Archives: Instructions

ENT Checklist

• Ask for copies of labs / scan/ consultation notes etc. to be sent for review
• Dr. Gordon has reviewed labs/scan etc. and/or has ordered and followed up on additional labs and orders
• Update medication list
• Blood thinners ie: Plavix aspirin Vitamin E etc.
• Medical History
• Social history
• OR Prep Questions:
• HX of hip knee valve surgery
• Prosthetic replacements
• Require antibiotic prior to dental procedures
• Heart murmur irregularity of valve prolapse
• Family history of anesthesia issues
• Hx Malignant Hyperthermia Pre-Op:
• Discuss surgical date
• St. Anthony’s will contact them the day before surgery for arrival time (after 3pm call them)
• Pre/Post Operative instructions get sent out via mail and e-mail
• Stop blood thinners (or any medications as per primary doctor)
• Plavix Aspirin Vitamin E etc.
• NPO Midnight the day before surgery
• Competent adult accompany and drive patient (family friend)
• Medical clearance checklist (based off of recommendations of clearing Dr.)
• Labs
• Clearance letter
• EKG or any additional workup deemed necessary by primary MD
• (Local Pt) Mention pt needs to return to the medical office 7-10 after surgery for stitches removal Post Operative:
• Post operative letters to referring MD and uploads to EMR
• P.A. ie:  1 week follow up phone call
• Schedule suture removal 7-10 days post surgery
• Medical office follow up 2 weeks post surgery

What is Streptococcus Salivarius?

Streptococcus Salivarius is a bacteria produced in the mouth and upper respiratory tract.  It has the ability to fight infections.  Streptococcus Salivarius has emerged as an important source of safe and efficacious probiotics capable of fostering more balanced health-associated oral microbiota.

What are the benefits of taking a probiotic that contains streptococcus Salivarius?

• Promotes healthy bacterial balance in the oral and sinus regions
• Keeps your immune system strong
• Helps keep your teeth gums throat ears and sinuses healthy
• Promotes fresh breath

Where can I find a probiotic that contains Streptococcus Salivarius?

• Online— do a search for “Streptococcus Salivarius probiotics”
• http://www.drdavidwilliams.com/product/probiotic-advantage-oral-sinus/
• http://www.nowfoods.com/OralBiotic-60-Lozenges.htm
• In Stores— You can go to your local pharmacy or health food store and look for an oral and sinus probiotic that contains Streptococcus Salivarius.

Overview

Tobacco use can lead to nicotine dependence and serious health problems. Cessation can significantly reduce the risk of suffering from smoking-related diseases.

Tobacco dependence is a chronic condition that often requires repeated interventions but effective treatments and helpful resources exist. Smokers can and do quit smoking. In fact today there are more former smokers than current smokers.

Nicotine Dependence

Nicotine is the psychoactive drug in tobacco products that produces dependence. Most smokers are dependent on nicotine. Nicotine dependence is the most common form of chemical dependence in the United States. Research suggests that nicotine is as addictive as heroin cocaine or alcohol. Quitting smoking is difficult and may require multiple attempts. Users often relapse because of stress weight gain and withdrawal symptoms. Examples of nicotine withdrawal symptoms include irritability anxiety difficulty concentrating and increased appetite.

Health Benefits of Cessation

Breaking free from nicotine dependence is not the only reason to quit smoking. Cigarette smoke contains more than 7000 chemicals. Hundreds are toxic and about 70 are carcinogenic (i.e. cause cancer). Fortunately people who stop smoking greatly reduce their risk for disease and premature death. Although the health benefits are greater for people who stop at earlier ages cessation is beneficial at all ages. Smoking cessation is associated with the following health benefits:

• Smoking cessation lowers the risk for lung and other types of cancer.
• Smoking cessation reduces the risk for coronary heart disease stroke and peripheral vascular disease. Coronary heart disease risk is reduced within 1 to 2 years of cessation.
• Smoking cessation reduces respiratory symptoms such as coughing wheezing and shortness of breath. The rate of decline in lung function is slower among persons who quit smoking.
• Smoking cessation reduces the risk of developing chronic obstructive pulmonary disease (COPD) one of the leading causes of death in the United States.
• Smoking cessation by women during their reproductive years reduces the risk for infertility. Women who stop smoking during pregnancy also reduce their risk of having a low birth weight baby.

