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Medical Forum / Diseases and Disorders / Sinusitis / November 2006ENT visit - surgery advice needed
OK, just got back from an ENT that I've been seeing for the past 5 months. He says I have received maximal medical treatment and since my turbinates and sinuses are still very swollen, I should consider surgery. I have used Rhinocort spray for 2 months and Nasonex for 5 months with no improvement. He recommends that I have a turbinoplasty and mini-FESS. I've been doing lots of reading concerning turbinate surgery and am concerned about the extent of turbinate reduction that he is recommending. He will reduce both inferior turbinates by 80% using a microdebrider tool, snip off the front portion of the middle turbinates with scissors and open up the ostia between the middle and inferior turbinates to assist drainage. I raised the concern of excessive dryness and empty nose syndrome and he said it is very rare. He says I may have problems in places such as Norway but not here in Australia. He says he has performed about 6000 of these procedures but I think he means only FESS not turbinoplasty specifically. He says 9/10 patients who have turbinoplasty have positive results. His website is at http://www.earnosethroat.com.au. My main concerns are the excessive turbinate reduction, though it seems like the mucosal membranes will be spared. I'm not sure exactly, but will ask again. Also, the snipping of the middle turbinates has me worried. He says the middle turbinates are also swollen and hence the front needs to go. He is of the opinion that it's better to be more aggressive so that results are permanent rather than be conservative with minimal long-term benefits. I'm considering surgery because for the last 10 months, I have not been feeling well. My turbinates seem to have become hypertrophied (bony or mucosal - I don't know) and as I result I am more prone to sinus infections. My symptoms include constant ear fullness, post nasal drip, constant nasal congestion and mucus production, general malaise, etc. I am hoping that sugery will fix these problems. I will be getting more opinions but would like to hear your thoughts on the surgery. Is it too excessive? Should I opt for a more conservative appraoch? I am 29 years old and am concerned that years down the track, I may develop dry nose and crusting as a result of aggressive turbinate reduction. Chris [...] > I will be getting more opinions but would like to hear your thoughts on > the surgery. Is it too excessive? Should I opt for a more conservative > appraoch? I am 29 years old and am concerned that years down the track, > I may develop dry nose and crusting as a result of aggressive turbinate > reduction. Have you looked into the possible use of cryogenics for turbinate reduction? -- RB > Have you looked into the possible use of cryogenics for turbinate reduction? No I have not. Is that like somnoplasty using RF waves or heat? > No I have not. Is that like somnoplasty using RF waves or heat? As far as I know, it's-like the opposite. It uses freezing cold to shrink the turbinates. -- RB > OK, just got back from an ENT that I've been seeing for the past 5 > months. He says I have received maximal medical treatment and since my [quoted text clipped - 5 lines] > the surgery. Is it too excessive? Should I opt for a more conservative > appraoch? Actually, I would consider a *more radical* approach to the sinuses and *less* work done to the turbinates. The University of Pennsylvania, here in the U.S., has a theory that the ethmoid sinuses are the root of all evil, due to their unique structure; and that to really clear sinusitis all the ethmoids must be completely reamed out. It has been my experience that there can be subtle problems in there that are too small for even a CT scan to detect. It's only after a surgeon really looks inside your sinuses that he can really see all the things that are wrong in there. Some folks on this NG (myself included) found out from surgery that there were more things needing fixing that the CT scans had showed. And once those things were fixed, there was improvement. For this reason, I always gave my surgeon written consent to fix anything else he found wrong in my sinuses, even if we hadn't discussed it prior to the surgery. I would get a second opinion from another ENT and discuss these possibilities.  SignatureSteven D. Litvintchouk Email: sdlitvin@earthlinkNOSPAM.net Remove the NOSPAM before replying to me. > Actually, I would consider a *more radical* approach to the sinuses and > *less* work done to the turbinates. [quoted text clipped - 15 lines] > I would get a second opinion from another ENT and discuss these > possibilities. But Steven, you don't seem to have had favorable results from all that radical intervention. Your sinus condition requires constant attention and keeps you from being able to work full time, no? Or was it just much worse before your surgery? Susan > x-no-archive: yes > [quoted text clipped - 23 lines] > > Or was it just much worse before your surgery? Before my surgery, I wasn't able to *live*. I was getting zero sleep because I was gagging and choking for all the yellow phlegm pouring (yes, POURING) down the back of my throat. I had constant bronchitis and asthma attacks from this as well. I was actually flirting with suicide at one point. At least after the surgery, I can actually sleep 8 hours a night. And