An overview of our ENT services
In these toggles, we provide some general information about the procedure we perform and the conditions we treat. For specific information about how we can help you, contact us for a consultation.
Endoscopic Sinus Surgery/FESS
Sinusitis means inflammation of the sinus. A viral infection usually causes this inflammation. Most people will have some degree of sinusitis with a cold.
The cheekbone (maxillary) sinuses are the most commonly affected. When this infection develops rapidly over a few days and lasts a short time, it is called acute sinusitis. Many cases of acute sinusitis last a week or so, but it is not unusual for it to last 2-3 weeks. If the sinusitis becomes persistent and lasts longer than three months, it is called chronic sinusitis.
What causes chronic sinusitis?
Most cases of chronic sinusitis develop following an acute sinusitis infection. We divide chronic rhinosinusitis into three different categories, depending upon the features that are present:
Chronic rhinosinusitis without polyps is the most common type of rhinosinusitis. This is caused by inflammation, due to certain predisposing factors such as allergy, irritation or structurally narrow drainage paths from the sinuses.
Chronic rhinosinusitis with polyps is where the lining of the nose and sinuses become so swollen that they appear like pale grapes. These common polyps are not cancer and do not develop into cancer. The polyps can become large and numerous enough to clog the sinuses and the nasal passage, causing symptoms.
Chronic rhinosinusitis with fungi: Fungi is normal in the air around us, and most of us can breathe in air containing fungi without problems.
However, in some people fungi causes the sinus lining to make thick, dense mucus that fills the sinuses and we can see fungi in the mucus under the microscope.
How do I diagnose chronic sinusitis?
I can diagnose chronic sinusitis by assessing your symptoms and examining your nose with a specialized instrument called a nasal endoscope.
The nasal endoscopy allows me to identify any abnormalities or deviation of the bones in your nose or the sinus drainage passage. I can also look for any other problems, such as nasal polyps.
As a general rule, X-Rays or scans are not used for the diagnosis of chronic sinusitis. This is because studies have shown that many people who have no sinusitis, have some findings on sinus scans. CT scan if requested, is usually done to help me plan surgery (not for sinusitis diagnosis) if medical treatment has failed.
How is chronic sinusitis treated?
Medical treatments:
Medical treatment is the first step, and this cures the majority of people. We recommend a more extended 4-12 week treatment for chronic sinusitis.
The medicines that we recommend include the following:
Steroids applied to the nasal lining using sprays or drops to help reduce inflammation. Initially, we suggest a course of steroid tablets by mouth for 10-14 days.
In patients without polyps, prolonged courses (4-8 weeks) of specific antibiotics at lower doses are sometimes helpful.
A saline nasal solution is beneficial to relieve congestion and blockage.
Surgical treatments
I suggest surgery if the condition does not improve with the above medical treatment. The primary purpose of surgery is to improve the drainage of the affected sinus. The most common operation is called functional endoscopic sinus surgery (FESS).
FESS refers to surgery inside your nose and sinuses with specially designed instruments.
I use an endoscope to look inside your nose. This a thin, rigid instrument that contains lenses that allows a detailed magnified view of inside the nose. I can then see the opening of the sinus drainage channels and remove any tissues (e.g. polyps) that are blocking the affected sinus. This helps to improve the drainage, ventilation and restore normal function to the sinuses.
If you have a deviated septum, I can straighten it out at the same time (septoplasty).
FESS is minimally invasive and does not require any cut or scar on your face or nose. It has a high success rate in relieving symptoms of chronic sinusitis.
FESS is carried out under general anaesthesia, i.e. while you are asleep. It takes a couple of hours on average, and you are typically discharged home the same day.
A more recently developed operation I offer is called balloon catheter dilation of sinus openings. This involves pushing a small balloon through a flexible tube in the nostril into the blocked sinus.
We inflate the balloon which pushes wide the blocked area. We then deflate the balloon and remove it. Following this procedure, there is a good chance that the sinus drainage channel is widened and can, therefore, drain properly.
What to expect after endoscopic sinus surgery
Bleeding
It is normal to have some bloody discharge for the first 3-5 days after sinus surgery, especially after you irrigate your sinuses. If steady bleeding occurs after surgery, tilt your head back slightly and breathe through your nose gently. You may dab the outside of your nose with tissue but avoid any nose blowing. If this does not stop the bleeding, you may use Otrivine spray. Several sprays will usually stop any bleeding. If Otrivine fails to stop steady nasal bleeding, then you should call A&E.
Pain
You should expect some nasal and sinus pressure and pain for the first several days after surgery. This may feel like a sinus infection or a dull ache in your sinuses. Extra-strength Paracetamol is often all that is needed for mild postoperative discomfort. You should avoid aspirin. If Paracetamol is not sufficient to control the pain, you should use the prescribed pain medication.
Fatigue
You can expect to feel very tired for the first week after surgery. This is normal, and most patients plan on taking at least one week off of work to recover. Every patient is different, and some return to work sooner.
Nasal congestion and discharge
You will have nasal congestion and discharge for the first few weeks after surgery. Your nasal passage and breathing should return to normal 3-4 weeks after surgery.
Postoperative visits
You will have a certain number of postoperative visits depending on what surgery you have. During these visits, I will clean your nose and sinuses of fluid and blood left behind after surgery. There is some discomfort involved with the cleaning, so it is best to take a pain medication (described above) 45 minutes before your visit.
What to avoid after endoscopic sinus surgery
- If you are a smoker, please do not smoke for at least four weeks after surgery.
- You should avoid straining, and heavy lifting (> 20 lbs) as this can cause bleeding. You can resume 50% of your regular exercise regimen at one week after surgery and your normal routine two weeks after surgery.
