasionally be affected by nodules. This requires a vocal cord evaluation after a complete history and physical exam.

Testing is typically recommended, usually a blood test to measure thyroid function and often a thyroid ultrasound to determine the exact nature and size of the nodule. This is painless and involves no radiation.

The central test for work-up of the thyroid nodule is a fine needle aspiration. Fine needle aspiration can be considered a microscopic needle biopsy. This often allows definitive diagnosis. Surgery is typically reserved for lesions that are identified as cancerous or suspicious on fine needle biopsy. Other treatment options are available for tumors confirmed to be benign after biopsy.

For large thyroid masses or goiter, additional evaluation is often necessary, and may include CT scanning, MRI scanning, or barium swallow. These tests measure the relationship of the thyroid mass to the adjacent swallowing tube (esophagus) and breathing tube (trachea).

At Mass. Eye and Ear, surgery of the thyroid and parathyroid glands at the Massachusetts Eye and Ear Infirmary is performed with an advanced recurrent laryngeal nerve monitoring system. This new technology allows real-time vocal cord monitoring to help in identification and preservation of this important nerve during thyroid surgery. The system may decrease the rate of vocal cord nerve injury and may reduce the incidence of voice and swallowing problems after thyroid surgery.

What does the evaluation of a neck lump entail?

A complete head and neck exam is essential to view the entire upper airway and digestive tract. It is important to assess a history of smoking in a patient with a neck nodule.

During the ENT office exam, the location of the nodule can often given a clue as to its identity. CT and MRI scanning and other imaging evaluation is sometimes necessary. Fine needle aspiration and biopsy is an important test and usually provides a definitive diagnosis without surgery.