Information regarding common ENT conditions

Balloon Eustachian Tuboplasty

What is the Eustachian tube?

The Eustachian tube is a narrow passage, approximately 3–4 cm long, that connects the middle ear (the space behind the eardrum) to the back of the nose. There is one tube on each side.

Its main functions are to:

• Equalise air pressure between the middle ear and the outside environment.

• Drain normal fluid and secretions from the middle ear.

A healthy Eustachian tube opens briefly when you swallow, yawn or chew. This happens many times each day and helps keep the middle ear working normally.

What is Eustachian tube dysfunction?

Eustachian tube dysfunction (ETD) occurs when the tube does not open and close properly. This can lead to symptoms such as:

• A feeling of fullness or pressure in the ear

• Ear discomfort or pain

• Popping or clicking sounds

• Changes in hearing

Symptoms are often more noticeable during changes in air pressure, for example when flying, travelling through tunnels, or driving at higher altitudes. Occasionally it can result in fluid build up behind the ear drum (glue ear).

What are Grommets?

Grommet surgery is performed mostly under either a local or general anaesthetic as a day case procedure in adults.  It is used to drain middle ear fluid when the fluid isnt draining via the eustachian tube.

 The procedure is performed using a microscope to make a small cut in the ear drum to drain the middle ear fluid. This is ten followed by placement of a small plastic ventilation tube that sits in the ear drum to equalise pressure and prevent further fluid build up. 

The procedure takes 30 or less and involves minimal discomfort afterwards. We expect grommets to remain in place for around a year, after which time the body usually pushes tem out into the ear canal naturally. Hearing will be tested at intervals during this time, and a decision can be made in the future as to whether a repeat procedure is necessary (needed in a small proportion of cases). 

The risks/complications of grommet insertion are small, but consist of infection, bleeding, early extrusion, persistent ear drum perforation and discharge - all of which can be discussed and addressed. 

I typically perform the first hearing test 3 months after the procedure to evaluate hearing improvement. 

What is Balloon Eustachian Tuboplasty?

Balloon Eustachian Tuboplasty is a minimally invasive procedure performed under a general anaesthetic.

A small deflated balloon catheter is passed through the nostril to the opening of the Eustachian tube using a fine endoscope (camera). Once correctly positioned, the balloon is inflated for approximately two minutes before being deflated and removed.

Does the procedure hurt?

Most patients experience little or no discomfort after the procedure. If needed, mild pain or discomfort can usually be managed with simple pain relief for a few days.

During the procedure

The procedure is performed entirely through the nose using an endoscope, so no external cuts or stitches are required.

The balloon is guided into the opening of the Eustachian tube and inflated using sterile saline to a controlled pressure. It remains inflated for approximately two minutes before being removed. Nothing is left inside the Eustachian tube.

Balloon Eustachian Tuboplasty may be performed:

• As a standalone procedure.

• At the same time as other ear or nasal surgery.

• On one or both Eustachian tubes during the same operation, if required.

After the procedure

After surgery, you will recover in the recovery ward where you will be monitored by the nursing staff.

Most patients are able to go home the same day.

You can usually return to work and most normal daily activities within 1–2 days, depending on how you feel.

Please remember that improvement in symptoms is not usually immediate. Most patients notice gradual improvement over several weeks as the Eustachian tube begins to function more normally.

What are the risks of Balloon Eustachian Tuboplasty?

Balloon Eustachian Tuboplasty is considered a safe procedure. However, as with any operation, there are potential risks and complications.

Common or uncommon risks

Bleeding
A small amount of bleeding from the nose may occur during the procedure. This is usually minor and has normally stopped before the operation is completed.

Temporary discomfort or worsening of symptoms
You may experience mild discomfort or a temporary increase in your symptoms during the first few days after surgery. Improvement often takes several weeks.

Tinnitus
If you already have tinnitus (ringing or other noises in the ear), it may temporarily become more noticeable after surgery. This has been reported in fewer than 1 in 100 patients.

Surgical emphysema
Very rarely, a small amount of air can become trapped beneath the skin around the treatment area. This usually settles on its own within a day or two without any lasting problems.

Patulous Eustachian tube
In fewer than 1 in 100 patients, the Eustachian tube may remain more open than normal after treatment. This can cause symptoms such as hearing your own voice or breathing unusually loudly in one ear. In rare cases, further treatment may be required.

Persistent symptoms
Although many patients benefit from the procedure, it cannot guarantee improvement for everyone. Some patients may have only partial improvement or no lasting benefit.

Rare and theoretical risks

These complications are considered extremely rare.

Scarring
There is a theoretical risk of scar tissue forming within the Eustachian tube, which could cause blockage to recur or, rarely, become worse than before.

Injury to the internal carotid artery
The internal carotid artery runs close to the Eustachian tube. There is a theoretical risk of injury to this blood vessel, which could result in severe bleeding, stroke or, exceptionally, death. The design of the balloon device and the surgical technique are intended to avoid this complication, and no such injuries have been reported.

Hearing loss
As with any ear procedure, there is an extremely small risk of permanent hearing loss. To date, no permanent hearing loss has been reported following Balloon Eustachian Tuboplasty.

Follow-up

You will be reviewed approximately 6 weeks after your procedure. At this appointment we will assess your recovery, discuss any ongoing symptoms, and repeat your hearing test.

Cholesteatoma and Combined Approach Tympanomastoidectomy

What is a cholesteatoma?

A cholesteatoma is a benign (non-cancerous) collection of skin cells that forms inside the ear. Although it is not a tumour, it gradually enlarges over time and can cause damage to the delicate structures of the ear if left untreated.

As the cholesteatoma grows, it can damage:

• The hearing bones (ossicles), causing hearing loss.

• The balance organ, leading to dizziness or balance problems.

• The nerve responsible for taste on one side of the tongue.

• The facial nerve, which controls movement of the muscles on one side of the face.

In rare cases, a cholesteatoma can grow towards the lining of the brain, increasing the risk of serious complications such as meningitis, brain infection, or seizures.

Because of these risks, treatment is recommended once a cholesteatoma has been diagnosed.

Why is surgery needed?

Unfortunately, cholesteatoma cannot be treated with medication. Surgery is the only effective treatment.

The main aim of surgery is to completely remove the cholesteatoma and prevent it from causing further damage to your ear and surrounding structures.

A second aim is to repair any damage already caused by the disease and, where possible, improve your hearing.

Cholesteatoma can be difficult to remove completely, particularly if it has spread into several parts of the ear. For this reason, some patients require a planned second operation to ensure that all of the disease has been removed and to complete any hearing reconstruction.

What does the operation involve?

The operation is called a Combined Approach Tympanomastoidectomy.

It is performed under a general anaesthetic through an incision hidden behind the ear.

During the operation, your surgeon will carefully remove the cholesteatoma from all affected areas, which may include:

• The ear canal

• The eardrum

• The middle ear

• The hearing bones (ossicles)

• The mastoid bone (the bone behind the ear)

To reach the disease safely, some of the mastoid bone is carefully drilled away using specialised surgical equipment.

Once the cholesteatoma has been removed, any damage is repaired where possible.

This may involve:

• Repairing the eardrum using cartilage or other tissue taken from around your ear.

• Rebuilding the hearing mechanism using a specially designed titanium hearing prosthesis if one or more of the hearing bones have been damaged.

• Occasionally using medical bone cement to repair partially damaged hearing bones.

The exact reconstruction depends on what is found during surgery.

What are the benefits of surgery?

The aims of surgery are to:

• Remove the cholesteatoma completely.

• Prevent further damage to the ear.

• Reduce the risk of serious complications.

• Preserve or improve hearing where possible.

• Create a safe, healthy ear that is easier to monitor in the future.

What are the risks of surgery?

