Information on Ear, Nose and Throat Surgeries Surgery Complications
Surgery Complications
Surgery Complications
 
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All patients who have an operation may develop a complication. Patients need to weigh the benefits of the surgery with the potential risks. All surgeries have the risk of reaction to drugs and anesthesia, airway obstruction, and the development of bleeding or infection after the operation. These risks are usually small but certain surgeries may have an increased risk of complications occurring.

If the patient has a full stomach, vomiting may occur at the beginning of the case. If this occurs and stomach acid gets into the lungs a life-threatening burn in the lungs may occur, producing an aspiration pneumonia. It is very important for the patient to have nothing by mouth before the surgery. The length of time needed to clear the stomach will depend upon the age and size of the patient. In adults, 8 to 12 hours is usually needed.

The head and neck is very vascular. This vascularity makes surgery more difficult to perform but has the advantage of making infections less likely to occur.
    

 

Reaction to drugs may be allergic or an adverse reaction caused by an abnormal or normal response to the medication. True medical allergies are rare to anesthetics. Delays in waking up after surgery and a life threatening condition, malignant hyperthermia, may be caused from congenital enzyme deficiencies. Narcotics normally cause a histamine release which may trigger an asthma attack or in patients with mastocytosis, anaphylaxis. It is normal for patients to develop an itchy rash after receiving the narcotic Demerol. This is from the drug's normal release of histamine.

Airway obstruction can occur during the start of surgery as the anesthetic tube is inserted into the patient's windpipe. Obesity, a short neck or cervical arthritis can obstruct access to the larynx (voice box). The anesthesiologist while inserting the tube can damage the vocal cords, tear the mucosa or lining of the back of the throat and chip or knock out the patient's teeth. If the patient is obese, visualization can be very poor and the excess soft tissue may prevent effective mask anesthesia. In these patients, airway control may be difficult and if the airway is lost the patient may suffocate.

Hemorrhage: Excessive bleeding more commonly occurs in patients taking aspirin or who are anticoagulated. Rarely are complications from bleeding caused during the actual ENT surgery. Most often it is after the surgery, that a previously clotted vessel or one which was in spasm breaks loose. Bleeding is a common complication in tonsillectomies occurring in 1 to 4% of all patients. The nose and sinuses are so vascular that packs to control bleeding are often left in place for many days. Bleeding in sinus patients often occurs within two hours after surgery when the vasoactive medications wear off.

Infection: Although not common in head and neck surgery, hospital acquired infections are on the rise, partly because of the increased resistance that many bacteria have developed to antibiotics. One of the most common is Staph aureus which causes swelling, redness of the wound and pus formation. MRSA is a drug resistant form of Staph aureus which is becoming commonplace in our health care facilities. If MRSA is not immediately detected and treated, septicemia (bacteria in the bloodstream) and death may result.

Medical Conditions: Patients in poor health have an increased chance of complications. Patients who frequently take steroids may not have adequate 'adrenal reserve' to produce the needed steroids during the stress of surgery. This can cause adrenal hypofunction and lead to life-threatening low blood pressure. To prevent this, additional steroids may need to be given prior to surgery.  Patients with heart disease and hypertension are at an increased risk for strokes and heart attacks due to the secretion of 'adrenalin'. Just like trying to run a race at top speed, surgery will place stress on the body which results in an increase in adrenalin production. In addition, the surgeon may also use vasoconstrictive agents (such as epinephrine) to help control bleeding. These agents are needed in surgery, since it is difficult to operate when bleeding obscures visualization of vital structures.

Obesity: I cannot stress enough the problems which obesity in our society has created. Not only does it promote diabetes and hypertension but it also creates additional risks. The surgical access is very restricted. The thick adipose tissue around the surgical wound reduces access and the wide girth of the patient often requires the surgeon to bend over the patient and strain to reach the surgical site.  This is a very difficult problem in thyroid surgery and ear surgery. Trying to perform a mastoidectomy with the patient's large shoulder in the way requires the surgeon to elevate his arm for hours in an abnormal and uncomfortable position. Needless to say, it is hard to do microsurgery, when your arm starts to ache.  In thyroid surgery, the obese patient's chest soft tissue rolls up onto the lower neck. An example of the problems which obesity can cause happened in a 350 lb patient who underwent thyroid surgery.  The surgical staff elevated the head of the bed so the abundant chest tissue would fall down off of the neck.  Instead, the whole patient started to slip off the table.  Luckily she was firmly strapped to the table and the table was engineered for this heavy of a patient.  In addition, adipose tissue predisposes surgical wounds to infections and dehiscence (falling open).