Smokers’ Attempts to Quit Among current U.S. adult smokers 70% report that they want to quit completely and millions have attempted to quit smoking.11 In 2008 an estimated 48 million adults (aged 18 years or older) were former smokers. Percentage of current smokers who tried to stop smoking during the previous 12 months: 51% of high school smokers during 2009 45% of adult smokers during 2008 (nearly 21 million people)

Methods to Quit Smoking

Effective treatments that can increase the chances of successful cessation include the following:

• Brief clinical interventions (i.e. when a doctor takes 10 minutes or less to deliver advice and assistance about quitting)
• Counseling (e.g. individual group or telephone counseling)
• Behavioral cessation therapies (e.g. training in problem solving)
• Treatments with more person-to-person contact and intensity (e.g. more time with counselors)

Cessation medications found to be effective for treating tobacco dependence include the following:

• Over-the-counter and prescription nicotine replacement products (e.g. nicotine gum inhaler nasal spray lozenge or patch)
• Prescription nonnicotine medications such as bupropion SR (Zyban®) and varenicline tartrate (Chantix®).

The combination of medication and counseling is more effective for smoking cessation than either medication or counseling alone. Quitline Services 1-800-QUIT-NOW Exit Notification is a free telephone support service that can help individuals who want to stop smoking or using tobacco. Callers have access to several types of cessation information and services including:

• Free support and advice from experienced counselors
• A personalized quit plan
• Self-help materials
• Social support and coping strategies

The latest information about cessation medications Over-the-counter nicotine replacement medications for eligible participants (in more than half of U.S. states) Cessation Services CDC’s How to Quit Web pages provide a variety of cessation tips tools and resources. Smokefree.gov Exit Notification is a Web site dedicated to helping smokers quit.

Insight into sinus problems in adults and children

• How are sinusitis symptoms different from a cold or allergy?
• When does acute sinusitis become chronic?
• What treatments are available?

Have you ever had a cold or allergy attack that wouldn’t go away? If so there’s a good chance you actually had sinusitis. Experts estimate that 37 million people are afflicted with sinusitis each year making it one of the most common health conditions in America. That number may be significantly higher since the symptoms of bacterial sinusitis often mimic those of colds or allergies and many sufferers never see a doctor for proper diagnosis and treatment.

What is sinusitis?

Acute bacterial sinusitis is an infection of the sinus cavities caused by bacteria. It usually is preceded by a cold allergy attack or irritation by environmental pollutants. Unlike a cold or allergy bacterial sinusitis requires a physician’s diagnosis and treatment with an antibiotic to cure the infection and prevent future complications.

Normally mucus collecting in the sinuses drains into the nasal passages. When you have a cold or allergy attack your sinuses become inflamed and are unable to drain. This can lead to congestion and infection. Your doctor will diagnose acute sinusitis if you have up to 4 weeks of purulent nasal drainage accompanied by nasal obstruction facial pain-pressure-fullness or both.  The sinus infection is likely bacterial if it persists for 10 days or longer or if the symptoms worsen after an initial improvement. 

When does acute sinusitis become chronic?

When you have frequent sinusitis or the infection lasts three months or more it could be chronic sinusitis. Symptoms of chronic sinusitis may be less severe than those of acute; however untreated chronic sinusitis can cause damage to the sinuses that sometimes requires surgery to repair.

What treatments are available?

Antibiotic therapy – Therapy for bacterial sinusitis should include an appropriate antibiotic. If you have three or more symptoms of sinusitis (see chart) be sure to see your doctor for diagnosis. An oral or nasal spray or drop decongestant may be recommended to relieve congestion although you should avoid prolonged use of nonprescription nasal sprays or drops.  Inhaling steam or using saline nasal sprays or drops can help relieve sinus discomfort.

Antibiotic resistance means that some infection-causing bacteria are immune to the effects of certain antibiotics prescribed by your doctor. Antibiotic resistance is making even common infections such as sinusitis challenging to treat. You can help prevent antibiotic resistance. One way is to wait up to 7 days before taking antibiotics for mild sinus infections allowing time for your body to fight the infection naturally. If the doctor prescribes an antibiotic it is important that you take all of the medication just as your doctor instructs even if your symptoms are gone before the medicine runs out.