Combined Approach Tympanomastoidectomy is a well-established operation that is performed regularly. Serious complications are uncommon, but all surgery carries some risks.

Infection, bleeding and scarring

All operations carry a small risk of infection, bleeding and scarring.

To reduce these risks:

• You will receive antibiotics during surgery.

• An antibiotic ear pack is placed inside the ear and remains in place for approximately two weeks.

• A pressure dressing is applied around your head after surgery to reduce bruising and bleeding beneath the skin. This is usually removed the following day.

• The incision behind the ear is closed carefully using dissolvable stitches to minimise scarring.

Significant bleeding after ear surgery is uncommon.

Hearing

If the cholesteatoma has damaged or become wrapped around the hearing bones, they may need to be removed to completely clear the disease.

Your surgeon will reconstruct the hearing mechanism whenever possible using a hearing prosthesis or bone cement.

Many patients notice an improvement in hearing following surgery, while others experience little change. Some patients may notice reduced hearing despite reconstruction.

There is also a very small risk of complete hearing loss in the operated ear.

Changes in taste

The nerve responsible for taste runs through the middle ear and may be affected during surgery.

Around 1 in 5 patients notice a metallic taste or altered taste on one side of the tongue after surgery.

This almost always improves over time, and permanent changes in taste are uncommon.

If your profession depends on your sense of taste—for example, if you are a chef or sommelier—please discuss this with your surgeon before your operation.

Tinnitus

If you already experience tinnitus (ringing or other noises in the ear), its response to surgery is unpredictable.

Some patients notice an improvement, some experience no change, and a small number find that it becomes more noticeable.

Balance

Temporary dizziness or imbalance is not uncommon after surgery and usually settles within a few days.

Permanent balance problems are very rare.

Facial nerve injury

The facial nerve, which controls movement of one side of the face, runs through the middle ear.

There is a small risk of injury to this nerve during surgery, particularly if the cholesteatoma is closely attached to it.

To minimise this risk:

• Your scans are carefully reviewed before surgery.

• A facial nerve monitor is used throughout the operation.

If weakness does occur, it is usually temporary. Permanent facial weakness is rare but may require further treatment or reconstructive surgery.

Leakage of brain fluid (CSF leak)

Very rarely, the cholesteatoma may have eroded the thin layer of bone separating the ear from the brain.

If this is found during surgery, it is usually repaired immediately using cartilage and other tissue taken from around the ear.

If a leak develops after surgery, a further operation may be required.

There is also a very small risk of meningitis associated with this complication.

Risks of general anaesthetic

This procedure is performed under a general anaesthetic.

Your anaesthetist will discuss the risks specific to you before your operation.

After your operation

The operation usually takes around 2–3 hours.

Most patients are able to go home 4–6 hours after surgery once they are:

• Eating and drinking normally.

• Comfortable on pain relief.

• Able to walk safely.

• Have passed urine.

• Accompanied by a responsible adult.

An ear pack will remain in the ear for approximately 2 weeks. While this pack is in place, your hearing on that side will usually be reduced. Hearing often improves once the pack has been removed in clinic.

You should:

• Keep the operated ear completely dry.

• Avoid blowing your nose forcefully.

• Avoid flying and other rapid changes in air pressure for approximately 2–4 weeks, or until advised otherwise.

• Avoid strenuous exercise and heavy lifting for the first couple of weeks.

Most people return to work after 1–2 weeks, depending on the type of work they do.

Follow-up

You will be seen in clinic approximately 2 weeks after surgery to remove the ear pack and examine the healing ear.

Further follow-up appointments, including hearing tests, will be arranged over the following months to monitor healing and ensure there is no evidence of recurrent cholesteatoma.

Because cholesteatoma can occasionally return, long-term follow-up is recommended, and some patients may require a planned second-look operation or MRI scan to confirm that all of the disease has been removed.

Stapes Surgery (Stapedotomy)

Why have I been offered this operation?

Your hearing loss is likely due to a condition called otosclerosis, where the movement of the third and smallest hearing bone (the stapes) becomes restricted.

The three small bones of hearing normally transmit sound vibrations from the eardrum to the inner ear. When the stapes becomes stiff, sound cannot be transmitted efficiently, resulting in hearing loss.

In some people, otosclerosis can also affect the inner ear itself, reducing the ability of the ear to detect sounds.

What are the treatment options?

The main treatment options are:

• Hearing aids

• Stapes surgery (stapedotomy)

A hearing aid is a safe, non-surgical option and some patients are very happy with this approach.

However, some people find hearing aids inconvenient or feel that they do not provide clear enough sound quality, particularly for understanding speech.

If hearing loss affects your daily life and hearing aids are not providing enough benefit, surgery may be considered.

What does stapes surgery achieve?

The aim of stapedotomy is to improve the movement of sound through the middle ear by creating a new pathway around the stiffened stapes bone.

A small prosthesis is inserted to replace the movement of the stapes, allowing sound vibrations to reach the inner ear more effectively.

The operation can improve the volume and quality of hearing, but it cannot reverse any damage that otosclerosis may have caused to the inner ear.

Around 99% of patients experience some improvement in hearing following surgery.

What happens during the operation?

Stapedotomy is usually performed as a day-case procedure.

The operation is carried out in theatre using:

• Local anaesthetic to numb the ear completely.

• Light sedation to help you relax while remaining awake.

The procedure is performed through the ear canal, so there is usually no external incision or visible scar.

The operation usually takes less than one hour.

At the end of surgery:

• A small pack is placed in the ear to protect the operated area and reduce the risk of infection.

• Antibiotic ear drops are usually required while the pack is in place.

• The pack is removed at a follow-up appointment, usually after around two weeks.

What are the risks of surgery?

Stapedotomy is a safe and well-established operation. Serious complications are uncommon, but all surgery carries some risks.

Hearing outcome

Most patients notice a significant improvement in hearing (90-97%)

However:

• Around 2-3% of patients do not notice an improvement.

• Rare risk of worsening hearing in that ear

• A very small number of patients (approximately 1 in 200) may experience severe or complete hearing loss in the operated ear.

Taste disturbance

A small nerve responsible for taste runs close to the eardrum.

Around 1 in 5 patients notice a metallic taste affecting one side of the tongue after surgery.

This is usually temporary and improves over time.

Permanent taste changes are very uncommon.

If your sense of taste is particularly important for your profession (for example, if you are a chef or sommelier), please discuss this with your surgeon before surgery.

Tinnitus

The effect of surgery on tinnitus (ringing or noises in the ear) is unpredictable.

After surgery:

• Some patients notice an improvement.

• Some notice no change.

• A small number may notice worsening tinnitus.

Balance

Some patients experience temporary dizziness or imbalance after surgery.

This usually improves over the following days.

Permanent balance problems are extremely rare.

After your operation

You will usually go home on the same day.

Because of the ear pack, your hearing may initially feel worse than before surgery. This usually improves once the pack is removed.

You should:

• Keep your ear completely dry.

• Use antibiotic ear drops as instructed.

• Avoid flying and rapid pressure changes for approximately 4 -6 weeks.

• Avoid activities that put pressure on the ear, such as forceful nose blowing or heavy straining.

Returning to normal activities

Most patients require 1–2 weeks off work, depending on the type of work they do.

You can gradually return to normal activities as you feel comfortable.

Follow-up

You will be reviewed after surgery to:

• Remove the ear pack.

• Check healing.

• Assess your hearing improvement.

A hearing test is usually performed after the ear has fully healed.

IteTympanoplasty Surgery

Repair and reconstruction of the eardrum and middle ear

What is tympanoplasty?

Tympanoplasty is an operation to repair or reconstruct the eardrum and, when necessary, the space behind the eardrum (the middle ear).

The operation is usually performed to treat:

• A hole in the eardrum (perforation).