- Avoid nose blowing for at least 14 days after surgery as this can cause bleeding. If you have to sneeze, do it with your mouth open to prevent nasal irritation.
- If you were taking nasal steroid sprays before surgery, you should avoid using these for at least two weeks after sinus surgery. This allows the lining of the nose and sinuses to heal. I will tell you when it is safe to restart this medicine.
- Postoperative care instructions
- The first night keep your head elevated; the higher, the better. Sleeping in a recliner can help. For the first week after surgery, keep your head elevated 30 degrees.
- Drink plenty of fluids. Use a cool-mist humidifier at your bedside to help moisturise membranes in your nose and mouth.
- Avoid any travel requiring rapid elevation changes, i.e., airline or mountain travel for 2-3 weeks.
- Please use the prescribed nasal drops as per instructions.
Nasal saline spray
Nasal saline mist spray must be used every 2-3 hours after surgery and can make your nose more comfortable after surgery. These sprays are over-the-counter medications, and you can purchase them in any pharmacy.
Sinus Irrigations
You will start the sinus irrigations twice daily, the day after surgery. At first, they will feel strange if you haven’t done them before. However, they will quickly become quite soothing as they clean out the debris left behind in your sinuses after surgery. You can expect some bloody discharge with the irrigations for the first few days after surgery.
The “sinus rinse” system is available at many pharmacies with prepared packets of salt-baking soda mixture. Alternately, you can make up the mixture using this recipe: Mix 1⁄4 teaspoon of non-iodised salt with a 1⁄4 teaspoon of baking soda in 250mL of room temperature tap water. Use a squeeze bottle to flush the solution gently through one nostril and allow it to come out through the other nostril or from your mouth.
These saline sprays and saline irrigations are critical for success after sinus surgery. You can not overdo this!
What are the possible complications from FESS?
All operations carry some element of risk in the form of possible side effects. There are some risks that you must know about before giving consent to this treatment. However, these potential complications are very uncommon.
There is the risk of bleeding with any operation. It is very common for small amounts of bleeding from the nose in the days following the procedure. Major bleeding is extremely uncommon, and it is very rare for a transfusion to be required.
Eye problems
The sinuses are very close to the wall of the eye socket. Sometimes minor bleeding can occur into the eye socket, which usually presents as some bruising around the eye. This often gets better without any special treatment, although it is essential that you do not blow your nose. More severe bleeding into the eye socket can sometimes occur; however, this is very rare. This level of bleeding can cause severe swelling of the eye, double vision or in very rare cases, loss of sight. If such a severe eye complication did occur, you would be seen by an eye specialist and may require further operations.
Spinal fluid leak
The sinuses are very close to the bone at the base of the brain. All sinus operations carry a small risk of damage to this thin bone with leakage of fluid from around the brain into the nose, or other related injuries. If this rare complication does happen, you will have to stay in the hospital longer and may require another operation to stop the leak. On very rare occasions, an infection can spread from the sinuses into the spinal fluid, causing meningitis, but this is extremely uncommon.
When to call A&E after surgery
- Fever after the day of surgery higher than 101°F
- Constant clear watery discharge after the first week of surgery
- Sudden visual changes or eye swelling
- Severe headache or neck stiffness
- Severe diarrhoea
- Steady, brisk nose bleeding that doesn’t get better after using Otrivine
Eardrum repair/tympanoplasty
The ear consists of the outer, middle and inner ear. Sound travels through the outer ear and reaches the eardrum, causing it to vibrate. The vibration is then transmitted through three tiny bones (ossicles) in the middle ear. The vibration then enters the inner ear where the nerve cells are. The nerve cells within the inner ear are stimulated to produce nerve signals. These nerve signals are carried to the brain, where they are interpreted as sound.
What is a hole in the eardrum?
A hole in the eardrum is known as a “perforation”. It can be caused by infection or injury to the eardrum.
Sometimes a hole in the eardrum does not cause any problem and can heal itself. However, if the hole in the eardrum is large, then the hearing may be reduced, and discharge may be present.
How is the condition diagnosed?
The hole in the eardrum can be identified using a special medical instrument called an auriscope. The auriscope consists of a magnifying lens and light. Examination with the auriscope is pain-free.
I may need to use a microscope to clear out wax or debris from your ear canal to get a good view of your eardrum and inspect the perforation.
The amount of hearing loss can be determined only by careful hearing tests done by an audiologist.
Severe hearing loss usually means that the ossicles are not working properly, or the inner ear is damaged.
How can a hole in the eardrum be treated?
If the hole in the eardrum has only just occurred, no treatment may be required. The eardrum may heal itself. If an infection is present, you may need antibiotics, usually as an ear drop. You should avoid getting water in the ear until the eardrum heals.
If the hole in the eardrum is causing discharge or deafness, or if you wish to swim, it may be sensible to have the hole repaired. The operation is called a myringoplasty.
Aims of the operation
The benefits of closing a perforation include prevention of water entering the middle ear while showering, bathing or swimming, which could cause an ear infection.
Repairing the eardrum may also improve hearing.
How is the operation done?
I will administer general anaesthetic through a small hidden cut made above the ear opening. Occasionally I make the cut behind the ear. In most patients, I use the cartilage from your ear – after shaping and thinning – to repair the perforation.
I then place dressings in the ear canal, and the skin closed with absorbable stitches.
Occasionally, I may need to widen the ear canal with a drill to get to the perforation.
How successful is the operation?
The operation can successfully close a small hole nine times out of ten. The success rate is not quite so good if the hole is large or if there is a major dysfunction of your eustachian tubes.
