The procedure: repair of a deviated septum, and turbinate reduction. The reason: I have had sinus infections for my entire life, a consequence of “chronic vasomotor rhinitis.” What that means is that the blood vessels in my sinuses don’t move blood rapidly enough, the linings swell up, and mucus accumulates in there. Over time, charming little microorganisms grow in there, producing an infectious sinusitis. The symptoms include swelling, pressure, pain, and disturbing colors of mucus. The deviated septum may be part of this (there was an unfortunate collision with a boulder when I was about five years old in Tapia Park, near Malibu), but the turbinates are apparently the real culprit. The turbinates are the tissues that control the openings to the sinuses; because these openings are too small, mucus tends to accumulate in there. All of this restricted airflow also means that I tend to snore very loudly, and this was another reason for having this procedure done. If you want a more technical discussion, see http://www.emedicine.com/plastic/topic101.htm or http://www.entnet.org/healthinfo/sinus/sinus_reduction.cfm. (The latter has the better diagrams.)
Dr. Tubach, on July 8, explained that what he did was a reduction of the inferior turbinate, and removal of a bone spur in my septum. The reduction was within a little gadget that grabs the flesh, grinds a bit of it away, then sucks it up and away.
The subject: I am 45 years old, in good health. I stand 5’11”, weigh 226 pounds (though I’m pretty muscular—most people guess that I weigh 180 or 190 pounds). I have only once undergone general anesthesia, for removing upper wisdom teeth at 26. I have since found out from discussions with the anestheologist that this was a far less powerful form of general anesthesia than I was going to get with this procedure—and I think at least half of the grief of this has been the aftereffects of the general anesthesia. The only other significant surgical procedure I have experienced was removal of lower wisdom teeth at 16 under a local anesthetic.
The decision that led to the surgery: I was referred by my family physician to Dr. Martin Tubach, an ENT specialist here in Boise. After attempting to get adequate turbinate reduction using saline washes, Astelin (a topical antihistamine) and NasacortAQ (a cortisone spray), he recommended a surgical procedure. He told me that he had done several hundred such procedures, and only one failed to get a benefit from it. I also spoke to two co-workers who had undergone the same procedure, and had found very noticeable improvements from it. My surgery was scheduled several weeks in advance, partly because of availability of surgery facilities, and partly because my employer was closing down the first week of July for a week of mandatory vacation. It seemed appropriate to put this unpleasant experience into a period when I would be off work anyway.
The hospital (St. Luke’s, in Meridian, Idaho), called me three times, taking a very detailed health history, giving some warning of the level of pain that I could expect. That’s also part of why I have prepared this account of my experience—so that you, considering comparable sinus surgery, would have some idea what to expect. Dr. Tubach told me that it would be painful and uncomfortable after the surgery—rather like a bad sinus infection. The sinus congestion and pain alone has been a bit worse than the worst sinus infections that I have experienced, but not dramatically so. The bad part has been the discomfort associated with the anesthesia aftermath.
I showed up at St. Luke’s at 7:10 AM for a scheduled 8:45 AM surgery. After completing some paperwork about financial responsibility, address, phone number, and similar administrivia, the nurses took me into a pre-op room where they took blood samples for CBC (essentially, checking white blood cell count to make sure that I wasn’t fighting some infection, I think). They then gave me a local anesthetic injection in my hand, and inserted an IV needle. The local anesthetic injection was the only painful part of the process going in. They also attached three EKG monitors to my chest and side.
The anestheologist came in next, and explained what would happen. He would give me a relaxant that would make me drowsy, and then before going into the operating room, they would give me something that would knock out me completely. Fat chance: the “relaxant” put me under completely about 8:30 AM—my wife was still there, and tells me that I was immediately snoring, at which point she explained to the nurse that this was part of why I was having this procedure done.
At that point, a breathing tube would be inserted down my throat, and I should expect a sore throat for a day or two after surgery. (Even on July 5, my jaws were still sore, and on July 6, my throat was still sore and raspy.) The anestheseologist was very careful to answer my questions. “Was there any chance of regaining enough consciousness to feel pain? I have read such reports. Do you see evidence of that in increased heart beat, changes in breathing?” He assured me that this is why he monitors those vitals signs. If he saw any sign that I was coming to, he could put me back under quickly, way before I would experience any pain.
The next thing I knew, I was in the recovery room, several hours later, feeling very groggy, but experiencing no pain. A few minutes later, my wife (who was fighting a bad head cold) reappeared. The nurses removed the EKG monitors, the IV needle, and the tape holding the IV needle. The tape ripping off my arm hair was by far the worst part of the actual operation.