• A weakened or retracted eardrum that has become stuck onto the hearing bones.

• Recurrent ear infections caused by an unhealthy eardrum.

• Hearing loss caused by damage to the eardrum or middle ear.

A damaged or weakened eardrum can allow bacteria and water to enter the middle ear, increasing the risk of infection. It can also reduce the efficiency of sound transmission, causing hearing loss.

Additional procedures that may be needed

Depending on what is found during surgery, additional procedures may be required.

Ossiculoplasty (repair of the hearing bones)

The middle ear contains three tiny bones responsible for transmitting sound:

• Malleus (hammer)

• Incus (anvil)

• Stapes (stirrup)

If these bones have been damaged by disease or previous infection, an ossiculoplasty may be performed.

This may involve:

• Repositioning the existing bones.

• Repairing the bones using bone cement.

• Replacing damaged bones with a small titanium prosthesis.

Titanium hearing prostheses are safe for future MRI scans and do not usually cause problems with airport security systems.

Canalplasty or meatoplasty

Sometimes the ear canal is too narrow to safely perform the surgery or to allow good drainage and cleaning afterwards.

In these cases, the ear canal may be widened using a procedure called canalplasty or meatoplasty.

What happens during the operation?

The operation is performed in an operating theatre under a general anaesthetic.

The approach depends on the size and position of the eardrum problem:

• Small perforations may be repaired through the ear canal.

• Larger perforations or areas requiring more access may require a small incision above or behind the ear.

If an incision is needed:

• It is closed using dissolvable stitches.

• The scar is usually well hidden and fades with time.

During surgery, the eardrum is repaired using a graft, usually made from tissue taken from around the ear.

The graft acts as a framework, allowing the new eardrum to heal.

How long does the operation take?

The operation usually takes around 1½ hours.

Most patients go home on the same day.

At the end of surgery:

• A pack is placed inside the ear to support healing and reduce the risk of infection.

• You may need antibiotic ear drops while the pack is in place.

• The pack is usually removed at your follow-up appointment after approximately 2 weeks.

Because of the ear packing, your hearing may initially feel worse. Hearing is assessed once the packing has been removed and the ear has healed.

After your operation

You should:

• Keep your ear completely dry.

• Avoid swimming until your surgeon confirms it is safe.

• Avoid flying and rapid changes in air pressure for approximately 6 weeks.

• Avoid forceful nose blowing or activities that create pressure in the ear.

Most patients require 1–2 weeks off work, depending on their job.

What are the alternatives to surgery?

The alternatives depend on the reason for surgery.

Hearing loss

If your main problem is hearing loss, a hearing aid may be an alternative.

Advantages:

• There is no surgical risk.

• Hearing aids can provide good hearing improvement for many patients.

However:

• Some people find hearing aids inconvenient.

• In some ears, hearing aids may increase moisture and contribute to infections.

Recurrent infections

If the main problem is ear discharge or infections:

• Keeping the ear dry (including during showers and swimming) can help.

• Any episodes of infection can usually be treated with antibiotic ear drops.

What are the risks of surgery?

Tympanoplasty and ossiculoplasty are safe and commonly performed operations. However, as with any surgery, there are potential risks.

Graft failure

The repaired eardrum may not heal successfully or may develop another hole in the future.

This occurs in approximately 10–20% of patients.

Further surgery may be considered if needed.

Hearing

The aim of surgery is to improve or preserve hearing.

However:

• Hearing may not improve.

• Hearing may occasionally become worse.

• Very rarely, complete hearing loss can occur in the operated ear.

If a hearing prosthesis is used, there is also a risk that it may move or fail to function as intended.

Infection

There is a small risk of infection after surgery, which may affect healing.

Tinnitus

If you have tinnitus (ringing or noises in the ear), it may:

• Improve after surgery.

• Stay the same.

• Occasionally become worse.

Dizziness

Temporary dizziness or imbalance can occur after surgery.

Persistent balance problems are uncommon.

Taste disturbance

A small nerve responsible for taste runs close to the eardrum.

Approximately 1 in 5 patients may notice a temporary metallic taste or altered taste on one side of the tongue.

Permanent taste disturbance is very rare.

Facial weakness

The facial nerve runs through the middle ear.

There is a very small risk of facial weakness after surgery. Permanent facial weakness is extremely rare.

Numbness and scarring

You may experience:

• Numbness around the ear.

• Altered sensation around any incision.

• A visible scar if an incision behind the ear is required.

These usually improve with time.

Other possible risks

Rare complications include:

• Bleeding.

• Pain.

• Reaction to ear dressings.

• Change in the position or appearance of the ear.

• Persistent eardrum perforation.

• Need for further surgery.

Follow-up

You will be reviewed after surgery to:

• Remove the ear packing.

• Check healing of the eardrum.

• Assess your hearing once the ear has recovered.

The final hearing result is usually assessed after the ear has fully healed.m description

Mastoid Obliteration Surgery

Why have I been offered this operation?

You have previously had ear surgery that has left you with a mastoid cavity. This is a space within the bone behind the ear that is created during some operations to remove extensive ear disease, such as cholesteatoma.

Although many people have no problems with a mastoid cavity, some develop ongoing symptoms including:

• Persistent or recurrent ear discharge.

• Repeated infections.

• Build-up of dead skin requiring regular cleaning.

• Difficulty getting water into the ear.

• Problems wearing a hearing aid.

If these problems continue despite regular cleaning and antibiotic drops, mastoid obliteration surgery may help.

What is mastoid obliteration?

Mastoid obliteration is an operation that removes any remaining infection or cholesteatoma and fills the mastoid cavity to reduce or eliminate the space where infection and skin debris collect.

The cavity is reconstructed using your own tissue (such as cartilage and bone) and, when appropriate, a synthetic bone substitute. The aim is to create a healthier, more self-cleaning ear.

What are the benefits of surgery?

The main aim of surgery is to create a safe, dry and low-maintenance ear.

The potential benefits include:

• Reducing or stopping ear discharge.

• Preventing recurrent infections.

• Reducing the need for regular microsuction and cleaning.

• Allowing water exposure with fewer problems once healing is complete.

• Improving hearing in selected patients.

If hearing cannot be improved surgically, creating a dry ear may make it easier to use a hearing aid or other hearing rehabilitation options.

How successful is the operation?

Around 85% of patients achieve a dry, trouble-free ear after mastoid obliteration surgery.

Although hearing can sometimes be improved, this is not possible for everyone and depends on the condition of the hearing mechanism found during surgery.

Before your operation

Most patients attend a pre-operative assessment several weeks before surgery.

During this appointment we will:

• Review your medical history.

• Check your general health.

• Discuss your medications.

• Answer any questions you may have.

If you smoke, stopping before surgery reduces the risk of complications and improves healing.

Anaesthetic

This operation is performed under a general anaesthetic, so you will be asleep throughout the procedure.

Most patients are able to go home later the same day.

Does my hair need to be shaved?

A small amount of hair behind the ear may need to be clipped immediately before surgery to allow the operation to be performed safely.

Please do not shave the area yourself, as this increases the risk of infection.

What happens during the operation?

The operation usually takes 3–5 hours.

An incision is made behind the ear, allowing access to the mastoid bone.

Your surgeon will:

• Remove any remaining cholesteatoma or infected tissue.

• Drill away any unhealthy bone if necessary.

• Fill (obliterate) the mastoid cavity using your own bone, cartilage and/or a synthetic bone substitute.

• Reconstruct the ear canal and eardrum where appropriate.

• Rebuild the hearing mechanism using a titanium hearing prosthesis if this is likely to improve hearing.

It is not always possible to know whether hearing reconstruction can be performed until the operation is underway.

At the end of surgery:

• The ear is packed with medicated ribbon gauze.

• The wound is closed using dissolvable stitches.