Possible complications
There are some risks that you must be aware of before giving consent to this treatment. These potential complications are rare:
Taste disturbance
The taste nerve runs close to the eardrum and may occasionally be damaged. This can cause an abnormal taste on one side of the tongue. This is usually temporary, but sometimes it can be permanent.
Dizziness
Dizziness is common for a few hours following surgery. On rare occasions, dizziness can last for months or even years if the inner ear is damaged during surgery.
Hearing loss
In a minimal number of patients, severe deafness can happen if the inner ear is damaged.
Tinnitus
Some patients may notice noise in the ear if the hearing loss worsens.
Facial Paralysis
The nerve for the muscles of the face runs through the ear. Therefore, there is a slight chance of facial paralysis; however, it is extremely rare. The facial paralysis affects the movement of the facial muscles that are required for the closing of the eye, making a smile and raising the forehead. The paralysis can be partial or complete. It may occur immediately after surgery or have a delayed onset. Recovery can be complete or partial.
Allergic reaction to the ear dressings
Some patients may develop a skin reaction to the ear dressings. If your ear becomes itchy or swollen, you should contact my secretary.
What happens after the operation?
The ear may ache a little, but this can be controlled with paracetamol or Brufen.
You will usually go home the same day
There may be a small amount of discharge from the ear canal. This usually comes from the antiseptic solutions in the ear dressings.
Some of the ear dressings may fall out. If this occurs, there is no cause for concern. It is sensible to trim the loose end of the ear dressings with scissors and leave the rest in place.
I will remove the dressings in the ear canal after two or three weeks at the hospital.
You should keep the ear dry and avoid blowing your nose too vigorously.
Plug the ear with a cotton wool ball coated with Vaseline when you are having a shower or washing your hair. If the ear becomes more painful or is swollen, then you should contact my secretary.
How long will I be off work?
The exact time needed off work varies between patients, but as a guide, you may need to take two weeks off work.Acknowledgement
The information has been taken from ENT UK with some modifications to reflect my practice.
Mastoidectomy/Cholesteatoma Surgery
The ear consists of the outer, middle and inner ear. The outer ear is covered by skin. A mucus producing membrane covers the middle ear. Sound travels through the outer ear and reaches the eardrum, causing it to vibrate. The vibration is then transmitted through three tiny bones (ossicles) in the middle ear. The vibration then enters the inner ear where the nerve cells are. The nerve cells within the inner ear are stimulated to produce nerve signals. These nerve signals are carried to the brain, where they are interpreted as sound.
What is the mastoid bone?
The mastoid bone is the bony prominence that can be felt just behind the ear. It contains several air spaces, the largest of which is called the antrum. It connects with the air space in the middle ear. Therefore, ear diseases in the middle ear can extend into the mastoid bone.
Why is mastoid surgery done?
Operations on the mastoid may be necessary when ear infection within the middle ear extends into the mastoid. Most commonly this is a pocket of skin growing from the outer ear into the middle ear, known as cholesteatoma. This causes infection with discharge and some hearing loss. The pocket slowly gets larger, often over many years, and causes gradual erosion of surrounding structures. Erosion of the ossicles can result in hearing loss. The only effective way to get rid of this pocket of skin is surgery.
How is mastoid surgery done?
There are several ways of doing the operation, depending on the extent of the ear disease. I will discuss these with you before the operation. The methods are called atticotomy and mastoidectomy and involve cutting either above or behind the ear while under a general anaesthetic.
I then remove the bone covering the infection within the mastoid cells. The resultant bony defect is called a mastoid cavity. I may leave the mastoid cavity open into the ear canal in very extensive disease. This allows inspection of the mastoid cavity easily.
In limited disease, I usually close up the mastoid cavity with bone, cartilage or muscle from around the ear. At the end of the operation, I will pack your ear while it heals.
The procedure takes between one and three hours.
Does it hurt?
The ear may ache a little, but this can be managed with painkillers such as Paracetamol or Brufen.
How successful is the operation?
The chances of obtaining a dry, trouble-free ear from this operation in my hands are over 80%. In some patients, it is possible to improve the hearing as well. I will discuss this during the consultation.
Possible complications
There are some risks that you must be aware of before giving consent to this treatment. These potential complications are rare:
Loss of hearing
In a small number of patients, the hearing may be further impaired due to damage to the inner ear. If the disease has eroded into the inner ear, there may be a total loss of hearing in that ear.
Dizziness
Dizziness is common for a few hours following mastoid surgery and may result in nausea and vomiting. On rare occasions, dizziness is prolonged.
Tinnitus
Sometimes the patient notices noise in the ear, in particular, if the hearing loss worsens.
A weakness of the face
The nerve that controls the movement of the muscles in the face runs inside the ear and may be damaged during the operation, but this risk is very rare. If it happens, the face may lose its movement on one side, but it is usually temporary.
What happens after the operation?
You will usually go home the same day after the operation. There is sometimes some dizziness, but this usually settles quickly. The stitches are typically self-dissolving.
There may be a small amount of discharge from the ear canal. This usually comes from the ear dressings. Some of the packing may fall out. If this occurs, there is no cause for concern. It is sensible to trim the loose end of packing with scissors and leave the rest in place.
I will remove the packing in the ear canal after 2 or 3 weeks.
You should keep your ear dry. Plug the ear with a cotton wool ball coated with Vaseline when you are having a shower or washing your hair. If the ear becomes more painful or is swollen, then you should contact my secretary.
How long will you be off work?
Two weeks.
Is there any alternative treatment?