Thus, all surgeries also carry the risk of death and stroke.  These risks are usually very small but become significant in patients with heart disease, diabetes and obesity.

Additional complications are dependent upon the type of surgery that a patient is undergoing.  Click on the links below to view the operation specific complications.


  Cervical Lymph Node and Neck Dissection   Go To Top

-- Injury to the carotid artery and jugular vein can cause massive bleeding and stroke.
-- Injury to the hypoglossal nerve can cause paralysis of half of the tongue.
-- Injury to the vagus nerve can cause vocal cord paralysis.
-- Injury to the spinal accessory nerve, can cause injury of the trapezius muscle which is responsible for raising the arm above the shoulder.
-- Paralysis of the phrenic nerve or nerve which goes to the diaphragm.
-- Injury to the lymphatic duct. This only occurs in operations on the left lower neck. It results in a disturbing chyle leak which is treated with a special fat free diet to decrease the flow of chyle and allow healing to occur.
 

  Ear Tubes   Go To Top     

--Hole in the Eardrum
--Cholesteatoma
--Massive bleeding from injuring a congenital dehiscence of the jugular bulb
--Hearing Loss and Vertigo

  Endoscopy   Go To Top

-- Tearing of tissues is the most common problem. This is most common in esophagoscopy using a rigid scope. Tearing of the mucosa of the esophagus or hypopharynx can cause mediastinitus or a severe infection in the chest. Injury to the vocal cords can occur with laryngosopy as can injury to the lungs during bronchoscopy. Lung injury can cause air to leak into the chest cavity. If severe it can fill the chest cavity and compress the lungs producing a tension pneumothorax. Insertion of a chest tube would be emergently required to treat the patient.

  Mastoidectomy   Go To Top  

-- Facial Nerve Paralysis
-- Hearing Loss
-- Tinnitus
-- Eardrum Perforation
-- Numb Side of the Tongue -- this may occur with the cutting of the chorda tympani nerve. Cutting of this nerve is one of the steps in mastoid surgery (this nerve is always cut). Some patients might experience numbness of the side of the tongue.  However, patients with chronic ear disease may already have damage to their chorda tympani and are unlikely to notice tongue numbness or change in taste if the nerve is injured or cut during surgery.  (Goyal a, Singh PP & Dash G - Oto HN Surg May 2009) 
View Abstract
-- Injury to the lining of the brain, meningitis, stroke and death.
Massive bleeding from injury to the sigmoid sinus or jugular bulb. This may result in stroke or death.

  Parotid Surgery   Go To Top

-- By far the most common and feared complication is facial paralysis. Not only is it cosmetically displeasing but can cause a dry eye with loss of vision and drooling. Surgical repair improves the symptoms but never makes the result good.
-- The greater auricular nerve is sacrificed during surgery. This will cause numbness in the lower part of the auricle.
-- A sialocele or a collection of saliva under the skin can form.  This is treated by drainage and anticholenergic agents. 

  Septoplasy  (nasal septum and turbinate surgery)   Go To Top

-- Recurrence of the septal deviation with recurrence of the airway obstruction. The nasal septum is made of cartilage. Cartilage has a memory and sometimes over the course of hours will bend back to the preoperative position.
-- Septal Hematoma: This can occur if a drainage hole was not created in the septum. (Note: most surgeons have the problem of too many holes created during surgery, not too few). The cartilage has no blood supply and receives its nutrients from the overlying mucosa. A septal hematoma elevates the mucosal flaps off of the cartilage, resulting in cartilage death and usually infection. If the entire septum is lost the nose may collapse creating a saddle deformity.
-- Hole in the nasal septum. This occurs where there are two opposing holes in the nasal septal flaps. A hole in the nasal septum may result in disturbing crusting, bleeding and whistling.
-- Saddle Nose: If too much supporting cartilage is removed, the mid-portion of the nose may sag creating a "Saddle Nose" deformity.