I was breathing only through my mouth—my nose was completely plugged. Because of my history of sinus infections, this was not a new experience for me. The nurse gave my wife instructions, a painkiller named Norco (codeine and acetaminophen), and a collection of pads to collect the copious output from my nose, held in place by a strap that wrapped around my ears. The nurse then wheeled me out to the parking lot, and I got into the car.
Once I got home, I fell asleep for several hours. When I woke up about 2:30 PM, I was now in pain. It was considerably worse than the worst sinus infection that I have ever experienced—about comparable to the post-op pain from having my lower wisdom teeth removed under a local anesthetic, and less pain than a broken wrist. I took a Norco, and went back to sleep.
A few hours later, I woke up again, thirsty and hungry. My wife brought me something to drink (water?) and some lentil soup. A few minutes later, my stomach rejected both with great enthusiasm. My wife next brought me some lightly buttered toast. That, too, was rejected, with great vigor. So was lemon Jell-O. An empty stomach gave me dry heaves. At this point, my wife called Dr. Tubach. Perhaps we have had our standards lowered by living in California, but she was able to reach Dr. Tubach, in the evening, in about five minutes. She told Dr. Tubach that she had a similar experience after a general anesthetic—that everything came back up immediately, because the intestines had stopped operating, and the stomach consequently decided that since there was no one receiving its output, it wasn’t going to bother processing any food.
Dr. Tubach prescribed a suppository that was supposed to solve the nausea (Promethegan 25mg). My wife ran off to the Walgreens that is open 24 hours, and filled the prescription. Within 10 minutes of inserting the suppository, the nausea had ended, and I was able to start eating again. (Note: alleviating the nausea isn’t the same as getting the GI tract working again—as the notes for the next few days will inform you.)
The pads under my nose were filling rapidly with blood, so we put a towel on my pillow, and replaced the pads often. You should probably plan on this before you get home from the surgery!
The next morning I woke up feeling very little pain. My nose was still clogged, but the sharp pain in the sinus area between my eyes was gone. I still had a sore throat (presumably from the breathing tube, or perhaps from blood drainage during the night), and a lot of soreness in my back and abdominal muscles from vomiting, but I was actually feeling pretty good. I was also feeling some curious discomfort in my upper jaw and teeth—perhaps the result of how they positioned the breathing tube, straining some muscles. I switched to Tylenol, since my experience is that just about all opiates cause nausea and constipation for me—the last thing I wanted.
By afternoon, I was beginning to get feeling back in my nose and sinuses—enough so that I could now feel the splints that Dr. Tubach had placed there to hold everything in position after correcting the deviated septum. This was a dull pain and discomfort, comparable to a medium sinus infection.
My nose was still draining blood, but increasingly it was draining mucus as well, and the pads went from crimson to pink. I also started using a saline nasal wash, which seemed to be accelerating the clearing of my nose. I was now starting to hear an interesting sound that suggested that there was now air passing through, or at least over where the splints were located. (The splints have some sort of tubes to allow air to pass through them between sinuses and nose.)
I am still easily fatigued, but not so fatigued that I couldn’t go out for a drive (as a passenger, not a driver) to deliver my son to the skateboarding park. On the other end of the trip, this is about the point where I became inspired to start keeping this account of my experiences for those of you considering this procedure.
2:45 AM: The inferior turbinates (the ones just behind the bottom of the nostrils) feel like they are on fire. I guess they have recovered from the shock enough to let me know that they did not appreciate being reduced. I took one Norco about 11:15 last night, so I guess I can take another one now. The good news is that I am occasionally get airflow through one or both nostrils. It isn’t regular enough to breath through my nose, but it’s still a good sign. Breathing entirely through your mouth--especially in a dry climate like Boise--means that you wake up with your mouth seemingly on fire. Plan to drink a lot of water for this reason.
Interestingly enough, the airflow through the splits wakes me up.
The splints seem to act as a reduced orifice, so it makes something like
a low-grade musical note when the air escapes. The pads aren’t requiring
changing as often, probably because the total volume of crud coming out
is dropping. Back to sleep, I hope.
But not for long! By about 5:15 AM, I was again awakened by a combination of pain in the inferior turbinates and restlessness, so I took another Norco. Sleep, blessed sleep!
About two hours later, I woke up a bit nauseated. Is it the Norco, an empty stomach, or constipation? A bowl of Cheerios went down just fine.
9:23 AM: The slight nausea and headache remains. Okay, solid food is going in just fine, but (to be delicate about this) there is no output from this process. It’s time to go for a gentle walk around the block, to encourage motion through the GI tract.
10:11 PM: The walk didn’t do the trick Neither did a glass of prune juice. Nor did two prunes. Nor did a big slice of watermelon, steak, baked potato, or a Coca-Cola. Groan. The suppository at least took away the nausea associated with the Norco.
