In Office Surgery

Biopsies

Biopsies are performed by excising a sample portion of a tumor or suspicious lesion. Biopsies are usually performed for unusual growths, lesions or areas that do not heal, or to determine a course of treatment. Some biopsies can and may be performed under the administration of local anesthetic in the physician’s office. Biopsies of tumors in deeper regions of the neck and throat are done under general anesthesia in the operating room with the use of an endoscope. Biopsies may take the form of a needle aspiration, an incision, shave biopsy, or excision.

Needle biopsies are typically performed in the office setting with a small needle. The procedure is sometimes referred to as a fine needle aspiration. A needle is injected into a mass and cells are removed and put on a glass slide for a pathologist’s microscopic examination and identification. Needle biopsies may be performed on masses in the soft tissues of the head and neck, as well as on glands such as the thyroid or salivary glands or on lymph nodes. A needle biopsy is limited in its accuracy by the surgeon performing the procedure, the technical preparation, and the size of the lesion. The bigger the size the less accurate the results may be. Also, certain glands or masses are less amenable to needle biopsy.

An incisional biopsy is performed when a small portion of the lesion or growth is removed. Sometimes this is in the form of a shave biopsy, as from the skin. Also, if a lesion is quite large, a small portion of it may be removed to determine its nature so that a course of treatment can be determined.

Finally, an excisional biopsy removes the entire lesion and the surrounding tissue so it can be studied. An excisional biopsy may be in the form of the removal of skin for malignancies and irritative lesions. Lymph nodes are typically excised in their entirety after a preliminary needle biopsy. Some excisional biopsies, such as in the thyroid may involve the entire gland. Most biopsies are performed in the office but some are performed at the hospital or in a hospital setting. This may include outpatient or inpatient procedures depending on the location and nature of the lesion.

Removal of Superficial Skin Cancers

The most frequent type of skin cancer is basal cell carcinoma. This cancer is slow growing and rarely metastasizes (spreads). Squamous cell carcinoma can involve both the skin and mucous membranes. Squamous cell carcinoma often extends deeper into the tissue and can ulcerate and metastasize. Surgical removal is the treatment of choice. Malignant melanoma is the most serious of skin cancers and is known for its invasiveness and metastatic behavior. Prognosis is dependent on the depth of the tumor. Therefore, detection and removal are critical.

There are several effective methods for the removal of skin cancers. However, the method chosen will depend upon the type of cancer, its location and size, and any previous therapy for skin cancer.

Freezing: Your doctor may destroy skin cancers by freezing them with liquid nitrogen. Once the dead tissue thaws it will slough off. This treatment may leave a small, white scar and you may also need a repeat treatment to remove the growth completely. If skin cancer treated with liquid nitrogen does not heal within one month, the cancer may extend beyond the area treated requiring a biopsy for further evaluation.

Excisional surgery: With this type of treatment, your doctor cuts out the cancerous tissue along with a surrounding margin of healthy skin. The removed tissue is then sent to a pathology lab to determine if the margins are clear (the outside border of the removed tissue contains no cancer cells). This type of treatment may be appropriate for any type of skin cancer and typically has a higher success rate than freezing.

Head and Neck Surgery

Sinus Surgery

Functional endoscopic sinus surgery (FESS)

involves the insertion of a very thin fiber-optic tube (endoscope), into the nose for a visual examination of the sinus openings. In the majority of cases the surgical procedure is performed entirely through the nostrils, leaving no external scars. The basic endoscopic surgical procedure is performed under local or general anesthesia.

The advantage to this procedure is that the surgery is less extensive; there is often less removal of normal tissues; and it can frequently be performed on an outpatient basis. After the operation the patient rarely has nasal packing. For the ten days following the procedure nasal irrigation may be recommended to prevent crusting. There is little swelling and only mild discomfort.

Head and Neck Cancers

Head and neck cancers often arise after prolonged exposure to specific factors such as tobacco, alcoholic beverages, and sunlight. Although the following signs and symptoms can occur with no cancer present, you cannot tell without an examination. Therefore, if one or more of the following occur, you should see your doctor:

• a lump in the neck;
• hoarseness that lasts for more than 2 weeks;
• an ulcer or swelling in the mouth that does not go away; blood in saliva or phlegm;
• difficulty swallowing;
• or constant pain in or around the ear if it is associated with difficulty in swallowing,
  hoarseness, or a lump in the neck; or any lesions of the face, head, or neck.

Endocrine Surgery

Two types of endocrine glands are found in the neck: the thyroid and the parathyroid glands. The thyroid gland regulates your body’s metabolism while your parathyroid gland regulates the calcium level in your body so your nervous and muscular systems will function properly.

