• Make a written list of all your questions—consider diet, activity, hygiene, return to work.
• Read your postoperative instructions. They will include general instructions and may include instructions specific to your surgery.
• Wear something comfortable that you don’t have to pull over your head, preferably dark colored. We don’t want you to irritate your fresh wound or stain your clothing.
• Consider what you might need to have on hand so you don’t need to go looking for it after surgery. For example, Tylenol, antibiotic ointment, bandages, hydrogen peroxide, ice packs (bags of frozen peas work well and are easy to refreeze).
• Hold the following medications and supplements for the specified amount of time.

• Aspirin—regular strength or baby strength – 7 days
• Vitamin E – 7 days
• NSAIDS (ibuprofen, naproxen, celecoxib or others in the class) – 5 days
• Plavix, Ranexa, Eliquis – 7 days
• Coumadin – 5 days

• Tylenol is an excellent pain reliever. This is always recommended for mild to moderate pain.
• Ice packs help with pain by decreasing swelling and throbbing and should be used where possible to help manage postoperative discomfort.
• Narcotics should be used only for moderately severe to severe pain. Narcotic pain medications can make you drowsy, cloud your thinking, cause nausea, and are highly addicting, especially if you try to use them for less severe pain.  We now are more aware that many people addicted to opioids have developed their habit following surgery; in other words, surgery does not make them safer or less addicting, rather careful limited use is the key to successful pain management.  Some guidelines to consider:  You will be given a card to try to help you assess when a narcotic is recommended rather than a medication with fewer safety concerns (a visual analog scale).

• If you need to take a narcotic medication because of extreme pain, you should always take the smallest amount for the shortest time. This does not mean that you should not take it if you need it; moderation is the key.  You cannot drive while taking a narcotic pain medication.

• When possible, alternate or go back and forth between a narcotic pain medication and Tylenol (or ibuprofen when it is approved).

• Use ice packs where practical.

• Stop the narcotic pain medication as soon as your pain level has decreased to a level controlled by other means. Do not hold on to narcotics after surgery.  This is another common way for them to get misused by yourself or others.  They can be flushed down the toilet or thrown out mixed with coffee grounds.

• Narcotic pain medication can cause severe constipation. If you are taking narcotics, we suggest using a stool softener such as Colace (docusate) and/or Milk of Magnesia.

Wound Care

• Wounds, including those covered with steri-strips, should be cleaned twice daily.
• Full strength hydrogen peroxide (OTC first aid aisle) is excellent for dissolving blood around the wound.
• If there are steri-strips, avoid peeling or removing them until at least one week after surgery.
• Antibiotic ointment (Bacitracin, Neosporin, or Triple antibiotic—all OTC in first aid aisle) should be applied twice daily after cleaning.

Bleeding

• Most bleeding will respond to pressure and ice (blood clots much quicker when it is cold!!)
• Apply pressure with gauze when possible until the bleeding is minimal or stops.
• Avoid clothes that need to be pulled over a wound to prevent soiling clothing or irritating the wound.

Other

• In most case, you may shower 24hr after surgery. Avoid washing the wound directly, do not submerge the wound, pat it dry gently.  Reapply dressing as needed.
• Unless specified elsewhere, diet may be advanced as tolerated. Stay hydrated.
• For nausea/vomiting, avoid any suspected medication such as narcotics. Push fluids.  Call for repeated episodes of vomiting.
• Low grade fevers (less than 100ºF) are not generally alarming. Consider Tylenol or a cool shower.  If fevers are higher or persist, call for further instructions.

Drain Care

• In the case of certain surgeries such as salivary gland surgery, thyroid surgery and other neck surgeries, a drain is often placed. The nurses will demonstrate how to use this.
• It should take more than 3 hours to fill half way. If it is filling more rapidly or you are developing neck swelling, pressure should be placed over the area of swelling and you should call.
• The drain will generally be removed 1-3 days after surgery in the office.

