A Few Years Later

Just a final update.  Ultimately, I think the surgery was unsuccessful.  My symptoms are the same as before I had the surgery.  In the previous two posts, you can see some guesses as to why.  I have ended up moving to warmer waters, and in warm water, the problem has always been much less pronounced.  So long as I get decent sleep and take my nasal corticosteroids, I rarely have problems.  I can’t remember if I mentioned this in previous posts, but another prescription I have is for Prednisolone acetate which is (kindof) an aqueous form of predinisone.  I use this very rarely — only if there’s a dive I feel I _must_ be able to do.  This would be for teaching or competition.  Prednisolone has serious side effects, so I’m very careful to only use it rarely.  That said, when I do use it, it’s very effective in combating my symptoms.

Met Again with Dr. Yeung

This was about 2 weeks ago now.  Told her about my not-so-great experiences diving since the surgery.  She had a few thoughts:

• The pain could have something to do with nerve sensitivity, as opposed to an actual blockage.  We both agree that this seems unlikely, but worth keeping in mind.
• It’s certainly possible that some sinus space blockage, something other than the frontal sinus ostia, is the source of the squeeze.  Very difficult to know for sure….
• Some more invasive surgery could help.  We avoided the turbinate reduction/septoplasty last time through, and I’m certainly a  prime candidate for that surgery.  It’s possible that a “thorough cleaning” of the nasal passages could root out the cause of the squeeze.  I don’t really want to do this, and won’t do it any time soon in any case.
• The frontal sinus ostia could be widened even more.  But, since the current signs/symptoms are the same as they were before the surgery, there’s a sense that those openings are just not to blame, not the source, and not worth widening any more.
• We agreed that I will try some stronger nasal steroids in hope of reducing the overall inflammation.

One other thing that popped into my head:  a possible correlation between the diving reflex and sinus inflammation.  We know that part of the reflex involves vaso-constriction at the extremities.  I believe that as the reflex strengthens, especially during longer breath-holds, there’s a contrasting dilation of core blood vessels, especially in the brain.  This may be adding to the swelling in the sinuses.  The timing seems right on (~30 mins. into the dive), and also correlates with the effectiveness of Afrin in quelling the symptoms (Afrin is a topical vaso-constrictor).

Back in the Water: Bad News

So, I finally went diving last weekend (10/25-26) down in Monterey.  Unfortunately, within about 1/2 hr. of getting back in the water, I felt that familiar squeeze in my sinuses.  It was really exactly the same as in the past in terms of timing, pain level, and symptoms:  essentially as though nothing had changed.

I dove through the pain on Saturday, then reverted to Afrin on Sunday.  Thankfully, the Afrin worked very well, as usual, and I had a really wonderful dive on Sunday.

I haven’t spoken with or gone back to see my surgeon yet.  I’m certainly unhappy about the outcome at this point.  Theories:

• The squeeze never was because of swollen shut ostia (drain holes) in my frontal sinuses.  Something else is swelling shut:  some other ostia, some other sinus.  This seems most likely to me at this point.  We never knew for sure that the problem we were trying to fix was actually what was causing the squeeze.
• Despite the successful surgery, the frontal sinus ostia are still too narrow, and they’re still swelling shut.  The symptoms are so similar to before that this doesn’t seem as likely to me.  Certainly possible.
• Maybe it’s not a sinus squeeze, but some other “space” in my nasal cavity.  There are a lot of twists and turns in there.
• Could have more to do with mucus than swelling.  I’ve wondered about this in the past.  I feel like I’ve done my due diligence here, religiously taking Mucinex (guaifenesen) and staying well hydrated, but maybe I need to try and isolate this a little better.

These are just off the top of my head.  Looking forward to talking with my surgeon about the possibilities.

Back in the Pool

So, it’s about 3 weeks after the surgery.  I got into the pool during rec swim today, and didn’t have any problems at all.  Put on fins, mask, snorkel and just did a bunch of mellow FRC dives to the bottom at 10 ft.  Not deep, but deep enough to know whether or not I have any sinus squeeze.  I wasn’t surprised that it went fine, but it’s still nice to know for sure.  Heading down to Monterey next weekend for two days in the sea.  Can’t wait.