  Sinus Surgery (fess) (functional endoscopic sinus surgery)   Go To Top    

--Injury to the lining of the brain, meningitis, stroke and death - most common in the approach to the frontal sinus but may also occur in operations on the sphenoid and ethmoid sinuses
--Injury to the carotid artery - most common in sphenoid sinus surgery
--Injury to the orbit, eye and eye muscles.   Most commonly the medial rectus muscle is injured, this can cause double vision.  The optic nerve can be injured during sphenoid sinus surgery.   Injury to the Nasolacrimal Duct can cause tearing.
-- Bleeding or air in the orbit. If this happens, blindness can occur due to pressure. Relief of the pressure is mandatory to prevent loss of sight.

  Stapedectomy and Ossiculoplasty   Go To Top

-- Facial Nerve Paralysis
-- Hearing Loss
-- Tinnitus
-- Eardrum Perforation
-- Numb Side of the Tongue - this may occur with the cutting of the chorda tympani nerve. This nerve sometimes needs to be cut for exposure. Some patients will experience numbness of the side of the tongue.

  Submaxillary Gland   Go To Top

-- Injury to the branch of the facial nerve going to the lower lip. This may result in loss of the ability to pucker. More commonly, injury results when the nerve has two branches and the lower branch loops well below the jaw. This branch contains fibers which depress the lip. Injury causes a high riding lip which is sometimes bit when the patient eats.
-- Injury to the hypoglossal nerve can cause paralysis to half of the tongue. Usually, the patient can still talk normally. Eating is affected and requires chewing on the opposite side of the mouth.
-- Injury to the lingual nerve will cause loss of touch and loss of some taste fibers. This is one of the worst injuries since when the sensation of touch is lost, the patient will bite the tongue causing disturbing bleeding.

  Thyroid Surgery   Go To Top   

-- Injury to the recurrent laryngeal nerve can occur in 5% of cases. A temporary paralysis of the nerve also may occur if the nerve is stretched during surgery. This may happen if a superior approach is used to remove the gland and the nerve is stretched between where it enters the larynx and below the thyroid next to where it may be bound to Berry's ligament.
-- Postoperative bleeding may occur around the trachea. If severe airway obstruction may occur.
-- Asymmetry of the skin flaps which may cause a cosmetic deformity.

If a total thyroidectomy is performed both recurrent laryngeal nerves are at risk. If both are injured, the patient will have a poor airway and placement of a tracheotomy may be necessary.
-- There are four small calcium glands, called parathyroids. The location of these glands is variable and they mimic fat and lymphnodes. If these glands are all removed, calcium metabolism will be disturbed and there will be a rapid (over hours) fall in the serum calcium. If left untreated, this will cause cramps, tetany and cardiac arrest.

  Tonsillectomy & Adenoidectomy   Go To Top   

--Bleeding occurs in 1 to 4% of patients
--Poor speech (hypernasal speech) occurs in 1/3000 patients.
--Nasopharyngeal Stenosis
--Chipped Teeth
--Electocautery Burns
--Death

  Tympanoplasty   Go To Top

-- Facial Nerve Paralysis
-- Hearing Loss
-- Tinnitus
-- Eardrum Perforation
-- Numb Side of the Tongue -- this may occur with the cutting of the chorda tympani nerve.  However, patients with chronic ear disease may already have damage to their chorda tympani and are unlikely to notice tongue numbness or change in taste if the nerve is injured or cut during surgery.  (Goyal a, Singh PP & Dash G - Oto HN Surg May 2009) 
View Abstract
 
   

 
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Kevin T Kavanagh,  All Rights Reserved

Page Last Updated 08/05/2016 
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Cervical Lymph Node
& Neck Dissection

 
Ear Tubes

 
Endoscopy
 
Mastoidectomy
 
Parotid Surgery

 
Thyroid Surgery
 
Tonsillectomy &
Adenoidectomy

 
Tympanoplasty
 
Septoplasy
(nasal septum surgery)
 
Sinus Surgery (fess)

 
Stapedectomy and
Ossiculoplasty

 
Submaxillary Gland

 

  
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