• Small amount of blood is not unusual in the day after tubes are placed. Bleeding that starts a week later, or even months later, usually suggests an infection and almost always will need medicated ear drops.
• There is NO real consensus about whether or not water should be avoided in the ears after tubes. The Academy of Otolaryngology feels that routine water protection such as ear plugs is not necessary:  ear plugs are not a guarantee that an ear infection will not occur and many will not get an ear infection if they get their ears wet.  Some general thoughts:

• Activities that can cause water to enter the ears under pressure present greater risk. These include activities such as diving, water skiing, and surfing.  Either avoid these activities or ear plugs and/or neoprene headbands are advised.

• Try to avoid submerging the ears in dirty soapy bathwater. If a little water gets in the ear, don’t worry unless the ear starts to drain or smell.  Don’t avoid baths in any case, consider ear plugs or a neoprene headband if you can’t prevent the behavior.

• Drainage, with or without odor, usually suggests infection or inflammation. Ear drops alone are often sufficient.  There are increasing numbers of resistant bacteria and trying to minimize the use of oral antibiotics is one goal of tube placement.  Hopefully, oral antibiotics can be reserved for failure of ear drops or signs of more serious infection that would not be managed by ear drops alone.
• Tubes are expected to stay in for 6 or more months. Sometimes they fall out earlier and may or may not need to be replaced.  Sometimes they stay in longer than they should and removal may be recommended.
  If they get plugged up (the hole is quite small), they don’t serve the purpose of pressure equalization and ventilation for which they were placed and they may need to be unplugged or replaced.
• Most kids who have tubes don’t like anyone playing with their ears!! They’ve been through the mill. It is not surprising that they generally HATE ear drops.  When you combine this fact with the fact that even Bactine© stings when you put it on a cut, be forewarned that they aren’t going to love the eardrops.  Consider keeping them out of the refrigerator for the duration of use and premedicating with ibuprofen or Tylenol.

Diet Recommendations are for 10 days after surgery.  (Does not apply to adenoidectomy alone—diet can be advanced as tolerated):

• The goal is to prevent unnecessary discomfort and bleeding. Anything that might get stuck in or rub the back of the throat increases the risk of increased pain and bleeding.
• The Rule of 5—Cool, soft, bland, moist, and easy to swallow. That means no popcorn, French fries, fried chicken, sandwiches, chips, pretzels, etc.  Red foods or drinks are fine!  Don’t run with a straw in your mouth!
• Push lots of fluid. It will keep you hydrated and that will make you less uncomfortable.  Gatorade, KoolAid, CapriSun, other juices, water and iced tea are great for hydration.

Pain and Sore Throat Management

• Stay well hydrated.
• Take pain medication (over the counter or prescription) as needed. We generally recommend giving medications around the clock for the first 24 hours.  It is also a good idea to make sure that pain is well controlled over night so that you don’t have to “chase” it all day—consider a dose at bedtime, 4-6hours later and on wakening.  It will be easier to gage what is needed the rest of the day.  Use narcotic pain medication only for moderately severe to severe pain.  Tylenol should be used when possible.  Do not continue to take narcotics for a sore throat; you would not take narcotics for a regular sore throat.
• Use Chloraseptic spray to ease the sore throat as an alternative to trying to bring the pain level to zero.
• There should be relatively little pain after an adenoidectomy alone. Tylenol is the only medication that should be necessary.
• Consider a laxative and/or a stool softener if narcotics are being used. Significant constipation can occur after just a few doses and straining increases the risk of bleeding.

Bleeding

• Bleeding can occur after any adenoidectomy or tonsillectomy but fortunately is usually self-limited. Most bleeding occurs a few days to a week after surgery.
• If bleeding is noted, gargle ice water immediately. Also apply an ice pack to the back of the neck.  Most of the time, this will stop the bleeding.
• If bleeding continues or keeps restarting, go to the nearest emergency room. Call and let me know if you are on your way to the emergency room.

Additional information

• Ear pain is not uncommon after tonsillectomy, especially as the scab is starting to separate.
• The back of the throat will appear to be infected. It will change colors; it may be black, green, or yellowish white.  This is all normal healing process and will turn back to the normal pink color in 2-3 weeks.