I can do some kinds of work. SignatureSteven D. Litvintchouk Email: sdlitvin@earthlinkNOSPAM.net Remove the NOSPAM before replying to me. > Before my surgery, I wasn't able to *live*. I was getting zero sleep > because I was gagging and choking for all the yellow phlegm pouring [quoted text clipped - 5 lines] > At least after the surgery, I can actually sleep 8 hours a night. And I > can do some kinds of work. Clearly you've had improvement from surgical intervention, then. But I still find it so disheartening that so many who've had FESS, even multiple times, still have chronic sinus disease. :-( Susan > x-no-archive: yes > [quoted text clipped - 11 lines] > still find it so disheartening that so many who've had FESS, even > multiple times, still have chronic sinus disease. :-( That's why it's called "chronic." Modern medicine hasn't been very successful at curing chronic disease generally. The last big success I remember was when they discovered how to cure peptic ulcer disease with antibiotics. But the treatment for such chronic illnesses as asthma, mental illness, COPD, arthritis, etc., remains "management." Not "cure." The disease has to be constantly monitored and treated. Relapses occur often, and there is a general decline in the quality of life. The goal of medical treatment is to minimize that decline in the quality of life. I have friends with mental illness. Over time they relapse, they get hospitalized again, they get stabilized again, they keep getting switched from one "cocktail" of medications to another, year after year. Browse newsgroups like alt.support.cancer, alt.support.depression, alt.support.ocd, alt.support.asthma and you'll see that the story is the same as right here on alt.support.sinusitis. It's a constant struggle. SignatureSteven D. Litvintchouk Email: sdlitvin@earthlinkNOSPAM.net Remove the NOSPAM before replying to me. > That's why it's called "chronic." > [quoted text clipped - 4 lines] > But the treatment for such chronic illnesses as asthma, mental illness, > COPD, arthritis, etc., remains "management." Not "cure." My asthma and arthritis were completely and/or almost completely cured by antibiotics. Except that I now have, possibly, a new infection in my foot, possibly seeded by my ethmoid. But after having been crippled twice, 7 years apart, by misdiagnosed Lyme arthritis, I've had no aches, pains or treatments for it for all the years I've taken antibiotics. I've had no asthma since doing aggressive allergy shots. Often, doctors treat rather than seek underlying causes. That's why we have to be so proactive in researching the literature and in noticing our own patterns of illness and improvement. Doctors are treatment and procedure oriented now more than ever, and it's not at all in the best interests of the patients. >The disease > has to be constantly monitored and treated. Relapses occur often, and > there is a general decline in the quality of life. The goal of medical [quoted text clipped - 3 lines] > hospitalized again, they get stabilized again, they keep getting > switched from one "cocktail" of medications to another, year after year. I worked with the mentally ill for many years, and provided the kind of support that prevented the scenario you describe, even with the very severely and persistently mentally ill folks I worked with. Not curative, but consistency of support and early interventions help a great deal. Obviously, sometimes folks do decompensate anyway. > Browse newsgroups like alt.support.cancer, alt.support.depression, > alt.support.ocd, alt.support.asthma and you'll see that the story is the > same as right here on alt.support.sinusitis. It's a constant struggle. Some folks get well. But most of us have to be our own medical detectives and then go doctor shopping for the right treatment, sadly. Susan > OK, just got back from an ENT that I've been seeing for the past 5 > months. He says I have received maximal medical treatment and since my [quoted text clipped - 39 lines] > > Chris As you can see, we all have different experiences and opinions. You will have to do a lot of research and reading and then trust your "gut" reaction as to what you should do. My first thought is that I would also definitely leave the turbinates alone for now. But, I would not do the radical approach of the sinuses at your age either. I think the minimimally invasive procedure might be in order just to open up the main ostia (openings). You mentioned in another post that aftrin would shrink the turbinates. I don't know much about that area, but wouldn't irritants also possibly cause the tissue to swell and obstruct. Could it be a problem with edema of those tissus rather than turbinates being too large. I would check into that further. I don't remember if you have been tested for allergies. If not, I would do that first. I would also definitely get a 2nd opinion from another ENT before I had any kind of surgery. At your age, if something goes wrong with the radical approach, you have a lifetime of misery to deal with. On the other hand, if the minimal procedure doesn't fix the problem, you can always have more done later. You can't put back what has been taken out. Kathyw > As you can see, we all have different experiences and opinions. You > will have to do a lot of research and reading and then trust your "gut" [quoted text clipped - 3 lines] > at your age either. I think the minimimally invasive procedure might > be in