The inferior turbinates are still on fire (Tylenol helps); my throat still aches slightly; my jaw still hurts; my teeth still feel loose. Oh yes, it being the 4th of July, there are fireworks going off everywhere, and four A10 Warthogs flew over my house so low as to drive my wife from the dinner table. Sleep? Even if the Tylenol took away the pain, the noise would preclude sleep.
Gas–lots of gas. There are two consolations. One is that it escapes readily, and the other is that my nose is so clogged that I can’t smell it. My wife and son tell me that I should be grateful, because they aren’t that lucky.
My upper back still aches—not severely, but constantly.
I don’t know if this is because of the vomiting the first night, or because
of some strain that they put me under when they exploring my sinuses.
I am increasingly aware of the splints holding the
septum in its new position. They aren’t very painful, but they are
very uncomfortable. I think these are a bigger annoyance than the
inferior turbinate pain right now.
Suggestion: if you have a mustache, shave it off before you have this procedure done. It just makes it a lot simpler to clean up the mess every couple of hours if there’s no whiskers in the way—and you won’t want to put any pressure on the mustache area in the first two days after the surgery.
3:45 AM: This nausea caused by constipation is just too difficult to sleep through. After using another of the Promethegan 25mg suppositories, and drinking a big glass of unpleasantly warm water, I had very limited success. But the ache in my back and the dull headache went away, so I took half of a Norco, and managed to fall asleep.
7:30 AM: Okay, the sleep didn’t last long, because the
Norco brought the nausea back in full force. It seems that the choice
is the drugged sleep of codeine, and severe constipation, or not being
able to sleep at all. I called up Dr. Tubach and left a long whining
message about this.He called me back in about 10 minutes, explaining that
he couldn’t understand parts of the message. I can’t claim to be
surprised—my voice is not what it used to be. I am hoarse, and perhaps
because of the part that the sinuses play in voice production as a resonance
chamber, I don’t sound at all like I should.
Dr. Tubach phoned in a prescription for a suppository that is supposed to break the logjam and resolve my constipation. There was some confusion, however, with the 24 hour pharmacy, because the laxative in question, Dulcolax, is no longer a prescription item. By 10:00 AM, I had the Dulcolax—though it didn’t do a lot of good at first.
Dr. Tubach also took pity on my misery, explaining that the congestion I am feeling is pretty typical. The splints that hold the septum in position have tubes through them to allow airflow, but those tubes clog pretty easily. He recommended that I buy some Afrin at the store, and spray that up through my nose to clear the airways in the splints. I did that, and it helped quite a bit. He also told me to call his office Monday morning at 8:00 AM to try and “squeeze me in” on Monday, instead of waiting for the scheduled Tuesday 4:50 PM appointment. He understands my desire to get these irritating chunks of plastic out of my breathing passages!
My sinuses are no longer in pain, except when I stretch my mouth in unusual ways. The bad side of this is that the oppressive and intrusive nature of the splints is now much more apparent—and real sleep (as opposed to dozing in the afternoon) is now only possible under the influence of codeine.
10:30 AM: Walked the dog with my wife. It wasn’t a very long walk, nor was it particularly hot outside, but the direct sunlight caused an unpleasant reaction in my skin. Has something about the surgery or the anesthesia made me sun sensitive?
5:30 PM: Continued efforts to get normally operating bowels have been met with a variety of bemused responses by my body, none of them exactly what I consider appropriate! I had something like a real dinner this evening—a breaded chicken breast, corn on the cob, and salad, and it still seems as though food is moving at glacial speed through my system. My appetite is back, but putting even a reasonable amount of food in my stomach (as distinguished from the unreasonable amounts that I sometimes give it) gave me a feeling of discomfort that I do not like.
8:30 PM: Went for another short walk. My intestinal tract is still uncooperative. Where is all that food going? It feels like most of it is waiting in my stomach.
3:25 AM: The splints in my nose are becoming a major nuisance. I can’t get comfortable enough to sleep without codeine, and that is the last thing I want to take. Why aggravate the problem that I am already having? The best that I can do is stay up, proofread upcoming but not yet published articles, and work on this little project.
I am going to work much harder on my health in the future—the prospect of having my GI tract shut down by general anesthesia again is just too horrifying to consider. I think it is time to start walking or bicycling to work everyday.
5:45 AM: I had the oddest sensation last night--that I was unable
to go to sleep, but I know that I did, because time elapsed. But
for a few minutes, I found myself seriously worried that something had
gone terribly wrong with this procedure, such that I would no longer be
able to fall asleep. It's amazing the fears that can grab you in
the twilight hours--especially when you have been watching back-to-back
Zone episodes on the Sci-Fi channel.