The most common diseases of the thyroid are called hyperthyroidism (over-activity of the thyroid gland) and hypothyroidism (under-activity of the thyroid gland).

There are several causes of hyperthyroidism. Over-activity of the thyroid may cause the thyroid gland to become enlarged, such as in Grave’s disease. Inflammation of the thyroid gland (thyroiditis) may also cause an excessive amount of the thyroid hormone to be released from the gland causing a goiter.

There are two fairly common causes of hypothyroidism. Sometimes, a previously inflamed thyroid gland can leave the cells of the gland damaged or dead and it can no longer produce a sufficient amount of thyroid hormone. This type of thyroid gland failure is called Hashimoto’s disease. Occasionally, hypothyroidism may occur after surgery is done to remove a portion of the thyroid gland because of a nodule or cancer. If the remaining thyroid cells are incapable of producing enough thyroid hormone for the body, hypothyroidism will result.

Your doctor may order a variety of tests to assist in the diagnosis of a thyroid abnormality. 
These tests include:

• An ultrasonic examination of your neck and thyroid;
• Blood tests of thyroid function;
• A radioactive thyroid scan;
• A fine needle aspiration biopsy;
• A chest x-ray; and/or
• A CT or MRI scan.

Thyroid surgery may be necessary to remove all or part of the thyroid gland. This type of surgery is performed in the hospital under general anesthesia. Surgery may be needed for the removal of a thyroid nodule (mass), for removal of a malignancy, or for removal of an area that remains questionable even after a fine needle biopsy. Patients who have thyroid surgery may be required to take thyroid medication to replace thyroid hormones after surgery. Some patients need to take calcium replacement if their blood calcium is low. This will depend on how much of the thyroid gland remains and what was found during surgery.

The single major disease of the parathyroid gland is over-activity of one or more of the four small endocrine glands located on the thyroid gland. Too much parathyroid hormone can cause a serious calcium imbalance. This is called hyperparathyroidism. Left untreated, hyperparathyroidism may be responsible for osteoporosis, bone factures, kidney stones, peptic ulcers, pancreatitis, and nervous system problems. Treatment of hyperparathyroidism requires removal of the overactive parathyroid gland.

Tonsillectomy/Adenoidectomy

Tonsils are located on the back of the throat and adenoids are located high in the throat behind the nose and the roof of the mouth. Adenoids are not visible through the mouth without special instruments. Tonsils and adenoids are believed to work as part of the body's immune system by filtering germs that attempt to invade the body. Children who must have their tonsils and adenoids removed suffer no loss in their resistance to germs.

Recurrent throat and ear infections are the most common problems affecting the tonsils and adenoids. Tonsils and adenoids can also become enlarged and obstructive which can lead to breathing and swallowing problems. In general, it is recommended that a tonsillectomy be performed for children who have three or more tonsillar infections per year.

During the surgery the patient is under a general anesthetic. The surgeon uses special instruments to cut the tissue in order to successfully remove the tonsils and adenoids. The surrounding blood vessels are then sealed to control bleeding. These procedures are usually performed on an outpatient basis and patients are typically able to return to normal activity in one week.

There are several postoperative symptoms that may arise. These include but are not limited to difficulty in swallowing, vomiting, fever, throat pain, and ear pain. Occasionally bleeding may occur after surgery. If the patient has any bleeding, your surgeon should be notified immediately.

Nasal Surgery

The nasal septum is the vertical wall that divides the nose into two nasal cavities. At birth the nasal septum is usually straight. However, as we age there is a tendency for the septum to bend to one side or the other. Often there is no history of injury to account for the irregular septum. Few adults have a septum that is completely straight. Sometimes trauma to the nose can play a major role in a septal deviation.

Septoplasty is an operation to correct a deviated septum. This procedure is usually done to improve the nasal breathing function but can also be done to provide adequate examination of the inside of the nose for the treatment and/or removal of nasal polyps, inflammation, tumors, or bleeding.

PE Tubes

In many cases ear infections or fluid do not clear up with proper medication and home treatment. If this is the case, a procedure called a myringotomy may be recommended. This procedure involves a small surgical incision into the eardrum to promote drainage of the fluid and to relieve pain. A ventilation tube (PE tube) can be placed in the incision to prevent further fluid accumulation and to improve hearing. The surgeon selects a ventilation tube that will remain in place for as long as required for the middle ear infection to improve and for the eustachian tube to return to normal. This may require several weeks or months. During this time patients must keep water out of their ear(s) because it could start an infection in the middle ear. Otherwise, the placement of a PE tube has no side effects and patients will often notice a remarkable improvement in hearing and a decrease in the frequency of ear infections. This procedure is performed in the office or at an outpatient surgical center.