• Small adhesive strips are applied to the incision.

• A head bandage is placed around your ear overnight.

Are there alternatives?

The only treatment that permanently removes a troublesome mastoid cavity is mastoid obliteration surgery.

If surgery is not suitable or you decide not to proceed, the alternative is ongoing outpatient care with regular ear cleaning and intermittent antibiotic drops or creams to control infection. This may improve symptoms but does not remove the underlying problem.

What are the risks of surgery?

Mastoid obliteration is a well-established operation with a high success rate. However, as with all surgery, there are potential risks.

Infection, bleeding and scarring

There is a small risk of infection, bleeding and scarring after any operation.

Some blood-stained discharge from the ear is common during the first few days after surgery.

The scar behind the ear usually fades well but may remain numb or sensitive for several months.

Hearing

Although hearing may improve, there is a possibility that hearing could remain unchanged or become worse.

Very rarely, complete and permanent hearing loss can occur in the operated ear.

Dizziness

Mild dizziness is common for the first few hours or days after surgery.

Persistent or severe balance problems are uncommon.

Tinnitus

If you already have tinnitus (ringing or noises in the ear), it may improve, remain unchanged or occasionally become worse after surgery.

Facial nerve injury

The facial nerve runs through the middle ear and controls movement of one side of the face.

A facial nerve monitor is used throughout the operation to reduce the risk of injury.

Temporary facial weakness is uncommon, while permanent facial paralysis is extremely rare.

Taste disturbance

The taste nerve also passes through the middle ear.

Some patients notice a metallic or altered taste on one side of the tongue after surgery.

This usually improves over time, although permanent changes can occasionally occur.

Cerebrospinal fluid (CSF) leak

Very rarely, surgery may expose the lining surrounding the brain, causing leakage of cerebrospinal fluid.

If recognised during surgery it is repaired immediately.

Occasionally a second operation is required if the leak develops afterwards.

Allergic reaction to dressings

Rarely, the ear dressing can cause redness, itching or swelling.

Removing the dressing usually resolves these symptoms.

Change in the shape of the ear

Some cartilage is usually taken from your ear during reconstruction.

In most patients there is no noticeable change in appearance, although a slight change in ear shape is possible.

Haematoma

Rarely, blood can collect beneath the skin around the ear after surgery.

This may require a small procedure to drain it.

General risks

As with any operation performed under general anaesthetic, there are small risks including blood clots in the legs or lungs and anaesthetic complications.

These will be discussed with you by your anaesthetist before surgery.

After your operation

Most patients go home the same day.

You will have:

• A head bandage, which can usually be removed the following day.

• An ear pack, which remains in place until your clinic appointment.

Because of the ear pack, hearing is usually reduced until it is removed.

Your ear may ache for a few days but this is normally controlled with simple painkillers such as paracetamol and ibuprofen.

Looking after your ear

During the first few weeks:

• Keep your ear completely dry.

• Use cotton wool coated with petroleum jelly (Vaseline) while showering.

• Avoid washing your hair until the ear pack has been removed (dry shampoo may be helpful).

• Avoid heavy lifting and strenuous exercise.

• Blow your nose gently.

• Avoid flying for approximately 2 months, or until advised by your surgeon.

• Avoid diving until you have been told it is safe.

A small amount of blood-stained discharge is normal.

If you develop increasing pain, offensive-smelling discharge, significant bleeding, fever or sudden hearing loss, please contact the ENT department.

Returning to normal activities

Most people require 2–4 weeks away from work, depending on the physical demands of their job.

Follow-up

Your first follow-up appointment is usually 4 weeks after surgery.

At this visit we will:

• Remove the ear pack.

• Examine the ear.

• Assess healing.

A further appointment is usually arranged at 3 months, when we will repeat your hearing test and discuss whether any further treatment is needed.

Because cholesteatoma can occasionally return, long-term follow-up is recommended.

Most patients are reviewed annually for at least five years, and your surgeon may arrange MRI scans during this period to ensure there is no recurrence.

What is a retracted eardrum? 

A retracted eardrum happens when the pressure on each side of your eardrum is not balanced. This is usually caused by eustachian tube dysfunction (when the tube between your nose and ear is not working properly). 

This creates negative pressure (like a vacuum), which pulls the eardrum inward. This can form small dips or pockets called retraction pockets, and the middle ear can become like it is vacuum-packed. 

The picture on the left shows a normal ear drum, and the picture on the right shows an ear drum with a retraction pocket (drawn in area).  

What do we need to do about them? 

Retraction pockets can be different in size and seriousness: 

• Some are very small, stable, and not worrying 

• Others can be larger, collect debris, cause hearing loss, and lead to infections 

Some retraction pockets stay the same for a long time, cause very few or no symptoms and only need to be watched over time (observation). 

Other retraction pockets may get deeper over time, cause worsening hearing loss, or trap debris and lead to infections. 

These may need an operation to stop them from getting worse and to prevent further problems. 

Your ENT doctor will ask about your symptoms and examine your eardrum carefully under a microscope. 

Then, together with you, they will discuss the risks and benefits of watching vs. treatment, and make a shared decision about what to do next. 

What are the complications of retraction pockets? 

Hearing loss 

A retracted eardrum, or the fluid it can cause (glue ear), can lead to conductive hearing loss. 

• If treated early, hearing can return to normal 

• If the problem continues, the eardrum may stay pulled in 

• Over time, the tiny hearing bones in the middle ear can become damaged 

• This may mean hearing does not fully recover 

Ear infections (otitis media) 

This includes acute ear infections (sudden and painful) and glue ear (fluid in the ear). 

Hole in the eardrum (perforation) 

Sometimes the pressure pulling on the eardrum is too strong, and the eardrum can burst, creating a hole. 

Treatment usually includes keeping water out of the ear, and using antibiotic ear drops if there is infection. Most holes heal on their own within about 6 weeks. 

Sometimes they do not heal and become long-term. In this case, surgery may be needed to repair the eardrum (called myringoplasty or tympanoplasty). 

Cholesteatoma 

Long-term eustachian tube problems can cause deep retraction pockets that trap skin debris. This can form a cholesteatoma, which is a growing collection of skin cells. 

It can: 

• Damage the bones in the middle ear 

• Spread to the inner ear or the bone behind the ear (mastoid bone) 

• Cause serious problems, especially if infected 

Treatment is usually surgery (called tympanomastoidectomy) to remove the trapped skin cells and prevent further damage to the ear. 

What is otitis externa? 

Otitis externa is an infection of the outer ear canal. This is the tube that goes from the outside of your ear to your eardrum. 

It is sometimes called “swimmer’s ear” because it often happens after water gets stuck in the ear. The skin inside the ear canal becomes sore, swollen, and sometimes infected. 

What causes otitis externa? 

Otitis externa can be caused by different things: 

• Water trapped in the ear (after swimming or bathing) 

• Damage to the skin inside the ear, for example: 

• Using cotton buds 

• Scratching inside the ear 

• Skin conditions such as eczema 

• Allergies or irritation from hair products or earphones 

• Bacteria or fungi (germs) growing in the ear 

What are the symptoms? 

Common symptoms include: 

• Ear pain, which can be quite strong 

• Itching inside the ear 

• Redness and swelling of the ear canal 

• Fluid or discharge coming from the ear 

• A feeling that the ear is blocked 

• Reduced hearing 

Sometimes the ear may be very tender to touch, and it may hurt when you pull the ear or chew. 

Diagnosis and treatment of otitis externa  

Who is more likely to get it? 

You may be more likely to get otitis externa if you: 

• Swim often 

• Get water stuck in your ears 

• Use cotton buds or put things in your ears 

• Have skin problems like eczema 

• Wear hearing aids or earphones a lot 

How is it diagnosed? 