• Some bleeding is normal and may be relatively heavy for the first 24 hr but should slow down. It might create a light stream but should NOT pour.  Keeping a “moustache dressing” under the nostrils above the lip will eliminate needing to repeatedly wipe.  A fairly simple gage of the amount of blood is timing how long it takes the gauze to saturate to the example in the middle, in other words, when you might want to change the gauze. [ADD PICTURE]
• If splints are placed, they have been sutured. It will hurt if you try to pull them out yourself.  They are easily removed in the office at 5-7days postoperatively.  Packing is rarely needed but may be more likely after inferior turbinate surgery.
• Narcotic pain medication may be prescribed for postoperative moderately severe to severe pain. An antibiotic will be added if splints are placed or if deemed necessary.
• Sleeping with several pillows for the first week may make it easier to breathe until the swelling in the nose decreases.
• Saline nasal spray (ex. Ocean, Ayr) 3-4 times a day will help reduce swelling and rinse blood out of the nasal passages.
• Nose blowing is discouraged for one week other than very gentle nose blowing (puffing). Let a sneeze come out of your mouth.  Avoid straining or heavy lifting
• Resume a normal diet as tolerated. Light activity may be resumed as tolerated; additional activity can usually be resumed after your first postoperative appointment.
• Avoid hot showers for the first week; keep it lukewarm.

POSTOPERATIVE SINUS SURGERY (WITH OR WITHOUT SEPTOPLASTY) INSTruCTIONS

• Some bleeding is normal and may be relatively heavy for the first 24 hr but should slow down. It might create a light stream but should NOT pour.  Keeping a “moustache dressing” under the nostrils above the lip will eliminate needing to repeatedly wipe.  A fairly simple gage of the amount of blood is timing how long it takes the gauze to saturate to the example in the middle, in other words, when you might want to change the gauze.
• Packing is rarely needed. Spacers may be placed that will be removed at the time of your first postoperative appointment.  If they fall out, although this is uncommon, nothing needs to be done.  If splints for a septoplasty are placed, they have been sutured.  It will hurt if you try to pull them out yourself.  They are easily removed in the office at 5-7days postoperatively.
• Narcotic pain medication may be prescribed for postoperative moderately severe to severe pain. An antibiotic will be added if splints are placed or if deemed necessary.
• Sleeping with several pillows for the first week may make it easier to breathe until the swelling in the nose decreases.
• Saline nasal spray (ex. Ocean, Ayr) 4-6 times a day while awake will help reduce swelling and rinse blood out of the nasal passages. If you use saline irrigation and/or a steroid nasal spray, wait until after the first postoperative appointment to resume them unless instructed otherwise.
• Nose blowing is discouraged for one week other than very gentle nose blowing (puffing). Let a sneeze come out of your mouth.  Avoid straining or heavy lifting.
• Resume a normal diet as tolerated. Light activity may be resumed as tolerated; additional activity can usually be resumed after your first postoperative appointment.
• Avoid hot showers for the first week; keep it lukewarm.
• You will generally need to have a debridement following sinus surgery; the number of times is variable based on the extent of disease and surgery. Numbing medicine will be given but consider taking a pain medication prior to the first postoperative visit and have someone else come with you.

Your physician has requested a Canalith Repositioning Maneuver also referred to as an Epley to treat your Benign Paroxysmal Positional Vertigo (BPPV).  Other names for the condition include canalithiasis or cupulolithiasis.  There are many subtypes.

BPPV is a disorder of in the inner ear.  It is the most common cause of vertigo, a sense of motion that is perceived in the absence of actual movement .  The term “benign” means that it is not life threatening as opposed to a real health risk; paroxysmal because it occurs in sudden bouts; and it is positional, occurring with head or body movement.  It can result in significant lifestyle impairment and an increased risk of falling.  BPPV results from dislocation of calcium crystals in the semicircular canals that result in abnormal signals to your eyes, causing them to move when they are not supposed to.  It is actually these uncontrolled eye movements that make you dizzy.