A Week +5 Days After

Things are going very well.  At this point, I’ve felt pretty much normal for the last 5 days.  I continue rinsing three times a day, but I haven’t had any unusual discharge for about 5 days.  I still haven’t started exercising again, but I’m pretty sure I could.  Just don’t want to push it until the full two weeks are up.

I had a post-op with Dr. Yeung exactly one week after the surgery.  She numbed my nasal passages and put a scope up my nose on both sides.  The display was on a monitor that I could see, and it was neat to see the inside of the passages.  There was a tiny bit of absorbable packing left in the passages, but very little.  I could see my huge turbinates, and then, up above them, the very clear, open drainage holes of my frontal sinuses.  They looked huge 🙂

So, at this point, all is well.  I still have to go diving, which I won’t do for a few more weeks….

Two Days After

Feeling better and better.  Took one Vicodin yesterday before bed and got a really good night’s sleep last night.  I didn’t _really_ need it for the pain, but it sure did knock me out.  Also listened to the healing recording before bed and again this morning.

I did three rinses yesterday:  each one had some gunk but nothing really nasty.  This morning’s rinse was fine; again, some blood clots and mucus, but not too much.  I’m using two whole 8 0z. Neilmed bottles for each rinse, just to be thorough.  Before this morning’s rinse, took a long shower to loosen things up.  Also making sure to brush my teeth and clean my mouth before I do the rinse.  After the rinse I laid down and put on a cold compress; I did the same yesterday after my other rinses, just to try and offset any swelling caused my the rinsing.  Maybe a little overkill, but it feels nice anyhow.

What else:  careful not to put my head lower than my heart.  Careful not to strain myself physically or otherwise elevate my blood pressure.  This was some of the main advice from the surgeon to try and prevent post-op bleeding as much as possible.  I do have a mild headache right at the base of my frontal sinuses.  It feels a little worse than my normal headache, maybe a 2-3 out of 10.  Not bad at all.

Lots of water, some juice, veggies, fruit, grains.  Basically, just trying to do myself as right as I can.  I rested a lot yesterday, watched “Borat” (not that great, but funny as hell in parts) and a couple episodes of Dollhouse.  There was this weird moment in one where the brainy computer guy, Topher, is just getting off the phone (starting a scene) and says something like “Oh, no, I definitely prefer the Valsava technique….”  A freediving thing, for those who don’t know, and he should have said Frenzel.  Weird.  Took a nap later in the day.  Just feeling lazy and healing.  Also feeling my normal “sick-wanna-be-alone” which is:  when I’m sick or hurt, I just want to be left alone and curl up.

Day After Surgery

Got a good night’s sleep and woke up feeling rested.  Not much pain at all.  Took a nice long shower, being careful not to heat my face up too much; want to keep any bleeding to a minimum.  Did my first sinus rinse:  careful to get the temp right.  Mostly just got some small blood clots coming out my nose, nothing too big or nasty.  I did one rinse through the nostrils and then another coming up “around the back” (squirting the water into my mouth and back of throat to eventually flow forward and out the nostrils).

Things feel fine today.  I haven’t taken any meds so far, and don’t feel like I need to.  My sinuses are a little swollen, I can feel that, but it doesn’t feel much different than normal.  Had a decent breakfast, did some light stretching, then started this blog.  I’m keeping my fingers crossed that this is the worst of the recovery; if so, it’s really been easy.  I could probably even work today if I had to (I’m a software engineer).  I’m certainly more tired than usual, but otherwise feelin’ good.  Gonna chill out and watch some tv, play video games, go for a walk….

Day of Surgery

Got there on time, filled out paperwork, started waiting.  They were running a little behind.  I listened one last time to the relaxation CD from Prepare for Surgery, Heal Faster.  The nurse came and walked me back to the changing room; got on the gown, slippers, and silly hat.  They had a comfy chair for me to sit in while waiting for the surgery.  The nurse put in an IV, then added a steroid through the IV.  She also gave me some Afrin, and I squirted in two big doses in each nostril.  Amanda was able to come back and sit with me while I waited, and I just relaxed, let my mind wander.  Eventually, Dr. Yeung came and we went over the procedures again, what would happen, and how I was likely to feel post-op.  She was very careful to ask (a few times) if I had any questions, and waited to make sure I was comfortable, which was great.  Also, the anesthesiologist came (he was really fantastic and positive), asked me a few questions, and asked if I had any.  We went over the healing statements, and he was very positive about the whole thing.  Then in we went.  I peed one last time on the way to the surgery.  Then, onto the table and a few light questions from the anesthesiologist as I went under.  I was gone fast, seemed like less than a minute.