A doctor or nurse will ask about your symptoms, and look inside your ear using a small light (otoscope). 

They may see red, swollen skin, fluid or discharge and a narrowing of the ear canal. 

How is it treated? 

Treatment usually includes: 

• Ear drops to treat infection and swelling (these may contain antibiotics or antifungal medicine) 

• Pain relief, such as paracetamol or ibuprofen 

• Keeping the ear dry 

In some cases, the doctor may gently clean the ear, or insert small sponge (ear wick) in the ear to help drops work better. 

What can you do at home? 

• Keep your ear dry when washing or showering 

• Do not put anything inside your ear, including cotton buds 

• Use ear drops exactly as prescribed 

• Avoid swimming until it has healed 

How long does it last? 

Symptoms usually improve within a few days of treatment, and most people feel much better within 1–2 weeks. 

What are the possible complications? 

Most cases get better with treatment, but sometimes problems can happen. 

• Ongoing infection 

• Narrow ear canal 

• Spread of infection 

• Hearing problems - usually temporary and improves after treatment 

When should you seek medical help? 

You should see a doctor if: 

• The pain is severe 

• Your symptoms are not improving after a few days 

• You have a lot of discharge 

• Your hearing gets worse 

• You feel unwell or have a fever 

How can you prevent otitis externa? 

• Keep ears as dry as possible with a cotton wool ball dipped in Vaseline, placed gently into the ear canal 

• Dry ears gently after swimming or bathing 

• Avoid putting anything inside your ears 

• Use earplugs when swimming if advised 

• Manage skin conditions like eczema 

What is a vestibular schwannoma? 

A vestibular schwannoma (also called an acoustic neuroma) is a tumour that is not cancer. It grows on the balance nerve that goes from your inner ear to your brain. This nerve is called the vestibular nerve. 

These tumours grow slowly over time. They come from Schwann cells, which are cells that protect nerves. The balance nerve is very close to the hearing nerve, so the first thing people often notice is hearing loss in one ear. 

How does it progress? 

Vestibular schwannomas usually grow slowly, but if they are not treated, they can press on the brain and nearby nerves. Some tumours do not grow at all. 

Common symptoms include: 

• Hearing loss in the affected ear 

• Tinnitus (ringing in the ear) 

• Balance problems, feeling unsteady, or dizziness 

If the tumour gets bigger, symptoms may also include numbness or tingling in the face, and headaches. 

Treatment options 

Your treatment will depend on the size, growth, and location of the tumour, your symptoms, and your overall health. 

Options include: 

• Surveillance: small tumours may not need surgery. Instead, they are checked regularly with MRI scans to see if they grow. 

• Surgery: the tumour can be removed with an operation under general anaesthetic. This is often done if the tumour is growing, causing symptoms, or pressing on important nerves or the brain. 

• Radiosurgery: high-dose radiation can be used instead of surgery to stop the tumour from growing, or after surgery to treat any tumour that is left. 

What the surgery involves 

All surgery is performed together with neurosurgeons. One common way to remove the tumour is called the translabyrinthine approach. This is often used when hearing in the affected ear is already very poor or gone. 

The surgeon makes an opening behind the ear and removes part of the mastoid bone. They then go through the balance part of the inner ear (called the labyrinth) to reach the tumour. 

This gives a clear view of the tumour and the facial nerve, which helps protect the nerve during surgery. However, hearing in that ear will be permanently lost. 

Another method is called the retro-sigmoid approach. Your surgeon will choose the best method based on your tumour and your hearing. 

After your surgery 

You will wake up in a recovery room and then move to a high care or intensive care unit for close monitoring overnight. 

You may have some tubes and drains, including: 

• A urinary catheter to drain your bladder 

• A drain in your thigh if fat was taken to help fill the area where the tumour was removed 

Most drips and drains are removed by the first day. The urinary catheter is usually removed on the second day. 

Risks of the surgery 

Problems after surgery are uncommon, but can include: 

• Damage to nearby nerves, which could affect speech, swallowing, breathing, shoulder movement, or cause double vision 

• Stroke 

• Meningitis 

• Brain infection 

• Hydrocephalus (increased pressure in the skull) 

• Bleeding 

• Pseudomeningocele (fluid collecting under the scalp) 

• A very small risk to life (0.2–0.05%) 

You can go home when both you and your medical team feel ready. This is usually about 5 days after surgery. 

Recovery after the surgery 

Dressings and wound care 

The head bandage is removed on day 3. 

Stitches are removed between day 10 and 12. 

Keep the wound behind your ear dry until advised. 

One week after stitches are removed, you can get the wound wet. 

Recovery at home 

A rough guide is 1 month of recovery for each centimetre of tumour. 

It is important to keep moving and do light activities like walking every day and gentle head movements to help your balance recover. 

Avoid: 

• Heavy exercise for 6 weeks (like lifting weights) 

• Blowing your nose hard (sniff gently or blow very gently) 

Watch for signs of a leak of fluid from around the brain, such as salty fluid from your nose or throat, and tell your medical team straight away. 

There are no legal rules about driving, but you must feel confident in your balance and reactions before you start again. 

When to get help 

Get medical help if you notice: 

• Clear, salty fluid from your nose or throat 

• Worsening weakness in your face 

• Fever, redness, or fluid from the wound 

• Severe or ongoing dizziness 

Head bandage and CSF leak prevention 

You will have a firm bandage around your head to reduce the risk of a CSF leak. CSF is the fluid that your brain floats in. Fat placed during surgery helps seal the area. 

Do not strain (like during bowel movements or lifting heavy things), as this can increase pressure in your head and cause a leak. You will be given a laxative to help with bowel movements. 

If you notice salty fluid from your nose or throat, tell staff immediately. 

Balance, dizziness, and nausea 

The tumour affects the balance nerve, which is removed during surgery. This means you will feel dizzy and sick for 2–3 days. 

You will be given medicine to help. It is important to start moving as soon as you can, as this helps your brain adjust more quickly. 

Facial nerve function 

The facial nerve controls your face muscles and helps you close your eye. Doctors try to protect this nerve, but it is common to have some temporary weakness or paralysis. This usually gets better over time. 

If you cannot close your eye properly, you may need eye drops, ointment, or tape your eye shut at night to protect it. 

This nerve also helps with taste. Some people notice less taste on one side of the tongue after surgery, but this usually improves within weeks. 

Tinnitus 

If you had ringing in your ears before surgery, it may get worse afterwards, especially if you still have some hearing. 

Things like deep breathing, white noise, music, and exercise can help distract you from it. 

Pre-operative gentamicin 

What is gentamicin? 

Gentamicin is a type of antibiotic that can damage balance cells in the ear. In this case, it is not used to treat infection. It is used before surgery to reduce the balance function in the affected ear. 

This helps your brain adjust slowly before surgery, instead of all at once, which can make recovery easier. 

How does gentamicin work? 

Gentamicin damages the balance cells in the inner ear on the side of the tumour. This helps your brain rely more on the healthy ear for balance before the tumour is removed. 

How many treatments are needed? 

You will usually have up to 3 treatments over several weeks. 

The last treatment is at least 3 weeks before surgery. 

What happens during the procedure? 

Your ear is numbed with local anaesthetic. 

Gentamicin is injected through your eardrum into the middle ear. You will lie on your side for 15–20 minutes so the medicine can reach the inner ear. 

You may feel more unsteady 1–2 weeks after each injection. This is expected. It is important to keep moving, doing daily activities, and gently turning your head to help your brain adjust. 

Side effects of gentamicin 

The injections are usually well tolerated. 

• Dizziness is common and expected 1–2 weeks after the injection 

• You can still drive on the same day because dizziness is delayed 

• You may feel some stinging in the ear, which usually goes away after a few days 

• Paracetamol can help if needed 

Will I lose hearing after gentamicin? 

