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Turbinate reduction under anesthesia - submucous resection

 
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primeke
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Location: Rivet

PostPosted: Tue Oct 11, 2011 3:18 pm GMT +0000    Post subject: Turbinate reduction under anesthesia - submucous resection Reply with quote

Doc,

I've struggled breathing through my nose my entire life because of constant congestion and in the last few years I've been working with doctors to figure out a way to address. To give you an idea - I cannot breath through my nose at all laying on my back and am a mouth breather at night. I also cannot force any air through my nose while racing so when I feed, I literally have to hold my breath until I've swallowed the drink/food before I can breath again.

Thing's I've tried include netti pot (still use daily), many allergy meds (still currently taking claritin), allergy shots (still taking these, too), outpatient turbinate reduction, and all sorts of changes to my bed and bedroom to address dust mite allergies.

Unfortunately, none of it has made much improvement and my ENT is recommending the procedure in the subject line. Do you have any anecdotal knowledge of endurance athletes (hopefully mtb'ers) undergoing this procedure and it's rate of success?

It's going to require me to be entirely off the bike for two weeks after the procudure and there's the inherent risk of any surgery, so I'm really on the fence.

I'd love to hear any thoughts you might have.

Thanks much,
Ken Primer
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The Bike Doc
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Location: Corpus Christi and Warda, Texas

PostPosted: Thu Oct 13, 2011 5:14 am GMT +0000    Post subject: Reply with quote

primeke:

If you are not already doing so irrigate your nasal passages with hypertonic saline (1.8% sodium chloride solution) instead of normal saline (0.9% sodium chloride solution). I recommend the NeilMed Sinus Rinse bottle 16 ounce size. http://www.neilmed.com/usa/sinusrinse.php You can use the enclosed packets but add two to the bottle to get the hypertonic saline concentration. When you have used up the packets you can make this very inexpensively by mixing 1 tsp plain table salt to 2 cups warm water. I recommend the sinus rinse bottle over the Nettie pot because with the gentle pressure you apply while squeezing the bottle, you can more effectively rinse the nasal passage clear.

After rinsing the nasal passages and blowing the nose gently clear, apply a topical nasal steroid which require a prescription from your doctor (several brands are available: Flonase, Nasonex, Omnaris, Rhinocort, Veramyst). In my real world experience about 10% of my patients do not tolerate the Flonase due to the preservatives and carrier solution in it. I have had this problem and it would cause my nasal turbinates to swell to the point of blocking my nasal passages. I use Rhinocort. Start off at twice daily irrigations and nasal steroids. One side effect of the nasal steroids that you may experience is nose bleeds. This was a problem for me. The tricks to prevent it are to pretreat the inside of your nosed along the middle protion that devides each side, the septum, with Vaseline or petroleum jelly applied with a cotton tip applicator (Q-tip). I take the the cotton tip with petroleum jelly and roll it gently along the nasal septum just far enought that the cotton tip is just fully inside the nostril but not forcing it back. The next trick is to remeber to spray towards the eye side of the nose. When you spray the nasal steroid remember this little ditty: "Head down and away from the side I spray." This directs the spray towards the troublesome turbinates. These two tricks have kept the nose bleeds away from me and my patients with the use of nasal steroids.

Look at any medications and supplements you may be taking as some have side effects of nasal congestion. The supplement L-arginine can cause nasal congestion by dilating the blood vessels. Some medications that act as vasodilators (they open up blood vessels) that are used for treating high blood pressure may cause nasal congestion. If you are on any meds with nasal congestion as a listed side effect, visit with your doctor about an alternative medication that may be used instead.

Keep me posted on how these tricks help you out.

Thanks,
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Paul K. Nolan, MD
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The Bike Doc
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Location: Corpus Christi and Warda, Texas

PostPosted: Fri Oct 14, 2011 3:43 am GMT +0000    Post subject: Reply with quote

primeke:

One other key item for aggravating the chronic nasal congestion is a problem called "rhinitis medicamentosa” or more commonly called rebound congestion. This is problem caused by chronic usage (more than three days) of nasal spray decongestants such as Afrin, Dristan, Neo-Synephrine and others. These medications work in a completely different way than the topical nasal steroids which work by suppressing local inflammation. The nasal spray decongestants work by constricting blood vessels that leads to decreased fluid getting into the surround mucous membranes. The problem is the body can tolerate constricted blood vessels so long and will compensate by releasing substances that make the blood vessels open back up. This can occur in as little as three days of routine use of the nasal decongestants, thus the warning they carry in the tiny print on the bottle or package that states if your symptoms last more than three days seek medical attention. So if you are using a nasal decongestant spray it is time to stop using it.