Intensive antibiotic therapy – If your doctor thinks you have chronic sinusitis intensive antibiotic therapy may be prescribed. Surgery is sometimes necessary to remove physical obstructions that may contribute to sinusitis.

Sinus surgery – Surgery should be considered only if medical treatment fails or if there is a nasal obstruction that cannot be corrected with medications. The type of surgery is chosen to best suit the patient and the disease.

Functional endoscopic sinus surgery (FESS) is recommended for certain types of sinus disease. With the endoscope the surgeon can look directly into the nose while at the same time removing diseased tissue and polyps and clearing the narrow channels between the sinuses. The decision whether to use local or general anesthesia will be made between you and your doctor depending on your individual circumstances.

Before surgery be sure that you have realistic expectations for the results recovery and postoperative care. Good results require not only good surgical techniques but a cooperative effort between the patient and physician throughout the healing process. It is equally important for patients to follow pre- and postoperative instructions.

When should a doctor be consulted?

Because the symptoms of sinusitis sometimes mimic those of colds and allergies you may not realize you need to see a doctor. If you suspect you have sinusitis review these signs and symptoms. If you suffer from three or more you should see your doctor.

What are the symptoms of sinusitis vs. a cold or allergy?

SIGN/ SYMPTOM	SINUSITIS	ALLERGY	COLD
Facial Pressure /Pain	Yes	Sometimes	Sometimes
Duration of Illness	Over 10-14 days	Varies	Under 10 days
Nasal Discharge	Whitish or colored	Clear thin watery	Thick whitish or thin
Fever	Sometimes	No	Sometimes
Headache	Often	Sometimes	Sometimes
Pain in Upper Teeth	Sometimes	No	No
Bad Breath	Sometimes	No	No
Coughing	Sometimes	Sometimes	Yes
Nasal Congestion	Yes	Sometimes	Yes
Sneezing	No	Sometimes	Yes

Can children suffer from sinus infections?

Your child’s sinuses are not fully developed until age 20. However children can still suffer from sinus infection. Although small the maxillary (behind the cheek) and ethmoid (between the eyes) sinuses are present at birth. Sinusitis is difficult to diagnose in children because respiratory infections are more frequent and symptoms can be subtle. Unlike a cold or allergy bacterial sinusitis requires a physician’s diagnosis and treatment with an antibiotic to prevent future complications.

The following symptoms may indicate a sinus infection in your child:

• a “cold” lasting more than 10 to 14 days sometimes with low-grade fever
• thick yellow-green nasal drainage
• post-nasal drip sometimes leading to or exhibited as sore throat cough bad breath nausea and/or vomiting
• headache usually not before age 6
• irritability or fatigue
• swelling around the eyes

If these symptoms persist despite appropriate medical therapy care should be taken to seek an underlying cause. The role of allergy and frequent upper respiratory infections should be considered.

Tips to prevent sinusitis

As always an ounce of prevention is worth a pound of cure. To avoid developing sinusitis during a cold or allergy attack keep your sinuses clear by:

• Using an oral decongestant or a short course of nasal spray decongestant
• Gently blowing your nose blocking one nostril while blowing through the other
• Drinking plenty of fluids to keep nasal
  discharge thin
• Avoiding air travel. If you must fly use a nasal spray decongestant before take-off to prevent blockage of the sinuses allowing mucus to drain
• If you have allergies try to avoid contact with things that trigger attacks. If you cannot use over-the-counter or prescription antihistamines and/or a prescription nasal spray to control allergy attacks

Allergy testing followed by appropriate allergy treatments may increase your tolerance of allergy-causing substances. If you believe you may have sinusitis see our tips for sinusitis sufferers.

Reference: American Academy of Otolaryngology. Head and Neck Surgery. http://www.entnet.org/HealthInformation/Sinusitis.cfm

Septoplasty is a surgical procedure performed entirely through the nostrils accordingly no bruising or external signs occur. The surgery might be combined with a rhinoplasty in which case the external appearance of the nose is altered and swelling/bruising of the face is evident. Septoplasty may also be combined with sinus surgery.