Hearing will be lost in the affected ear after surgery to remove the tumour. 

This means that even if hearing is affected by gentamicin before surgery, you would not be able to hear from that ear after surgery anyway. 

What is vestibular migraine? 

Vestibular migraine is a type of migraine and is the second most common cause of dizziness. 

Migraines are usually described as repeated attacks of strong headaches, which are thought to happen because of changes in blood flow in the brain. About 30–40% of people with migraines also feel dizzy. 

Vestibular migraines can happen with a headache, or without a headache. They can also cause other strong symptoms that affect vision, balance and the body. 

Because vestibular migraines can happen without a headache, they can sometimes be missed, harder to diagnose or take longer to identify. 

If a headache does happen, it can come: 

• Before the dizziness 

• During the dizziness 

• After the dizziness 

Migraines are more common in females, and more likely if there is a family history of migraines or headaches. 

 They can be hard to diagnose because there is no single test that proves someone has a migraine. 

Symptoms 

The main symptom of vestibular migraine is dizziness. 

“Dizziness” can mean different feelings, such as: 

• Spinning 

• A swimming feeling 

• Feeling confused or disoriented 

• Poor balance 

• Being sensitive to movement 

Symptoms can last from 4 to 72 hours. 

Other symptoms include: 

• Problems with balance (imbalance), vertigo (spinning), or not tolerating movement (these usually last minutes to hours) 

• Feeling sick (nausea) or being sick (vomiting) 

• Vision problems, such as being sensitive to light (photophobia) and blurred vision 

• Tinnitus (ringing in the ears) or being sensitive to sounds 

• Headache (this may happen before, during, after, or not at all) 

• An aura before the migraine starts, such as pressure in the head, changes in vision or increased sensitivity to light, sound, or touch 

Potential triggers 

Migraines are often linked to things called triggers, which can start an attack. 

Lifestyle 

• Not exercising enough 

• Or exercising too much 

Food and drink 

Certain foods and drinks can trigger migraines, such as: 

• Cheese 

• Processed foods 

• Chocolate 

• Nuts 

• Caffeine 

• Alcohol 

Also triggered by kipping meals, or going a long time without food or drink. 

Stress and anxiety 

High stress levels can make migraines happen more often. 

Hormones 

Hormonal changes can trigger migraines. This is one reason migraines are more common in females. 

Sleep habits (sleep hygiene) 

• Poor sleep 

• Not enough sleep 

• Irregular sleep patterns 

Helpful tips 

Treat this like a normal migraine. Take painkillers or anti-migraine medicine if prescribed and lie down in a dark, quiet room. 

Be careful: 

• Taking too many painkillers can cause rebound headaches 

• Do not take them more than twice a week or 8 days a month 

If you need them more often, preventative medicines may help, such as amitriptyline or nortriptyline. 

Try to avoid things like: 

• Cheese, caffeine, chocolate, citrus fruits 

• Alcohol 

• Dehydration 

• Missing meals 

• Lack of sleep 

If your symptoms improve when you avoid triggers or take migraine treatment, this helps confirm the diagnosis. 

If screens make symptoms worse, turn down brightness, use a coloured screen filter and take regular breaks. It is better to take breaks early, before symptoms get worse. 

Eat regularly, do not skip meals and keep a healthy diet. Eating regularly helps keep your blood sugar steady. 

Keep a food diary, writing down what you eat and when symptoms happen. This can help you find your personal triggers. Some evidence suggests a low sugar or low carbohydrate diet may help. 

Stress can trigger migraines, try to relax and take care of yourself. 

Keep a regular sleep routine, try to bed and wake up at the same time every day, even on weekends. 

Aim for moderate exercise 3–5 times per week, with each session about 20–30 minutes long. It is best to choose something you enjoy, so you keep doing it. 

Persistent Postural-Perceptual Dizziness (PPPD)

What is PPPD?

Persistent Postural-Perceptual Dizziness (PPPD) is a functional neurological disorder that affects the way the brain processes information about balance and movement.

People with PPPD often feel dizzy, unsteady or off balance, even though the balance organs and nervous system are structurally normal.

PPPD is diagnosed when the following features are present:

• Symptoms of dizziness, unsteadiness or a sensation of movement (without the room spinning) are present on most days for at least three months.

• Symptoms are often worse when:

  • Standing or walking upright.

  • Moving yourself or being moved (for example in a car or lift).

  • Looking at busy visual environments, such as supermarkets, scrolling on a phone, crowds or moving traffic.

• Symptoms begin after an event that affects balance, such as:

  • An inner ear disorder (for example, vestibular neuritis or BPPV).

  • A migraine.

  • A medical or neurological illness.

  • A period of significant stress or anxiety.

• The symptoms interfere with everyday life, work or social activities.

• No other condition better explains the symptoms.

Understanding PPPD

One way to think about PPPD is the "hardware and software" analogy.

Your hardware—the brain, inner ears and nerves—is intact and working normally.

However, the software—the way the brain processes balance information—has become over-sensitive and is not functioning as efficiently as it should.

Following an illness or balance disturbance, the brain can remain in a heightened "protective" mode. As a result, it becomes overly aware of normal balance signals and visual movement, leading to persistent dizziness and unsteadiness.

Although the symptoms are very real, they are caused by a change in how the nervous system functions rather than damage to the nervous system itself.

The encouraging news is that, because the brain is capable of adapting (a process known as neuroplasticity), these symptoms can improve with the right treatment.

Treatment

Treatment aims to help the brain return to processing balance information normally.

This usually involves a combination of:

• Vestibular physiotherapy, which gradually retrains the balance system and reduces sensitivity to movement.

• Psychological therapy, such as cognitive behavioural therapy (CBT), to help reduce the cycle of dizziness, anxiety and avoidance that can maintain symptoms.

• Medication, particularly selective serotonin reuptake inhibitors (SSRIs), which can be helpful for some people by reducing nervous system sensitivity and improving recovery.

Recovery is usually gradual and takes time, but most people improve with appropriate treatment and regular practice of the recommended exercises.

Septoplasty and Inferior Turbinate Reduction

Why have I been offered this operation?

You have been recommended for surgery because your nose is blocked due to one or both of the following:

• A deviated nasal septum – the wall of cartilage and bone that separates the two sides of the nose is bent, reducing the space for airflow.

• Enlarged inferior turbinates – these are normal structures inside the nose that warm, humidify and filter the air you breathe. They can become enlarged due to allergies, chronic inflammation or prolonged use of decongestant nasal sprays, contributing to nasal blockage.

Nasal obstruction is frequently caused by both anatomy and inflammation.

Correcting both problems during the same operation often provides the best improvement in nasal breathing.

What is a septoplasty?

A septoplasty is an operation to straighten the nasal septum by reshaping and repositioning the cartilage and bone inside the nose. This improves airflow through the nasal passages.

What is an inferior turbinate reduction?

Inferior turbinate reduction reduces the size of the enlarged turbinates while preserving their normal function of warming and humidifying the air you breathe. I commonly perform this using a microdebrider or submucosal diathermy techniques.

What does the operation involve?

The procedure is performed under a general anaesthetic, so you will be asleep throughout.

The operation usually takes 1½ to 2 hours.

All surgery is performed through the nostrils, so there are no external scars.

Most patients go home the same day.

What are the benefits?

The main aim of surgery is to improve nasal breathing by reducing nasal obstruction.

Many patients also notice:

• Easier breathing during exercise.

• Improved sleep.

• Reduced mouth breathing.

• Improved quality of life.

If you have allergies or chronic inflammation inside the nose, surgery improves the space available for breathing but does not treat the underlying inflammation.

Are there alternatives?

Before considering surgery, treatment usually includes:

• Regular saline nasal irrigation.

• Steroid nasal sprays.

• Antihistamines, where appropriate.