Chronic oral decongestants such as pseudoephedrine (Sudafed) are undesirable as they not only constrict the blood vessels in the nose but elsewhere in the body causing elevated blood pressure, elevated heart rate and in rare case strokes so I do not recommend the use of oral decongestants.

You can do the hypertonic saline nasal irrigations to help decongest your nasal passages without the risk of rebound congestion. You can do the hypertonic saline nasal irrigation as often as needed. I recommend at twice daily for a start and if you need to do an irrigation in the middle of the night or middle of the day to open your nasal passages, it is safe to do so. When I get an upper respiratory infection (a cold), I usually irrigate 4 times a day to keep my nasal passages open and cleared of the excess drainage.

If you fail all these interventions, then it would be time to give serious consideration for the nasal turbinate reduction surgery.

Thanks,
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primeke
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PostPosted: Tue Oct 18, 2011 11:48 am GMT +0000    Post subject: Reply with quote

Doc - thanks for the thorough response. Sorry to hear you suffer from the same symptoms, but it sure is a lucky coincidence for me!

I misspoke in my first post and left some things out that I had forgotten.

I do not use the netipot - I use the NeilMed Sinus Rinse bottle just as you recommend with the saline mix. I have tried using it multiple times in a day, but I always seem to clog back up within a few minutes of the rinse. It's real value for me seems to be the daily flushing that is warding off the colds and sinus infections that I had more often before I began the irrigations.

I have also tried Nasonex, Rhinocort, Veramyst, and Omnaris most recently, with none of them producing a demonstrable improvement. I only learned the proper spraying technique before starting the Omnaris - do you think it might be worthwhile to try the others again with the proper spraying technique?

I do not use any steroid inhalers or Sudafed, nor do I take anything else that is a vasodilators, supplement or drug.

It seems like maybe the surgery is the next logical step unless another run at one of those sprays makes sense?

Aside - do you suffer from dust mite allergies, as well? They are my most severe allergy so I'm getting the ducts and carpets cleaned to see if I find some improvement with that, too. After that, I will have exhausted the list of home changes the allergist recommended short of ripping the new carpet out of our bedroom.

Thanks,
Ken Primer
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The Bike Doc
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PostPosted: Wed Oct 19, 2011 4:00 am GMT +0000    Post subject: Reply with quote

primeke:

If you did the Omnaris for a month with correct spraying technique without improvement, then it is unlikely that the other nasal steroids will offer any further benefit. If not already doing the hypertonic saline rinse (2 packets to the bottle or 1/2 tsp plain table salt to each cup of warm water) then do try that with your Sinus Rinse.

Dust mite allergy afflicts me as well. Things that you can do beyond cleaning the duct works in the house and monthly filter replacements are get rid of feather pillows. Switch to polyester filled pillows. Cover the pillow with a hypoallergenic pillowcase cover then double pillow cases. Cover the mattress with a hypoallergenic mattress cover, then a cotton over polyester filled mattress pad, then sheets. Wash the bed clothes including mattress pad in hot water and dry in hot drier once weekly. If possible, carpet and throw rugs should be removed from the home, at a minimum from the bedroom you sleep in.

Failing all these interventions, then purusing the nasal turbinate reduction surgery should then be considered seriously.

Thanks,
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Paul K. Nolan, MD
AKA: The Bike Doc
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primeke
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PostPosted: Thu Oct 20, 2011 11:46 am GMT +0000    Post subject: Reply with quote

Thanks for all your help, Doc. I appreciate it - it's great to have a neutral, professional opinion.
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alan-31
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PostPosted: Fri Dec 16, 2011 3:07 pm GMT +0000    Post subject: Reply with quote

I found this thread through a Google search. I have so much to say about all of this, I could write a novel about what I had to go through and what my experiences have been. All respect to Dr. Paul, the Bike Doc (you may know about the nose than the doctors I've seen) but I gotta share this.

I have nasal congestion too (enlarged turbinates) and have had 3 failed surgeries to correct it. I've seen about 10 doctors, from local doctors to a doctor 700 miles away.
I have a 4th surgery scheduled in two weeks. As to why this is #4: In #1, the surgeon did nothing to the turbinates but operated in the sinuses. #2, he tried to do it but it was too little. #3 was done by another doctor and he too did too little. So now I'm hoping #4 does enough.