The main symptoms of BPPV are vertigo, imbalance and nausea that last for a short time, only to return with a change in body or head position. Some people report a feeling of imbalance that lasts throughout the day.  It may occur without alone or in association with other disorders of the balance system.  Performing special balance exercises or using a canalith repositioning maneuver often relieves BPPV.  The movements you will be subject to are precise, like a marble moving through a labyrinth, with the goal of moving the free floating particles to a location where they can be dissolved.  What to expect during a Canalith Repositioning Maneuver, or Epley Maneuver:  With the correct diagnosis and in the absence of coexisting problems, the Epley Maneuver can be highly successful although may need to be repeated more than once.

The Epley maneuver consists of four movements that are generally repeated 2-4 times in the office.  They may provoke the same dizziness you have been experiencing but the good news is that with the correct diagnosis in the absence of coexisting conditions, you could leave the office free of the dizziness!

Because there are several variants of BPPV, each of which is treated with different maneuvers, we will have you follow up to make sure that the problem has been cleared completely and no other underlying issues are present that could continue to put you at risk for falling.

Please be prompt. A 90 minute block of time has been reserved specifically for you. If you are unable to keep this appointment, please give us 24 hours notice. Please wear comfortable clothing such as pants or slacks. The test is performed with the patient in a lying or sitting position.  We ask that you please follow these very important steps to assure accurate results:

1) Many medications can suppress the responses we look for in this test. We will not get accurate results unless you have stopped these for at least 48 hours prior to the testing. These include Antivert, meclizine, Valium, Dramamine, or scopolamine patches.

2) Other medications that should be held 48 hours prior to your appointment include: anti-depressants (Zoloft, Prozac, Wellbutrin), sleeping pills, tranquilizers, anti-anxiety medications, sedatives, prescription pain killers that contain narcotics (Tylenol #3, etc), any cold or allergy medications that make you sleepy such as benadryl, Nyquil, etc. Some of these should not be stopped abruptly so we recommend that you check with your pharmacist or prescibing doctor before stopping them.

3) Do not drink any alcohol for 48 hours prior to the test. This includes: liquor, wine, or beer.

4) Please eat very lightly the morning of the test. Avoid greasy foods such as bacon, eggs, etc. Toast or cereal are good choices.

5) Please do not wear any moisturizer, cream, lotion, foundation make-up, or Vaseline on your face. Please do not wear ANY eye make-up and make sure any residual make-up is completely removed.

6) Some patients experience a slight increase in symptoms immediately after testing. You may wish to have someone available to call if you do not feel comfortable driving home.

In preparation for the ECOG, the audiologist will scrub your forehead and ear canal before attaching electrodes that will measure brainwaves generated in the inner ear.  Makeup will interfere with the measurements.  After the electrodes are in place, a tiptrode (electrode/insert) is placed in the ear canal.  You will hear a loud series of clicks.  These clicks will be presented at a slow rate.  It is very important to stay as relaxed and still as possible.  It is also asked that you keep your eyes closed through the entire testing.  Movement can cause interference and can affect the test’s reliability.  This test lasts about one hour.  After the test is complete the audiologist may be able to give some idea of the results, but needs to analyze and then send to the referring physician.  It may take up to one week for you to receive the results from the physician.

If you are unable to keep this appointment, please give us 24 hours notice.

In preparation for the ABR, the audiologist will scrub your forehead and earlobes before attaching electrodes that will measure the function of the auditory (8TH ) nerve.  Makeup interferes with the readings from the electrodes.  After the electrodes are in place, inserts are placed in the ear canals.  You will hear a loud series of clicks.  These clicks will be presented at different rates.  It is very important to stay as relaxed and still as possible.  It is also asked that you keep your eyes closed through the entire test.  Movement can cause interference and affect the reliability of the test.  This test lasts about one hour to one and a half hours.  After the test is complete, the audiologist may be able to give some idea of the results, but needs to analyze and then send a report to the ordering physician.  It may take up to one week for you to receive the results from the physician.

If you are unable to keep this appointment, please give us 24 hours notice.