• Avoiding triggers such as smoking, allergens and overuse of decongestant nasal sprays.

If these treatments do not provide adequate relief, surgery may be recommended.

What are the risks?

Septoplasty and inferior turbinate reduction are common and safe procedures. However, all surgery carries some risks.

These include:

• Bleeding – a small amount of blood-stained discharge is common during the first few days. Occasionally, further treatment is needed to control bleeding.

• Infection – uncommon and usually treated with antibiotics.

• Pain or discomfort – most patients experience mild discomfort for several days, which is usually controlled with simple pain relief.

• Failure to improve symptoms – although most patients breathe more easily after surgery, improvement cannot be guaranteed.

• Scar tissue (adhesions) – scar tissue can occasionally form inside the nose, causing blockage and sometimes requiring further treatment.

• Temporary numbness – numbness of the tip of the nose, upper teeth or upper lip may occur and usually improves over time.

• Septal perforation – a small hole can occasionally develop in the nasal septum. This is uncommon and may not cause any symptoms, although it can occasionally result in crusting, whistling or bleeding.

• Change in the shape of the nose – this is rare but can occur if the septum provides less support to the nose after surgery.

• Reduced smell - this may occur temporarily after the surgery due to swelling but isnt usually long lasting.

Recovery

Most patients require 1–2 weeks off work, depending on the nature of their job.

You should avoid:

• Heavy lifting.

• Strenuous exercise.

• Contact sports.

for 1–2 weeks after surgery.

Although you should notice gradual improvement over the first few weeks, complete healing may take 2 months or longer.

Looking after your nose after surgery

Good postoperative care is essential for the best possible result.

Saline nasal irrigation

Starting the day after surgery, rinse your nose using a NeilMed Sinus Rinse bottle.

Use:

• Three full bottles, three times each day, for 4 weeks, or until your follow-up appointment.

Regular irrigation removes blood clots and crusting, promotes healing and helps prevent infection.

Steroid nasal spray

Restart your steroid nasal spray one week after surgery, unless your surgeon advises otherwise.

Some patients will need to continue using a steroid nasal spray long term.

Although surgery improves the shape of the inside of the nose, it does not cure allergies or inflammation of the nasal lining. If these continue to cause symptoms, ongoing treatment with nasal sprays or allergy medication may still be required.

Follow-up

You will be reviewed in clinic approximately 4 weeks after surgery to assess healing and remove any remaining crusting if required.

Further information

For more information about these procedures, please visit:

• ENT UK – Septal surgery: https://www.entuk.org/patients/conditions/62/septal_surgery_new/

• ENT UK – Inferior turbinate surgery: https://www.entuk.org/patients/conditions/91/turbinoplasty_or_surgery_to_the_inferior_turbinates/

What are sinuses? 

Sinuses are air-filled spaces in the bones of the face and head. They are connected to the inside of the nose through small openings. The sinuses are important in the way we breathe through the nose and in the flow of mucus in the nose and throat. When the sinuses are working properly we are not aware of them, however if they become inflamed of infected the can cause symptoms. This is known as sinusitis. Symptoms of sinusitis can include a blocked nose, pressure or congestion in the face, runny nose or mucous problems, headache or loss of sense of smell. 

What is functional endoscopic sinus surgery (FESS)? 

Endoscopic sinus surgery is the name given to operations used for severe or difficult to treat sinus problems. You will likely have been given nose drops, sprays or antibiotics to try and improve your symptoms, however if these medications have been unsuccessful in treating your sinus problems then an operation may be required. 

What does the operation involve? 

The operation usually takes about 1-2 hours. You will be asleep for the surgery. The operation is all done inside the nose and there is usually no need for cuts outside the nose. The surgeon will use special telescopes and other instruments to unblock your sinuses. Small amounts of bone and the swollen lining of your nose are removed. If you have nasal polyps these can also be removed. 

What are the risks? 

Sinus surgery is safe, but there are some risks. Sometimes your nose can bleed after this operation, and we may have to put packs into your nose to stop it. This can happen within the first 6-8 hours after surgery or up to 5-10 days after surgery. If there is bleeding during the operation you may wake up with a pack already inside your nose. 

Infection in your nose is rare after this operation, but if it happens it can be serious, so you should see a doctor if your nose is getting more and more blocked or painful. 

The sinuses are very close to the wall of the eye socket. Rarely bleeding into the eye socket can occur. If this is mild you may notice some bruising around the eye, however if the bleeding is more severe you may experience some double vision or in very rare cases loss of sight. This may require further operations to fix this. 

The sinuses are also very close to the bone at the base of the brain. Very rarely this bone can be damaged during the operation, if this happens there may be a leak of the fluid that surrounds the brain into the nose. This may require a further operation to fix this leak. On very rare occasions infection can spread from the sinuses into the fluid surrounding the brain causing meningitis but this is extremely uncommon. 

In general, serious complications are very rare. In a survey of all ENT surgeons who do this type of operation in England. Eye complications happened one in every five hundred operations and spinal fluid leaks happened one case in every one thousand operations. 

What can I expect after the operation? 

You will most likely go home the same day, however if there is bleeding during the operation and your nose needs packing you may need to stay overnight. 

You will be given some nasal drops or a spray or some tablets to take home with you which will help to prevent your symptoms from recurring. These will contain a steroid medication that will help to reduce the inflammation in your nose. You may need to continue these medications long term. You will need to take at least a week off work to allow the nose to heal. 

Your nose will be a bit painful for a week or so, simple painkillers such as paracetamol or ibuprofen should be enough to relieve this pain. 

For the next 2 weeks 

Breathe gently through your nose, do not blow or sniff as this will not relieve the feeling of blockage and may increase the swelling 

If you are going to sneeze, sneeze with your mouth open to protect your nose 

Avoid lifting heavy weights or doing strenuous exercise as this increases the swelling and risk of bleeding 

You may get some blood coloured watery fluid from your nose for the first two weeks or so. This is normal 

Your nose will be blocked both sides as if you have a heavy cold 

Follow up 

I will see you in the outpatient clinic about 4 weeks after the operation to check your symptoms have improved and you are happy with the results of the surgery 

Is there any alternative treatment? 

There are numerous medications that can help improve the symptoms associated with sinus problems including nasal steroids and antibiotics. 

ItemNasal Treatment Instructions

Regular nasal irrigation (saline rinse)

Rinsing your nose with saline helps to clear mucus, reduce inflammation and improve the effectiveness of your nasal medication.

Use a NeilMed Sinus Rinse bottle twice a day. These are available from most pharmacies or can be purchased online.

Alternatively, you can make your own saline solution:

1. Dissolve:

   • 1 teaspoon of salt, and

   • ½ teaspoon of bicarbonate of soda (baking soda)

2. Mix with 500 mL of freshly boiled water that has been allowed to cool.

3. Use the solution with a nasal irrigation bottle or a neti pot.

Prepare a fresh solution each day and discard any unused solution after 24 hours.

Always perform the saline rinse before using any nasal medication.

Intranasal steroid treatment

Step 1: Betnesol® drops

Use 2–3 drops in each nostril twice daily for 2 weeks only.

• Use the drops in the head-down position (see below).

• Do not use Betnesol® for longer than 2 weeks unless specifically advised by your doctor.

Step 2: Flixonase® Nasules

After completing the 2-week course of Betnesol®, start Flixonase® Nasules.

• Use one Nasule, dividing the contents equally between both nostrils.

• Use twice daily in the head-down position.

• Continue this treatment long term, or until advised otherwise by your specialist.

Head-down position

For both Betnesol® drops and Flixonase® Nasules, use the head-down position so that the medication reaches the deeper parts of the nose and sinus openings.