The only way to remove the infection entirely is a mastoid operation. In patients who are unfit for surgery, the only alternative is the regular cleaning of the ear and the use of antibiotic eardrops. This at best; can only reduce the discharge
Will you need further operations?
It is usual to have a “second look” surgery to ensure there is no residual infection. This is usually done after a year.
In some cases, if the mastoid cavity is free of disease but too big, you may benefit from a mastoid obliteration. This is a procedure undertaken to reduce the size of the cavity, making the ear easier to look after by reducing wax and debris build-up. It also makes it possible to enjoy swimming without the risk of ear infection.
Some patients may require hearing reconstruction if their ear remains free of infection. I will discuss this if suitable in your case.
Acknowledgement
The information has been taken from ENT UK with some modifications to reflect my practice.
Balance and Tinnitus Management
Although there is no simple pill or operation to cure the majority of cases of tinnitus, there are several strategies that are very helpful in improving the condition.
For people with mild tinnitus, simple explanation and reassurance may be all that is required. For more intrusive tinnitus, a form of counselling may prove helpful. This can be administered as a standalone therapy or as part of a broader treatment strategy such as tinnitus retraining therapy (TRT) which us a mixture of counselling and sound therapy.
If tinnitus is associated with hearing loss, then trying to correct the hearing loss is usually very helpful. Depending on the cause of the hearing impairment, medication, surgery or hearing aids may be needed.
Sound therapy can help many with tinnitus. This can take the form of an electric device that sits at the person’s bedside and produces low-level soothing sound to distract them from their tinnitus at night. During the daytime, it is possible to wear a sound generator, which is a small device that resembles a hearing aid and produces white noise.
Psychological techniques such as cognitive behavioural therapy (CBT), mindfulness meditation and relaxation therapy can be beneficial for those who find that stress worsens the problem.
For a very small number of people, usually those with objective tinnitus, there may be a drug or a surgical procedure that can cure the problem.
Monitoring and re-assessment
Tinnitus is such a variable symptom that is challenging to make any hard and fast rules regarding long-term management.
This is a very individual decision that will be made by you and your specialist.
Uncertainties
There are many questions regarding tinnitus that remain to be answered regarding both the mechanisms by which it is generated and the search for more effective treatments. Various research avenues are currently being explored, including the use of certain types of drug and electromagnetic stimulation of the auditory system.
Throat disease
What is thyroid? What does it do in my body?
The thyroid is a gland in the lower part of your neck in front of your windpipe (trachea). It is shaped like a butterfly, with a right lobe and a left lobe. The isthmus, a thin piece of tissue, connects the two lobes. You cannot feel a healthy normal thyroid through the skin.
The thyroid uses iodine, a mineral found in some foods and in iodized salt, to help make a hormone called Thyroxine. Thyroxine helps in the control of your heart rate, body temperature, and how quickly food is changed into energy (metabolism).
At the back of your thyroid, there are 4 attached small glands, called parathyroid, two on each side. The Parathyroid hormone is essential to control the amount of calcium in the blood.
What causes thyroid cancer?
In most cases, we cannot say what has caused thyroid cancer. There are certain events which are known risk factors for thyroid cancer. However, having a risk factor does not mean that you will get cancer. Equally, not having risk factors doesn’t mean that you will not get cancer.
The known risk factors for thyroid cancer are:
- Being exposed to radiation to the head and neck as a child.
- Having a history of an enlarged thyroid (goitre) due to any reason.
- Having a family history of thyroid disease or thyroid cancer.
- Rarely certain genetic conditions such as familial medullary thyroid cancer (FMTC), multiple endocrine neoplasia type 2A syndromes
Also, thyroid cancer is much more common in females, in Asians and the age between 25 to 65 years.
What are the different types of thyroid cancer?
There are five main types of thyroid cancer:
- Papillary thyroid cancer – By far, the most common type of thyroid cancer (80%).
- Follicular thyroid cancer or Hürthlecellcarcinoma – The second most common type of thyroid cancer.
- Medullary thyroid cancer– treated with surgery like papillary and follicular cancer
- Anaplastic thyroid cancer – the rarest variety with extremely poor cure rate and survival
- Thyroid lymphoma – This is treated with Radiotherapy and not with an operation
The first two types of thyroid cancer, papillary and follicular, are grouped under differentiated thyroid cancers. These two make up more than 90% of all thyroid cancer, and our discussion will primarily focus on their treatment.
When should you suspect thyroid cancer? What are the symptoms of thyroid cancer?
Thyroid cancer usually does not produce any distress or discomfort. It is sometimes found during a routine clinical exam or scans for other health problems. Symptoms may occur as the tumour gets bigger. Other conditions may cause the same symptoms. However, it is advisable to get a checkup if you have any of the following problems, especially if you have any of the risk factors mentioned above:
- A lump in the neck
- Trouble breathing
- Trouble swallowing
- Hoarseness
How do you find out if I have thyroid cancer?
The diagnosis of thyroid cancer usually begins with a clinical examination of your body to check for signs of disease. The signs include lumps or swelling in the neck, voice box, and lymph nodes, and anything else that seems unusual. I will also take a history of your health habits and past illnesses and treatments. It is common to examine your voice box with a thin tube passed through your nose to see if the vocal cords are moving normally.
In all cases, I will check your blood for abnormal levels of thyroid-stimulating hormone (TSH). In almost all cases with thyroid cancer, this is within the normal level. After that, an ultrasound exam of your thyroid gland is carried out. The ultrasound uses high-energy sound waves (ultrasound) that are bounced off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. This procedure can show the size of a thyroid tumour and whether it is solid or a fluid-filled cyst.