Having heard of ENS, I was afraid of getting anything done by the wrong doctor. My doctor #1 was the director of the ENT rated as #1 by usnews. Doctor #2 is nationally known for fixing problems where other doctors caused ENS.
So I thought I was in good hands but it looks like that today in 2011, ENT doctors generally have a very poor understanding of the turbinates and they do not know what to do with them.
All other doctors would spray my nose with decongestant and then tell me everything looked fine. Ofcourse it does. Thats not the way my nose is when I wake up in the morning with one side completely blocked. Most refused to do more surgery, without seeing my CT scans or trying to understand what was happening.

Removing the outer layer of the turbinate is bad (even if done partially) and can cause ENS, a devastating condition. There's a special mucosal layer that is not found on any other part of the body. This layer is built to let air pass over it and humidify and warm it. Our bodies have evolved for millions of years and every structure has a purpose and a function.
You can have the SMR done, thats fine. It thins the turbinate from the inside.

Nasal irrigation is temporary, its not a solution. I dont know why people recommend it so much. I've tried it myself many times. People need a permanent solution. It works for 10 minutes and then swollen turbinates will come back so whats the point? Its helpful in post-op care or really occasionally, otherwise one shouldn't have to constantly flush water up our noses. Thats not normal. Evolution did not build us in a way that we need to "irrigate" our noses 4 times a day. They're supposed to function correctly on their own. If they're not, they need to be fixed.
Also I cant find the link but there was a study published that said that too much irrigation (4 times a day) leads to increased risk of infections because the mucus is meant to be helpful in many ways and if we constantly wash it out, thats not good. I can find that link again if needed.

Topical nasal steriods are also temporary. I shouldn't have to take a steroid all the time to keep the turbinate in control. Again a normal nose is not supposed to have turbinates which swell up like that.
Medications can be tried temporarily to examine the effect but appropriate surgery is the permanent and correct solution.

So do this. Ask your doctor to explain the procedure to you and make sure he will not do anything to the outside. If thats done, you're in for ENS (empty nose). Make sure he knows about that. This condition is real, it happens, its not a myth or over or mis-diagnosed. When it does happen, your life is over.
I did all this and much more and it still didnt help. I have done EVERY thing I can, and I've had no improvement. I trusted the doctors knew what they were doing. They did not.

Another thing. Some doctor websites say SMR only includes partial removal of the turbinate bone and others include resection (removal) of the soft tissue inside the turbinate. Your doctor should know about this and he should be able to justify the decision as to whether it will be the bone and/or soft tissue, and how he made that choice.

As far as I can tell, the worst that can happen is - not getting better.

I've had a few nights where I breathed through the nose freely and it was magical. I dont know what will happen in surgery #4. I have stopped trusting doctors and at the same time I do my best. I cant live in this state.

So dont depend on nasal irrigation and steroids. Correct surgery is your only option. That is what will get your turbinates down permanently.
The problem is finding a doctor who knows what he's doing. Once again, make sure they do not:
- do anything to the external mucosal layer
- remove any part of the turbinate

There's 3 turbinates actually, but the biggest one is the inferior and thats the one I refer to in this post. The middle turbinate is smaller and the 3rd one is even smaller. Its only the inferior turbinate where you need the fixing done, where all the action happens. Rarely does the middle turbinate need fixing. The CT scan will tell some of whats going on.

Its like living in the 1800's and there's no anesthesia and lobotomies are performed because doctors dont know any better.

All this has effected my cognition badly. Anyway, here you go. Good luck to both of us :.-(.
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Redmountainbike
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PostPosted: Fri Feb 06, 2015 2:50 pm GMT +0000    Post subject: Reply with quote

A year ago I went to Dr. Zach Wassmuth at Nasal and Sinus Center of Austin for:
Turbinate reduction
Balloon sinuplasty
Septoplasty to repair deviated septum
A year later, no more sinus infections, the usual fall allergies have not been a problem and my breathing is just better. I also used to feel awful when dry cold fronts came through; that seems to be resolved.

As I said, these were all done as an in-office procedure, although you can opt for general anesthesia.
I'd highly recommend these folks. On my first appointment, they did a 30 second scan across the mid portion of my face immediately prior to the appointment so the doc can see exactly what is going on. The scan showed that what I'd assumed to be a sinus infection was actually inflammation.

Competent & cutting edge in their treatment.

I think Dr. Wassmuth is also a triathlete, so likely to better understand these types of problems relative to athletic pursuits.
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