7:30 AM: After oatmeal for breakfast, I was
rewarded with an unexpected, unprompted, and unsuppositoried need to run
to the bathroom! It's still not normal, but there is hope!
4:03 PM: I am almost feeling human, except
for the congestion caused by the splints, and this awful chemical flavor
that everything seems to have. I suspect the splints are the source
of the flavor. I am counting down the hours to when these awful chunks
of obstruction go away.
11:30 PM: We went to a party this evening thrown by some of my wife's Scottish country dance friends. I figured that if I was going to be miserable, I might as well be miserable somewhere different than my house. I actually felt relatively okay the whole evening, but by the time I returned home, I was beginning to feel the effects of too many hours without painkillers of any sort. I wonder if taking my second dose of Cephalaxin several hours late may have also been a problem.
7:00 AM: I managed to get something close
to a normal night's sleep, with only two interruptions to use saline nasal
washes. I was in considerable pain when I did finally rise, so I
took two more Tylenol, my Cephalaxin, raisin toast and Limeade for breakfast,
and went back to sleep.
11:05 AM: Slept through church, but after a Coca-Cola, the first completely normal bowel movement since the surgery. I can remember a time when I was younger where I found the advertising emphasis on laxatives and "regularity" both bizarre and amusing--rather, I suppose, the way that atheists regard the popular focus on religion. You only have to have a few days like these to see why this is a subject of paramount importance to many Americans.
I am still in some pain, and a lot of discomfort. Tomorrow, though, they are going to take this pieces of plastic out of my nose. I have not looked forward to a change in my life with such enthusiasm in a very long time.
5:00 PM: I went to see Men in Black II with my wife. The aliens are gross, but nothing like what happened when I sneezed! A mucus plug worked its way through the airway of the right splint that was large enough to produce its own gravitational field. Yuck!
1:30 PM: Dr. Tubach snipped a stitch in each nostril (very mild pain as he pulled each out), then pulled out the splints that have been my nemeses these last few days. They are clear silicone plastic, and the airway through them is large enough that it should not have been a problem--except for the incredible collection of goo that was clogging those airways. Then he took a little vacuum and drained the various mucus chunks still sitting around back there. Yuck! One of them reminded me of the mind control worms from Star Trek 2: The Wrath of Khan.
I am breathing very well, and detecting scents that were previously not within my ability to smell. Dr. Tubach says that there will be some swelling this evening, followed by 4-6 weeks of improvement in my sinuses.
9:30 PM: Sure enough, Dr. Tubach was right. There is some
swelling, and the wonderful sensation of being able to smell everything,
no matter how subtle, has gone away. I took some more painkillers
Yahoo! The surgery seems to have solved the snoring problem.
My wife tells me that instead of a sawmill in the bed next to her, all
that she hears now is "heavy breathing." That's real progress.
The last few days have been unremarkable, so I didn't bother to make any
remarks! There is still a bit of crusting inside my nose, perhaps
where scabs are forming on the stitch holes. This is uncomfortable,
but it does seem as though I am sleeping much more deeply than before the
Okay, maybe I jumped the gun on the "no snoring." While I am definitely much quieter, I'm not quiet enough for my wife and I sleep in the same bed. Maybe the same room. Even that is progress. Sleep is definitely better--on a consistent basis--than at any time except when I went backpacking in the Sierras as a child.
The jaw pain? Maybe it wasn't caused by the surgery, or maybe it wasn't entirely caused by the surgery. I now realize that I was having intermittent pain caused by too many teeth crowded into my lower jaw before the surgery. I have had several days in which I have been miserable all day, and a day or two with no pain at all. I am going to get into a dentist and see if perhaps it's time to do some orthodontic work.
An unexpected side effect: I can no longer moo! One of the peculiar talents has been the ability to do a very, very cow-like mooing noise. This often gets rather interesting reactions from cattle. We approached a longhorn today in a field north of Boise, and when I mooed--it ignored me! My wife tells me--and I can hear it--I don't moo very well anymore. The resonance just isn't there.
My dreams are consistently more vivid and I seem to remember more of them when I wake compared to before the surgery.
I am still doing the saline washes, but the quantity of yellow mucus (usually an indicator of bacterial infection) has dropped to essentially zero. There is still a lot of mucus accumulating in my nose, which must be removed with the tip of a fingernail. My nose is still quite sensitive, however, which limits nasal excavation.
It has been almost five years since I had this procedure done and I documented it here. My, how times flies! Increasingly, I wish that I had pursued this years earlier. In the meantime, I have discovered that I have obstructive sleep apnea. You can read some more of my adventures with this--and my low cost, low nuisance solution to it, in a series of fascinating but not gross blogposts here, here, here, here, here, here, and here.
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