Ultrasound is used to guide a fine-needle aspiration biopsy. This refers to passing a thin needle into the suspicious-looking thyroid nodule while looking with ultrasound to suck few cells from that nodule (called as FNAC).
I insert the needle through the skin into the thyroid while you are awake in the clinic. Several tissue samples are taken from different suspicious parts of the thyroid.
A pathologist views the tissue samples under a microscope to look for cancer cells. There are international standards for grading these cells into different types by the pathologist that helps the surgeon give you an idea about the risk of cancer and decide on your treatment. Ultrasound with needle biopsy may also be done if you have enlarged lymph nodes in your neck. Occasionally further scans such as CT or MRI Scan may be requested, usually to find out if cancer has spread elsewhere out of your thyroid gland.
In many patients, a definite diagnosis cannot be made on scan or needle biopsy. In this case, the only way to confirm the presence or absence of thyroid cancer is by removing the lobe of the thyroid of the suspicious nodule. The decision to do so is made after discussing the risk of thyroid cancer in your case based on your examination, history and findings on the needle biopsy.
Are all thyroid nodules cancer? Does everyone with thyroid nodule require surgery?
No, not every thyroid nodule needs treatment. The vast majority of thyroid nodules do not require any treatment at all. Thyroid nodules are incredibly common; some studies in the western world indicate that ultrasound scans show the presence of thyroid nodules in more than 50% otherwise healthy adults. The probability of developing a thyroid nodule rises with age and is more common in females.
This figure is likely to be even higher for India due to widespread Iodine deficiency.
Only a small minority, less than5% to 10% of these nodules, will have cancer. Generally, no investigation is required if the nodules are smaller than 1 cm, especially if you do not have any of the above-mentioned risk factors.
How is thyroid cancer treated?
Thyroid cancer is primarily treated by an operation to remove the cancerous part.
Surgery
Surgery is the most common treatment of thyroid cancer. I will use one of the following procedures:
- Lobectomy – Removal of one thyroid lobe, the one which has the nodule with, suspected cancer.
- Total thyroidectomy – Removal of the whole thyroid.
- Neck Dissection – This refers to the removal of lymph nodes in the neck that contains cancer. This is required if scans or needle biopsy suggest enlarged lymph nodes in your throat. The extent of neck dissection depends upon the area and number of diseased lymph nodes.
In some cases, with large thyroid nodules, neck dissection may be done even if there are no apparent diseased enlarged lymph nodes. This is because several studies have shown a high rate of microscopic spread of cancer cells in lymph nodes adjacent to the thyroid gland.
Radiation therapy, including radioactive iodine therapy
If your thyroid cancer is large or has spread to lymph nodes in the neck, I may advise treatment with radioactive Iodine (RAI). RAI is taken as a tablet and kills any remaining thyroid cells, including cancer, which may have spread to other parts of your body. To prevent the effect of radiation coming out from this chemical, you will need to be in the hospital in an isolation room for about 24-48 hours, especially if there are children at your house.
Occasionally we may recommend external beam radiotherapy if the cancer has come back and is causing discomfort.
Chemotherapy
I rarely use chemotherapy for control of advanced thyroid cancer that has spread to different parts of the body.
Thyroid hormone therapy
Thyroid-stimulating hormone (TSH) can cause your thyroid cancer cells to grow. Therefore, in some cases, we advise tablet with thyroid hormone, thyroxine, for treatment of your thyroid cancer, to prevent the body from making TSH.
Also, because thyroid cancer treatment kills thyroid cells, the thyroid is not able to make enough thyroid hormone. After treatment, you are likely to require thyroid hormone replacement pills for life.
What is the cure rate/prognosis for thyroid cancer?
Papillary and follicular thyroid cancer has amongst the best rate of cure amongst all cancer. The outlook for most people (> 90%) with thyroid cancer is very good with an excellent chance of cure with treatment. Most patients who have thyroid cancer do not die because of thyroid cancer, but due to other causes such as other medical diseases, age, accidents or from natural causes.
However, as with any other cancer, your cure rate can be worse if your cancer is caught at an advanced stage. So, it is essential to seek medical help at an early stage.
Some factors that affect the cure rate are mentioned below:
- Your age
- Your type of thyroid cancer
- Your cancer stage – the size of the cancer and if has spread out of thyroid gland
- Whether your cancer has just been diagnosed or has recurred
Do you need any follow-up after treatment for thyroid cancer?
After your treatment for thyroid cancer, you will require to follow up with regular checkup and tests. This is necessary to look for any feature indicative of the return of cancer. In addition to clinical examination, this usually requires a blood test for thyroglobulin performed at regular intervals. Thyroglobulin is a protein that is usually only made by the healthy thyroid gland, but it can also be produced by papillary or follicular thyroid cancer cells. Measuring thyroglobulin levels is a way of detecting any remaining papillary or follicular cancer cells. In addition, you may also have an ultrasound scan, CT scan or radioactive iodine scans from time to time, to ensure there are no thyroid cancer cells in your body.
When is parathyroid surgery required?
The commonest reason for removing your parathyroid gland is when they are secreting an abnormally high amount of parathyroid hormone (PTH). In normal circumstances, the amount of PTH that they secrete is tightly linked to the level of calcium in your blood. However, due to a benign tumour in these glands or due to excess growth of these glands, you can have an excess amount of these hormones in your blood. This leads to excess calcium in your blood that is taken out mainly from your bones.
Excess calcium due to this reason leads to many side effects; some of the important ones are mentioned below:
- Osteoporosis. The loss of calcium often results in osteoporosis or weak, brittle bones that fracture easily.