When I came to, I was back in my comfy chair where they had done the pre-op.  Dr. Yeung and the anesthesiologist were there (or it seemed like they showed up quickly), and told me I was fine, and that the surgery had gone quickly and well.  She had said the surgery would take approx. an hour and a half, but I don’t think it took that long.  I remember doing a quick “system check,” and being surprised at how good I felt.  I drank some water right away.  Amanda showed up shortly, and it was great to see her.  I was still pretty groggy, and I just sat, relaxed and took sips of water.  After ~1 hr. they said I was good to go.  By then, I was pretty lucid.  I didn’t have any real trouble getting to my feet, though I took it very slow and was a little woozy.  I went to the bathroom, dressed, and went downstairs in a wheelchair to the car.  I felt amazingly good.

When we got home, Amanda took great care of me.  I laid on the couch with my head propped up, and started by eating some saltines.  I kept drinking water, had an Emergen-C (vitamin packet) and eventually moved onto some soup.  I just chilled out, relaxed and laid on the couch.  I had some very minor pain in my nose and throat, but not even as bad as the feeling of a cold.  I had some pain medication, but didn’t take any:  I honestly didn’t feel like I needed it.  I was very able to get around, go to the bathroom, etc.  I had a little bit of blood draining out my nose every once and a while, but very little (not even a teaspoon altogether, just dotted it up with tissue).  I assume I had some draining down my throat too.  I put a cold compress on my face for a while, and again later that evening.  Eventually, I dozed off for an hour or two.

Basically, I felt fine.  Later that day, I decided to take some Tylenol, just to take the edge off a minor headache.  I watched a movie with Amanda (“Man on Wire,” fantastic) and went to bed around 10.  I slept propped up and listened to the healing cd again before sleeping.  I was nervous about not getting a good night’s sleep, and I woke up two or three times during the night to pee.  Ultimately, though, I slept very well.

Preparation

I did a few things to get prepared for the surgery:

• Probably the most important thing:  I bought this book:  Prepare for Surgery, Heal Faster, by Peggy Huddleston.  My partner, Amanda, had used this book during her surgery, and recommended it hightly.  I tried to follow as much of the advice in this book as I could.  I used the “Relaxation/Healing CD” in the days before the surgery.  This was incredibly helpful in reducing my level of stress leading up to the surgery.  I also took the advice of the book and asked my anesthesiologist to read a list of “healing statements” during the surgery.  I felt a little self-conscious about asking for this, but I think it was a really good idea, and it certainly didn’t hurt.
• I wrote out a list of questions for the surgeon and asked each question in the pre-op meeting (this was about a week before the surgery).  I made sure to get satisfying answers to all of my questions.  Some of these were about what to do after the surgery, others about what to expect.  This whole process was very helpful and reassuring.
• I made sure I was in good shape and exercising in the months leading up to the surgery.
• I don’t each much dairy, but I was even more careful about this leading up to the surgery (except one giant ice cream cone I had a few days before:  woops!  Yummmm.)
• Got a good night’s sleep before the surgery.
• I was lucky enough to have my partner, Amanda, take the day off, sit with me in pre-op, wait for me, and be there when I came around after the surgery.  It was so nice to see her face right there, and have her comfort and support.

Background – What the Surgery Is and Why I Had It

I had a sinuplasty surgery to open the two drainage holes (ostia) which connect my frontal sinuses to my main nasal passages.  Before the surgery, these holes were ~1.5 mm in diameter.  My understanding:  the surgeon inserts a “balloon” into the the existing drainage hole and inflates the balloon.  As the balloon expands, it actually breaks the very thin, “honeycomb,” boney structures which give form to the drainage holes.  In this way, the inflating balloon increases the diameter of the openings.  After the surgeon removes the balloon, the broken bones stay “crushed,” and so the holes stay more open.  In my case, these holes where increased to ~5mm in size.  Here’s a great link which describes the surgery (there’s even a video):

http://www.calsinus.com/otolaryngology_ent_ear_nose_and_throat/balloon_sinuplasty/treatment.php

I’m a freediver, which means I hold my breath and dive down into the water, sometimes pretty deep.  As a diver dives, the weight of the water increases the amount of pressure on the body, so that the diver has to equalize the non-compressible air-spaces in the body.  These spaces include the sinuses.