Video instructions

For demonstrations on how to perform nasal irrigation and use your nasal medications correctly, visit:

Abscent – NoseWell Advice: https://abscent.org/nosewell/advice description

Silent Reflux (Laryngopharyngeal Reflux – LPR)

What is silent reflux?

Silent reflux, also known as laryngopharyngeal reflux (LPR), occurs when stomach contents travel up into the throat and voice box (larynx).

Unlike typical acid reflux (heartburn), people with LPR often do not experience burning in the chest, which is why it is commonly called "silent" reflux.

The stomach contents may contain acid, digestive enzymes (such as pepsin), bile or a combination of these. Even small amounts can irritate the delicate lining of the throat and voice box.

Common symptoms

Symptoms vary from person to person and may include:

Throat and voice

• Frequent throat clearing.

• Hoarseness or a husky voice.

• A persistent dry cough.

• A sore, irritated or burning throat.

• Excess mucus or the need to keep clearing the throat.

Swallowing

• A feeling of a lump in the throat (globus sensation).

• Difficulty swallowing.

• Episodes of coughing or choking, particularly at night.

Other symptoms

• A bitter or unpleasant taste in the mouth.

• Bad breath.

• A sensation of postnasal drip.

• Worsening asthma, wheeze or chronic cough in some people.

How is it different from acid reflux (GORD)?

People with gastro-oesophageal reflux disease (GORD) typically experience heartburn and indigestion.

In LPR:

• Heartburn is often absent.

• Symptoms mainly affect the throat and voice.

• The throat is much more sensitive than the oesophagus, so even small amounts of reflux can cause troublesome symptoms.

What causes silent reflux?

Often there is no single cause.

Factors that may contribute include:

• Weakening of the valve between the stomach and oesophagus.

• Delayed stomach emptying.

• Being overweight.

• Smoking.

• Alcohol.

• Stress.

• Eating large meals.

• Eating shortly before lying down.

Some foods can trigger symptoms in susceptible people, including:

• Fatty or fried foods.

• Spicy foods.

• Chocolate.

• Peppermint.

• Coffee and other caffeinated drinks.

• Fizzy drinks.

• Citrus fruits and juices.

• Tomatoes.

Not everyone has the same triggers, so it can be helpful to identify which foods worsen your own symptoms.

Treatment

Treatment usually involves a combination of lifestyle changes and, where appropriate, medication.

Lifestyle measures

These measures are often the most important part of treatment.

• Stop smoking.

• Aim for a healthy weight if overweight.

• Eat smaller meals more frequently rather than large meals.

• Eat slowly and avoid overeating.

• Avoid eating within 3 hours of going to bed.

• Reduce alcohol intake, particularly in the evening.

• Limit caffeine if it worsens your symptoms.

• Avoid foods that you know trigger your symptoms.

• Drink plenty of water throughout the day (around 2 litres if appropriate for you).

• Avoid tight clothing around your waist.

• Bend at the knees rather than bending forwards from the waist when lifting heavy objects.

• Raise the head of your bed by 10–15 cm (4–6 inches) using blocks under the bed legs or a wedge pillow. Extra pillows alone are usually less effective.

• If your voice is affected, avoid repeatedly clearing your throat. Instead, try taking a sip of water or swallowing.

Voice care

If hoarseness is one of your symptoms:

• Keep well hydrated.

• Avoid shouting or speaking over background noise.

• Avoid whispering, which can strain the voice.

• Rest your voice when needed.

Medication

Medication may be recommended depending on your symptoms.

Your doctor may prescribe:

• Proton pump inhibitors (PPIs) such as omeprazole or lansoprazole to reduce stomach acid. If prescribed twice daily, these are usually taken 30–60 minutes before breakfast and before your evening meal.

• Alginate preparations (such as Gaviscon Advance) may help by forming a protective barrier that reduces reflux reaching the throat. They are often most effective when taken after meals and before bedtime.

Not everyone with LPR benefits from acid-suppressing medication, and treatment is tailored to each individual.

If you have been taking PPIs for several months, do not stop them suddenly, as this can lead to rebound acid production. Your doctor will advise you on how to reduce the dose gradually if appropriate.

How long does treatment take?

Symptoms usually improve gradually rather than immediately.

Many people notice improvement within 2–3 months, although recovery of the throat and voice may take 6 months or longer.

Consistency with lifestyle changes is often just as important as medication.

When should I seek further medical advice?

Please seek medical review if you experience:

• Difficulty swallowing that is getting worse.

• Food sticking in your throat.

• Unexplained weight loss.

• Coughing up blood.

• Persistent hoarseness lasting more than 3 weeks (particularly if you smoke).

• New or worsening symptoms despite treatment.

These symptoms do not necessarily mean anything serious, but they should be assessed promptly.

One evidence-based suggestion I'd make is replacing "PPIs are recommended" with "PPIs may be recommended." Recent large studies and UK ENT guidance have shown that proton pump inhibitors are not consistently more effective than placebo for many patients with isolated LPR symptoms, so most laryngologists now emphasise lifestyle measures, dietary modification, and alginate therapy first, with PPIs reserved for selected patients or those with proven reflux disease. This wording better reflects current practice while still supporting their appropriate use. description.

LPR is a clinical diagnosis and that throat symptoms can have several contributing factors, including allergies, chronic rhinitis, muscle tension, and heightened laryngeal sensitivity.

Tonsillectomy   

A tonsillectomy is a surgical procedure to remove the 2 tonsils at the back of your throat usually due to recurrent infections. This is performed through your mouth usually with bipolar (a heat instrument to remove the tonsils and seal the blood vessels at the same time). It is usually recommended for recurrent tonsillitis, large tonsils causing sleep apnoea, tonsil stones causing halitosis or in suspected cancer. 

The risks of surgery include a risk of bleeding. Some bleeding can happen in up to 10% of cases but severe bleeding is usually 1-2% of cases which may require a return to the operating theatre to control the bleeding. Infections are possible after surgery and may present with a fever with worsening pain or bad breath, eating and drinking regularly and avoiding crowded places can help. A small risk of injury to the surrounding areas, tongue, teeth, jaw or lips is possible but rare.  

It is a common procedure requiring 10-14 days recovery period. The pain usually peaks between day 3 and 7. 

It is common to get an earache as well as throat pain as the same nerves supply the throat and the ear. 

1. Pain management 

Take pain medications regularly, set a timer for pain relief for the first 7 days. This keeps the pain manageable and ensures you are able to eat and stay hydrated. 

Take painkillers 30-40 minutes before meals can help with swallowing 

Throat spray such as difflam can help provide some relief 

Sucking on ice lollies and using a humidifier at night can help prevent the throat drying out. 

2. Eating and drinking 

Eating a normal solid diet is really important to aid your recovery. Toast, cereal and crisps can be helpful rather than only soft foods. Eating and drinking regularly helps remove the white /yellow scab at the back of the throat which reduces the risk of infection and bleeding. 

Drinking 2-3 litres of water a day can help prevent dehydration 

Avoiding very hot or acidic (e.g. orange juice) or spicy foods can help prevent stinging 

3. Activity 

Rest: Rest at home for at least 48 hours. Avoid crowded places (schools, supermarkets) to minimise the risk of catching an infection 

Time off work: You will need 10-14 days off work or school to avoid infection 

Oral hygiene: Brush your teeth as normal to keep the mouth clean and reduce the risk of infection. 

Avoid strenuous activity for 3 weeks 

4. What to expect after surgery 

White slough/scabs at the back of the throat: This is normal and is the healing tissue left behind after the tonsils have been removed. This is not an infection. 

Bad breath: This is common for the first 2 weeks and is due to healing tissue in your mouth 

5. When to seek help 

Fresh bright red bleeding: If you cough/spit out more than a teaspoon of bright red blood you should go immediately to your nearest A+E.  

If you cannot swallow any fluids or have reduced urination