The time required for the operation averages about one to one and a half hours depending on the deviation. It can be done with a local or a general anesthetic and is usually done on an outpatient basis. After the surgery nasal packing is inserted to prevent excessive postoperative bleeding. During the surgery badly deviated portions of the septum may be removed entirely or they may be readjusted and reinserted into the nose.

If a deviated nasal septum is the sole cause for your chronic sinusitis relief from this severe disorder will be achieved.

Where Are Your Salivary Glands

The glands are found in and around your mouth and throat. We call the major salivary glands the parotid submandibular and sublingual glands.

They all secrete saliva into your mouth the parotid through tubes that drain saliva called salivary ducts near your upper teeth submandibular under your tongue and the sublingual through many ducts in the floor of your mouth.

Besides these glands there are many tiny glands called minor salivary glands located in your lips inner cheek area (buccal mucosa) and extensively in other linings of your mouth and throat. Salivary glands produce the saliva used to moisten your mouth initiate digestion and help protect your teeth from decay.

As a good health measure it is important to drink lots of liquids daily. Dehydration is a risk factor for salivary gland disease.

What Causes Salivary Gland Problems?

Salivary gland problems that cause clinical symptoms include:

Obstruction: Obstruction to the flow of saliva most commonly occurs in the parotid and submandibular glands usually because stones have formed. Symptoms typically occur when eating. Saliva production starts to flow but cannot exit the ductal system leading to swelling of the involved gland and significant pain sometimes with an infection. Unless stones totally obstruct saliva flow the major glands will swell during eating and then gradually subside after eating only to enlarge again at the next meal. Infection can develop in the pool of blocked saliva leading to more severe pain and swelling in the glands. If untreated for a long time the glands may become abscessed.

It is possible for the duct system of the major salivary glands that connects the glands to the mouth to be abnormal. These ducts can develop small constrictions which decrease salivary flow leading to infection and obstructive symptoms.

Infection: The most common salivary gland infection in children is mumps which involves the parotid glands. While this is most common in children who have not been immunized it can occur in adults. However if an adult has swelling in the area of the parotid gland only on one side it is more likely due to an obstruction or a tumor.

Infections also occur because of ductal obstruction or sluggish flow of saliva because the mouth has abundant bacteria.

You may have a secondary infection of salivary glands from nearby lymph nodes. These lymph nodes are the structures in the upper neck that often become tender during a common sore throat. In fact many of these lymph nodes are actually located on within and deep in the substance of the parotid gland or near the submandibular glands. When these lymph nodes enlarge through infection you may have a red painful swelling in the area of the parotid or submandibular glands. Lymph nodes also enlarge due to tumors and inflammation.

Tumors: Primary benign and malignant salivary gland tumors usually show up as painless enlargements of these glands. Tumors rarely involve more than one gland and are detected as a growth in the parotid submandibular area on the palate floor of mouth cheeks or lips. An otolaryngologist-head and neck surgeon should check these enlargements.

Malignant tumors of the major salivary glands can grow quickly may be painful and can cause loss of movement of part or all of the affected side of the face. These symptoms should be immediately investigated.

Other Disorders: Salivary gland enlargement also occurs in autoimmune diseases such as HIV and Sjögren’s syndrome where the body’s immune system attacks the salivary glands causing significant inflammation. Dry mouth or dry eyes are common. This may occur with other systemic diseases such as rheumatoid arthritis. Diabetes may cause enlargement of the salivary glands especially the parotid glands. Alcoholics may have salivary gland swelling usually on both sides.

How Does Your Doctor Make the Diagnosis?

Diagnosis of salivary gland disease depends on the careful taking of your history a physical examination and laboratory tests.

If your doctor suspects an obstruction of the major salivary glands it may be necessary to anesthetize the opening of the salivary ducts in the mouth and probe and dilate the duct to help an obstructive stone pass. Before these procedures dental x-rays may show where the calcified stones are located.

If a mass is found in the salivary gland it is helpful to obtain a CT scan or a MRI (magnetic resonance imaging). Sometimes a fine needle aspiration biopsy in the doctor’s office is helpful. Rarely dye will be injected through the parotid duct before an x-ray of the gland is taken (a sialogram).