- Kidney stones. The excess of calcium in your blood may cause small, hard deposits of calcium and other substances to form in your kidneys. A kidney stone usually causes significant pain as it passes through the urinary tract.
- Cardiovascular disease. Although the exact cause-and-effect is unclear, high calcium levels are associated with cardiovascular conditions such as high blood pressure (hypertension) and certain types of heart disease.
- Neonatal hyperparathyroidism. Severe, untreated hyperparathyroidism in pregnant women may cause dangerously low levels of calcium in newborns.
When should you suspect hyperparathyroidism and seek medical consultation?
Most patients with hyperparathyroidism have no significant discomfort, and the diagnosis is accidentally made when high calcium level is found in their blood test that is being done for other medical reasons.
Symptoms due to hyperparathyroidism may be so mild and nonspecific that they don’t seem at all related to parathyroid function, or they may be severe. The range of signs and symptoms include:
- Kidney stones
- Excessive urination
- Abdominal pain, peptic ulcer disease
- Tiring easily or weakness
- Depression or forgetfulness
- Bone and joint pain
- Frequent complaints of illness with no apparent cause
- Nausea, vomiting or loss of appetite
If you have been found to have excessive calcium in your blood or one of the above symptoms, it is advisable to seek medical opinion.
What investigations are usually carried out to aid diagnosis and treatment for hyperparathyroidism?
Due to the positioning and small size of the parathyroids, they are almost never felt from the outside, even when enlarged.
The standard tests for management include:
Blood tests
If the results of a blood test indicate you have elevated calcium in your blood, I will likely repeat the test to confirm these results after you have not eaten for a period of time (fasted). A number of conditions can raise calcium levels, but we can make a diagnosis of hyperparathyroidism if blood tests show you also have elevated parathyroid hormone.
Imaging tests before surgery
If we recommend surgery, we will likely use a combination of two imaging tests to locate the parathyroid gland or glands that are causing problems:
Ultrasound
Ultrasound uses sound waves to create images of your parathyroid glands and surrounding tissue. A small device held against your skin (transducer) emits high-pitched sound waves and records the sound wave echoes as they reflect off internal structures. A computer converts the echoes into images on a monitor.
Sestamibi scan
Sestamibi is a specially designed radioactive compound that is absorbed by overactive parathyroid glands and can be detected on computerized tomography (CT) scans. I will inject a small dose of the compound into your bloodstream before the imaging is done. I can often do this on the morning of surgery with special instruments (gamma camera) that can show the area of maximum radioactivity to help guide us to the right gland.
How is hyperparathyroidism treated?
Treatment of hyperparathyroidism is surgery to remove them.
However, if you meet the criteria mentioned below, it may be safe to monitor you if you do not want the operation. The criteria include:
- Your calcium levels are only slightly elevated
- Your kidneys are functioning normally
- Your bone density is average or only slightly below average
- You have no other symptoms that may improve with treatment
If you choose this watch-and-wait approach, you’ll likely need a test to check your blood calcium levels at least twice a year. You will also have to have the following monitoring tests once a year:
- Bone mineral density test (bone densitometry). The most common test to measure bone mineral density is dual-energy X-ray absorptiometry or DXA scan. This test uses special X-ray devices to measure how many grams of calcium and other bone minerals are packed into a segment of bone.
- Urine tests. A 24-hour collection of urine can provide information on how well your kidneys function and how much calcium is excreted in your urine. This test may help in judging the severity of hyperparathyroidism or diagnosing a kidney disorder causing hyperparathyroidism.
- Imaging tests of kidneys. We will also order X-rays or other imaging tests of your abdomen to determine if you have kidney stones or other kidney abnormalities.
Surgery
Surgery is the most common treatment for hyperparathyroidism and provides a cure in at least 90% of all cases. We will remove only those glands that are enlarged or have a tumour (adenoma). If all four glands are affected, we will likely remove only three glands and perhaps a portion of the fourth — leaving some functioning parathyroid tissue.
I typically perform surgery through a small neck incision in the lower part of your neck. You can usually go home after 12-24 hours.
We have decided that I will have interval monitoring rather than surgery. Is there any specific precautions or medication I need to follow?
If you have chosen to monitor, rather than treat, your hyperparathyroidism, the following suggestions can help prevent complications:
Monitor how much calcium and vitamin D you get in your diet – I recommend 1,000 milligrams (mg) of calcium a day for adults ages 19 to 50. That calcium recommendation increases to 1,200 mg a day if you’re a woman age 51 or older or a man aged 71 or older. In addition, I also recommend 600 international units (IUs) of vitamin D a day for adults ages 19 to 70 and 800 IUs a day for adults age 71 and older.
- Drink plenty of water
- Drink six to eight glasses of water daily to lessen the risk of kidney stones.
- Exercise regularly
- Regular exercise, including strength training, helps maintain strong bones. An exercise program that involves weight-bearing is best for your bone strength.
- Don’t smoke
- Smoking increases bone loss as well as increase your risk of several serious health problems.
- Avoid calcium-raising drugs
Certain medications, including some diuretics (water tablets given for high BP) and lithium, can raise calcium levels. If you take such drugs, ask your doctor whether another medication may be appropriate for you
How can I help ?
Many surgeons offer thyroid and parathyroid surgery. Your cancer cure and complication rate from the operation is heavily influenced by the expertise and skills of your surgeon.
It is essential that no part of the thyroid gland is left behind over the nerve as this can injure the nerve of your voice box.
This can lead to worse cancer outcomes due to a higher rate of cancer recurrence. If you have incomplete removal of the thyroid gland, we cannot use a blood test to monitor for cancer recurrence. Also, the risk of injury to the nerve to your voice box is higher in revision surgery.