Since my teens (I’m now 38), I’ve had problems with inflammation in my nasal passages and sinuses.  I’ve been to many, many doctors and tried many, many therapies:  various antihistamines, a long list of nasal steroids, sinus rinse, candida treatment (probiotics), silver colloidal sprays, acupuncture, etc.  Some things seemed to help a little, but no solid treatment.  Honestly, the thing which seems to make the biggest difference is getting a good night’s sleep.  I also believe there’s a psychological component to the inflammation (something, maybe, like John Sarno’s Tension Myositis Syndrome).  More recently, my GP diagnosed me with Vaso-motor Rhinitis; this shows the signs and symptoms of Allergic Rhinitis, but the standard treatments don’t work well.  It’s the best diagnosis I’ve had.

I don’t always have trouble with my sinuses during a dive.  But, when I do, it’s a real show stopper.  The openings which connect the frontal sinuses to my nasal passages sometimes swell up.  Seems to be worse in cold water.  When this happens, my frontal sinuses start having more and more trouble equalizing.  It becomes very painful:  I dive, the pressure builds, the pain increases, until I either turn around or the sinus equalizes with a “sqeeeeeeeeeeeep” sound.  I’ve pushed it to the point of bleeding.  I can take Afrin, and this usually does the trick short term.  But, the Afrin is painful and uncomfortable in its own right (gives my sinuses/nasal passages a “raw” feeling), and Afrin has a whole host of associated problems, the worst being an inevitable “rebound effect,” where when the medication wheres off, the inflammation will actually become worse.  The label says not to take it for more than three days in row, most divers will tell you five days.

I had heard of sinus surgery, but it always sounded very invasive.  I had recently switched insurance, and gotten a new GP, Dr. Milovanovich (aka Dr. Milo).  He’s a great GP, part of San Francisco’s One Medical Group.  I accidentally stumbled on this group, and I can’t say enough good things about it.  On top of my insurance, I pay a yearly fee ($100), and I couldn’t be more happy with what I get from this:  exceptional service, same day appointments, exceptional doctors.  They have a nutritionist, acupuncturist, and other uncommon services.

I had been working with Dr. Milo on my sinuses.  I also suffer from daily headaches at the frontal sinuses; it’s unclear whether the headaches are directly related to the sinuses.  In any case, we were talking about different treatments, and he mentioned the sinuplasty.  It sounded like it could be a good fit for me, so he referred me to a surgeon at the San Francisco Otolaryngology Medical Group, Dr. Andrea Yeung.

Dr. Yeung was very kind, clear, and helpful from the beginning.  I couldn’t have been more happy.  After talking through the issue at hand, she asked me to do a two week “course,” where I was careful to take nasal steroids and do two sinus rinses a day (I use Neilmed.  It’s awesome.)  Then we took an MRI of my sinuses.  The imaging was incredible, and she was able to show me exactly what it looked like in there, by scrolling back and forth (on a computer monitor) through the different views of my sinuses.  I have a very badly deviated septum from an old injury (broken nose), and also have enlarged turbinates.  She showed me that the drainage passage from my frontal sinuses was small, but open under normal circumstances.

We talked about the various options at length.  Even though my septum is badly deviated, and I have enlarged turbinates, I don’t have any real trouble breathing through my nose, and I don’t snore.  Apparently, a sinuplasty often goes hand-in-hand with a septoplasty (straightening a deviated septum) and turbinate reduction.  But, in my case, I really only wanted the sinuplasty.  Dr. Yeung agreed that she would try to do this.  The only issue was that she might have trouble threading the balloon past my septum on the left side.  In this case, she might have to cut open the septum slightly, to allow her to do the sinuplasty.  But, if she had to do this, it wouldn’t be a “full septoplasty,” just enough to let her get to balloon threaded.  This made sense to me, and so we agreed to move forward.