A lip biopsy of minor salivary glands may be needed to identify certain autoimmune diseases.

How Is Salivary Gland Disease Treated?

Treatment of salivary diseases falls into two categories: medical and surgical. Selection of treatment depends on the nature of the problem. If it is due to systemic diseases (diseases that involve the whole body not one isolated area) then the underlying problem must be treated. This may require consulting with other specialists. If the disease process relates to salivary gland obstruction and subsequent infection your doctor will recommend increased fluid intake and may prescribe antibiotics. Sometimes an instrument will be used to open blocked ducts.

If a mass has developed within the salivary gland removal of the mass may be recommended. Most masses in the parotid gland area are benign (noncancerous). When surgery is necessary great care must be taken to avoid damage to the facial nerve within this gland that moves the muscles face including the mouth and eye. When malignant masses are in the parotid gland it may be possible to surgically remove them and preserve most of the facial nerve. Radiation treatment is often recommended after surgery. This is typically administered four to six weeks after the surgical procedure to allow adequate healing before irradiation.

The same general principles apply to masses in the submandibular area or in the minor salivary glands within the mouth and upper throat. Benign diseases are best treated by conservative measures or surgery whereas malignant diseases may require surgery and postoperative irradiation. If the lump in the vicinity of a salivary gland is a lymph node that has become enlarged due to cancer from another site then obviously a different treatment plan will be needed. An otolaryngologist-head and neck surgeon can effectively direct treatment.

Removal of a salivary gland does not produce a dry mouth called xerostomia. However radiation therapy to the mouth can cause the unpleasant symptoms associated with reduced salivary flow. Your doctor can prescribe medication or other conservative treatments that may reduce the dryness in these instances.

Salivary gland diseases are due to many different causes. These diseases are treated both medically and surgically. Treatment is readily managed by an otolaryngologist-head and neck surgeon with experience in this area.

Reference: American Academy of Otolaryngology. Head and Neck Surgery. http://www.entnet.org/HealthInformation/salivaryGlands.cfm

Prescription renewals are most efficiently handled through our practice's messaging system which is available on this website. Please try to anticipate your need for prescription refills by notifying the office at least 48 hours in advance or by advising your physician of your needs during regularly scheduled office visits. If you have not been seen in this practice within the past six months it is our policy that you make an appointment to renew your medication.

Do not take aspirin vitamin E ibuprofen or any pain or anti-inflammatory medications for one week prior to surgery. Most pain medications can increase bleeding so it is important that you let your doctor know if you have taken any of these medications. You may take Tylenol.

If you are on coumadin or any other blood thinner you must see your internist to make sure you are off this medication before surgery. You will need medical clearance from your internist if you are over 65 or if you have any medical problems. Do not eat or drink anything after midnight prior to surgery unless instructed otherwise.

Please check with your insurance company for surgery approval or second opinion. Any co-payment or deductible is your responsibility. If you have any questions as to whether the hospital anesthesiologist or pathologist participate with your insurance plan please call them to check.

You may find their telephone numbers if you call the Hospital. If they do not participate you may be responsible for the bill from these other healthcare providers. Call the hospital after 3:00 PM the day before surgery to find out the time you will need to be in the hospital. Ask for same day surgery.

Preoperative Instructions 

Very Important: For one week prior to surgery you should not be taking any aspirin baby aspirin advil ibuprofen vitamin E Plavix or any medication that can increase bleeding or decrease clot formation. If you are on Coumadin or other blood thinners this will need to be stopped approximately 4-5 days before surgery and you will need to consult with your Internist and/or Cardiologist.

Contacting Us: Postoperatively If you have any concerns postoperatively we encourage you to contact us any time day or night. 

Wound Care: When you leave the hospital you will have a small bandage over your wound. Underneath this bandage are strips that cover the wound called “steri-strips.” This is what protects the wound. You can remove the covering bandage the day after surgery and leave the steri-strips in place for one week after surgery. During that week try to keep the steri-strips dry. If you do get them wet in the shower simply pat the wound dry.