By choosing me as your surgeon, you will be choosing someone who has extensive experience in quality thyroid and parathyroid surgery with access to the best centers of the UK, USA and Australia. I can ensure a quality operation with minimal risk of complications. The difference is in quality. You have one body, and it deserves the very best.
If your cancer has spread to lymph nodes in the neck, I can do neck dissection at the same time. You can follow this link to learn more about neck dissection.
In addition, I can also offer robotic thyroid surgery, which will allow you to avoid any visible scar on your body. You can follow this link to learn more about robotic surgery.
Tonsillectomy
What are tonsils?
Tonsils are small glands in the throat, one on each side. They are there to fight germs when you are a young child. As you get older, the tonsils become less important in fighting germs and usually shrink.
Do you need them?
Your body can still fight germs without them. We only take them out if they are doing more harm than good.
Why take them out?
We will only take tonsils out if they cause recurrent sore throats despite treatment with antibiotics. The other main reason for removing tonsils is if they are large and block the airway. A quinsy is an abscess that develops alongside the tonsil, as a result of tonsil infection, and is very unpleasant. People who have had quinsy therefore often choose to have a tonsillectomy to prevent having another. We also remove tonsils if we suspect there is a tumour in the tonsil. A rapid increase in the size of a tonsil, ulceration or bleeding occurs if a tumour of the tonsil develops.
Before your operation
Arrange for two weeks off work. Let us know if you have a chest infection or tonsillitis before your admission date because it may be better to postpone the operation. It is very important to tell us if you have any unusual bleeding or bruising problems, or if this type of problem might run in your family.
How is the operation done?
You will be asleep under general anaesthetic. We take the tonsils out through the mouth and then stop the bleeding. This takes about 30 minutes.
How long will you be in the hospital?
We usually perform a tonsillectomy as a day case procedure.
Possible complications
Tonsil surgery is very safe, but every operation carries a small risk. The most serious problem is bleeding. This may need a second operation to stop it. As many as five adults out of every 100 who have their tonsils out will need to be taken back into hospital because of bleeding. However, only one adult out of every 100 will require a second operation.
Bleeding can be serious. If you notice any ongoing bleeding from your throat, you must go to your nearest hospital casualty department.
During the operation, there is a tiny chance that I may chip or knock out a tooth, especially if it is loose, capped or crowned. Please let me know if you have any teeth like this.
Some patients notice a temporary change in how food and drink taste after the operation.
Postoperative care instructions following tonsillectomy
The following instructions will help you know what to expect in the days following surgery.
Physical activities
After this surgery, you should rest. Normal non-strenuous activity is allowed if you feel up to it. Strenuous physical activity following surgery is discouraged. You may return to work (school for children) whenever comfortable; usually after ten days.
Diet
Drink plenty of fluids: The more you drink, the sooner the pain will subside. Water, smoothies and Gatorade are excellent sources of liquid. Soft foods such as ice cream, sherbet, yoghurt, pudding, applesauce and jello, should also be encouraged. Other soft, easily chewed foods are also excellent. Avoid hot or spicy foods or foods that are hard and crunchy. Often, chewing gum speeds comfortable eating by reducing the spasm after surgery and can be started any time after surgery.
Pain
For the first 10 -14 days following surgery, pain in the throat is inevitable. In some cases, the pain is worse between day three and six after surgery. We can manage this pain with Paracetamol or Codeine (prescription will be given at the time of surgery).
Avoid medication containing aspirin for two weeks. Pain is often worse at night and may prompt the need for additional pain medication. Ear pain, especially with swallowing is also a common occurrence; it is not an ear infection, but due to referred pain from the surgery. Occasionally a stiff neck may occur.
Ice collar
An ice collar can also be helpful for postoperative sore throat. Make this by placing ice cubes and water in a large Zip-Loc bag and wrapping it in a towel. Gently lay the ice pack on the front of the neck.
Fever
A low-grade fever (less than 101 degrees) following surgery may occur and should be treated with Paracetamol. While children have a fever, they should play quietly or remain in bed. If the fever persists (more than two days) or if a higher fever develops, call. Fever may indicate that you have not taken in sufficient fluids or may have an infection.
Bleeding
Postoperative bleeding is unusual, but it can occur up to two weeks after surgery. Most bleeding is minor, and you may only see a little coating of blood on the tongue. Put your child into bed, sitting upright, and place an ice collar on their neck. Watch for spitting, coughing, or vomiting of blood.
If you have a significant ongoing fresh bleed following surgery, call A&E immediately.
What else do you need to know?
- If you are a smoker, please do not smoke for at least three weeks after the surgery.
- Do not take any pain medication not prescribed. Please do not use aspirin (which children should never receive anyway) as this increases the risk for bleeding.
- Bad breath may be present for 10-14 days following the procedure.
- You may have constipation for several days after the procedure. Narcotic pain medications tend to make this worse.
- If you look inside the mouth, you may see two whitish areas where the tonsils used to be. This is normal and not a sign of infection.
- I strongly recommend that you stay in the local area for a minimum of two weeks after surgery due to the small but important risk of bleeding.
- Plan on making a follow-up appointment 3 – 4 weeks after surgery
Acknowledgement
The information has been taken from ENT UK www.entuk.org with some modifications to reflect my practice.
Grommets
What are grommets?
Grommets are tiny plastic tubes, which sit in a hole in the eardrum. They let air get in and out of the ear, which keeps the ear healthy.
Why do we use grommets?