One week after surgery you should get the steri-strips very wet in the shower and this will help you to peel them off. The sutures for the wound are self-absorbing. This means that you do not need to have them removed. After the steri strips are removed you should place Bacitracin Ointment or Triple-Antibiotic ointment on the wound for another 2 weeks. Although your scar will heal just fine at this point for decreased scar formation I then recommend using a gel called Mederma. In some instances you may have a removable skin suture. This is removed approximately one week after surgery. If you are from out-of-town we will provide you with instructions for your local doctor to remove this suture. If you are local then you should be seen 1 week after surgery to remove this suture. A surgical drain is sometimes necessary depending upon the extent of the operation. If this is required it is removed in the hospital the day following surgery.

Showers and Bathing: You can shower the next day after surgery. Try to keep the wound dry and if it gets wet simply pat it dry. The steri-strips seal the wound but it is important that they don’t become too moist as this may lead to a wound infection. If the steri-strips become persistently moist then you can remove them yourself.

Activity: The day after surgery you can resume most normal activity. We suggest that you take off at least 2-3 days after surgery from work in order to allow your body to recuperate. Avoid strenuous activity like heavy lifting and vigorous exercise for about 1 week after surgery. Elevate the head when laying down by sleeping on 2 pillows. After one week you can resume your normal routine.

Diet: You can resume a normal diet after your surgery as tolerated. Sometimes there can be nausea after anesthesia but this is usually temporary. You are not limited in what you can eat but it is best to avoid foods that are difficult for you to swallow or digest.

Pain Control: Most patients experience only mild pain or discomfort at their surgical wound site which lasts for 1-2 days. You will be given a prescription for Tylenol with Codeine or Lortab pills in case you experience moderate pain. Many patients get by with no pain medication or taking only Tylenol.

Calcium and Vitamin D Supplements: Patients with primary hyperparathyroidism should supplement with vitamin D and calcium. Approximately 600mg or one calcium pills with vitamin D should be taken daily preoperatively. Preoperatively this has shown to minimize PTH secretion bone turnover and calcium loss. Calcium and Vitamin D supplements should be taken pre-operatively as well as post-operatively. All patients should be taking this routinely daily postoperatively and continuously. This will help to re-build your bone calcium stores that were lost when you had the parathyroid adenoma. There are many formulations on the market of Calcium with Vitamin D. It is recommended that you take approximately 1200mg of elemental calcium i.e. 2 calcium with Vitamin D pills a day continuously and without stop.

*No Aspirin or Ibuprofen for two weeks prior to surgery and one week after surgery.

1. Normal activity can be resumed after the first week depending on the patient’s comfort level. For the first week there should be no heavy lifting or exertion.
2. Diet: You may have soft foods such as oatmeal soups pureed fruits and vegetables jello ices and ice cream in the first few days following surgery. Avoid hard foods that cause straining or pain. It is extremely important that you drink sufficient water/liquids to avoid dehydration. You should drink at least six glasses of water each day. Sufficient pain medicine should be administered if pain is preventing you from taking in enough fluids. You may not want to take in any food — this is acceptable.
3. It is necessary to keep the mouth and teeth clean after a tonsil operation. The teeth should be brushed gently two or three times a day. If you have a humidifier it should be used.
4. Many patients complain of earache after a tonsil operation. This is normal and frequently the ear pain is worse than the throat pain. This pain is coming from nerve fibers in the throat. This is not an ear infection. Usually the pain is most intense on the third to sixth postoperative day.
5. Some fever is expected. If it is over 102 degrees F call my office. There will be a white covering/scab where the tonsils were. This is normal.
6. It is expected that there will be some bloody secretion. Should there be a significant amount of bright red blood call our office immediately. If the phone is answered by the answering service the doctor will be notified immediately. Should there be any problem or difficulty with contacting the doctor report to the emergency room. The emergency room physician will have to see you in this situation and contact the covering surgeon as necessary.
7. Call the office for an appointment two weeks following surgery. School or work may resume as your energy level increases. This is usually one to two weeks after surgery. It is not unusual to have difficulty swallowing throat discomfort and a feeling that there is something in your throat for several months after the procedure.
8. Medication for pain: Tylenol with Codeine OR Percocet. They should be taken as prescribed and not both at the same time.