Some people get fluid behind the eardrum, often referred to as ‘glue ear’. It is very common in young children, but it can happen in adults too. In most cases, it is thought to be due to dysfunction of the ear tube (eustachian tube) and its failure in maintaining adequate pressure behind the eardrum.
Most young children will have glue ear at some time, but it doesn’t always cause problems. We only need to treat it if it is causing problems with hearing or speech, or if it is causing lots of ear infections.
How are grommets inserted?
I place the grommets in the eardrum under a short general anaesthetic (occasionally under local anaesthesia in adults). I usually carry out the procedure as a day case admission to hospital. The surgery takes place inside the ear canal, so there are no cuts to see on the outside of the ear. A small opening is made in the eardrum using a microscope to magnify the area, and the fluid is sucked out of the ear with a fine sucker. I then place the grommet in the opening in the eardrum. The procedure takes between ten and twenty minutes.
How long do grommets stay in for?
Grommets fall out by themselves as the eardrum is continually growing. They may stay in for six months, or a year, or sometimes even longer in older children. You may not notice when they drop out.
Does your child have to have grommets?
Glue ear tends to get better by itself, but this can take a while. We like to leave children alone for the first three months because about half of them will get better in this time. After three months, I will see your child again and decide whether we need to put in grommets.
If the glue ear is not causing any problems, we can wait for it to settle by itself. If it is causing problems with poor hearing, poor speech or lots of infections, it may be better to put grommets in.
If we do put in grommets, the glue ear may come back when the grommet falls out. This happens to one child out of every three who has grommets put in. I may need to put more grommets in to last until your child grows out of the problem.
What are the alternatives to grommets?
Steroid nasal sprays may help some children if they have a nasal allergy.
Antibiotics, antihistamines and decongestants do not help this type of ear problem.
Using a nasal balloon (Otovent) to open the tube to the ear may help older children if used regularly.
Taking out the adenoids may help the glue ear get better, and I usually do this at the same time as putting grommets in.
A hearing aid can sometimes be used to treat the poor hearing and speech problems that are caused by glue ear. This would require an operation.
Can you do anything to help your child?
Speak clearly and wait for your child to answer. Make sure he or she can see your face when you talk. Call your child’s name to get them to look at you before you speak. Let nursery and schoolteachers know that your child has a hearing problem. It may help your child to sit at the front of the class.
Are grommets sore?
Grommets are not usually sore at all. You can give your child simple painkillers (e.g. paracetamol or ibuprofen) if you need to. Grommets should improve your child’s hearing straight away. Some children think everything sounds too loud until they get used to having normal hearing again. This usually takes only a few days.
What about ear infections?
Most people with grommets do not get any ear infections. If you see yellow fluid coming out of the ear, it may be an infection. It will not be as sore as a normal infection, and your child won’t be as ill. In this situation, we advise you to take your child to see your GP or make an appointment to see me. If you get some antibiotic ear drops, the problem will quickly settle.
Can your child swim with grommets in?
Your child can start swimming a couple of weeks after the operation; diving under the water is not a good idea as water may pass through the grommet into the ear. Some parents have earplugs made if their child is a very keen swimmer, to use until the grommets have come out, or use special headbands and ear putty to stop water getting in. The hole in the grommet is too small to let water through unless the water is dirty or has shampoo or soap in it. So, you need to be careful in the bath or the shower. You can plug your child’s ears with a cotton-wool ball covered in Vaseline until the grommets have come out.
How long will your child be off nursery or school?
Your child should be able to get back to normal the day after the operation.
What else should you know about grommets?
It is ok to fly in an aeroplane with grommets. The pain from the change in pressure in the aeroplane cannot happen when the grommets are working.
We need to check your child’s hearing after grommets have been put in, to make sure their hearing is better, and see your child once the grommets have come out to check their ears and hearing; this will usually be about nine to twelve months after the operation.
Sometimes when a grommet comes out, a small hole in the eardrum is left behind. This usually heals up with time, but sometimes we need to operate to close the hole.
The grommet can leave some scarring in the eardrum; this does not usually affect the hearing.
Acknowledgement
The information has been taken from ENT UK www.entuk.org with some modifications to reflect my practice.
If you would like to know more about this treatment please get in touch for a consultation with a member of our expert team.
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More useful information
Provides an entire overview of the procedure. Click here for more information
Great advice for potential patients who are considering ear drum repair. Click here for more information.
An NHS guide and overview of the treatment. Click here for more information.
An overview of both the symptoms and treatments possible for balance and tinnitus. Click here for more information.
A government website that gives a great amount of information on the cancer and treatment. Click here for more information.
An overview of the symptoms and treatment. Click here for more information.
Goes over the risks, as well as the overall process of receiving ear grommets. Click here for more information.
Mr Mrinal Supriya | Facial Cosmetic Surgeon
FRCS (OTOL-HNS), MRCS Ed, DO-HNS, MS in ENT, MBBS
About the expert
Mr Mrinal Supriya is a Consultant ENT, Head and Neck Surgeon with a special interest in facial cosmetic surgery. He is the clinical director for head and neck service in Northamptonshire and works as an ENT Consultant. He is the lead head and neck robotic surgeon at the University hospital of Northamptonshire (2023). Previously, he held the post of ENT, Head and Neck consultant at St.George’s University Hospital, London and at Ninewells University Hospital, Dundee.
Mr Supriya has previously worked in top hospitals around the world, including the UK, Australia and USA. He has also spent time with Dr Andrew Jacono who has been named one of the top face lift surgeons in the USA.
Mr Supriya is among the 30 surgeons (2022), who are certified by The Royal College of Surgeon to provide facial cosmetic surgery in UK.