order just to open up the main ostia (openings). I must disagree. I think when it comes to sinus surgery, the more radical the better. One of the most common reasons for revision surgery is overly conservative first surgery. That was my experience. The one pair of ethmoids my surgeon didn't touch the first time, turned out to be the one place my surgeon had to fix the second time. It's just like cancer. The surgeon has to get it all out (as much as he can see), or else it won't be effective. > At your age, if something goes wrong with the radical approach, > you have a lifetime of misery to deal with. On the other hand, if the > minimal procedure doesn't fix the problem, you can always have more > done later. You can't put back what has been taken out. I distinguish between turbinate surgery and sinus surgery. I agree that overly aggressive turbinate surgery is risky, and you can't put back what has been taken out. But nobody ever wants to put an ethmoid sinus back together after it's been reamed out. Those honeycomb partitions in the ethmoid are just like your appendix--they serve no useful purpose and you'll never regret having them removed. Less turbinate reduction and more sinus procedures is still my recommendation. SignatureSteven D. Litvintchouk Email: sdlitvin@earthlinkNOSPAM.net Remove the NOSPAM before replying to me. > > As you can see, we all have different experiences and opinions. You > > will have to do a lot of research and reading and then trust your "gut" [quoted text clipped - 32 lines] > >But Steven, You are automatically assuming that everyone's problem is in the ethmoids. I kept thinking that my problem was from the reactive bone formation in the ethmoids that remained from my first surgery that included a partial ethmoidectomy, but accroding to Dr. Kennedy and Dr. Sherris it was not. The sphenoids were completely ignored then and based on my past medical records and most recent surgery, they should have been addressed many years ago As a general rule, from the research that I have done (by means no expert), maxillary sinusitis is the most common form, so why remove the ethmoids if they aren't diseased. There are more risks involved in more extensive surgury. From what I have read just widening the main ostia seems to be effective for most people. They don't often even do the "windows" or remove tissue any more from what I have been told by my ENT. Of course, if the ENT determines from CT scans or during surgery that there is diseased ethmoids that aren't going to clear on their own, then by all means, I think surgery there or anywhere else that there is actual disease is appropriate Most of us that keep posting here are the exception, not the rule. I respect your opinions and advice and I may still may have to have more extensive surgery myself, because I'm still miserable, but more functional than I was; however, I still think less is better unless you have proof to support what is being done. Kathyw Thanks for the input. I'm leaning towards less turbinate surgery at this time and will be seeking further ENT/allergist advice. As someone who has had 5 surgeries: 1) Antrostomies--1980's, generally no longer done 2) FESS--1990's--somewhat helpful 3) Radical FESS, done at Mass Eye and Ear with use of 3-D CT: 2000--left with severe bone infection 4) Debridement of dead bone--local surgeon-2001 5) Second repair of thick scar tissue--local surgeon 2002 Started low dose macrolides 2002, and currently doing very well. I would agree with the concept that once it's gone, you can't put it back. The thinking and approach to sinus surgery is changing constantly, and I've found that some surgeons approach all patients with their personal approach, but it's not personalized to the patient. The latest thinking, according to my ENT, is that "less is more": and I heard the same thoughts expressed at Lahey Clinic as well--but the Lahey doctor admitted that my surgeon in Boston continues to remove excessive amounts of sinus tissue--despite some evidence that you should leave as much anatomy intact. The Lahey surgeon is currently using the balloon for all procedures, my local surgeon believes it should only be used in frontal disease, and it works by crushing the ethmoid cells to open the ostea. We've been getting opinions for my daughter who has an IgA deficiency,and so far they diverge radically--to book you immediately for the balloon, to "your CT may look great, but with your immune deficiency, you still may get infections". My daughter is not yet in the mood to see if a third opinion would agree with either of the other two. So, ENT's are idiosyncratic, the literature and the approach changes, yet each surgeon appears to have their individual beliefs and approaches. Where does that leave us? Do the least possible, because you can't undo surgery. Realize that there are a lot of opinions out there, and many don't agree. There is a steep learning curve with the endoscope, so pick an experienced surgeon. Many ENT's want to do surgery, and then are no longer interested in managing your sinus disease, which quite likely will not be "cured" by the surgery. Find someone who will stick with you for the long haul. Good luck. It's a moving target. Judy > Thanks for the input. I'm leaning towards less turbinate surgery at > this time and will be seeking further ENT/allergist advice. Judy, your words of wisdom are greatly appreciated. Thanks. Thanks Chris. After all my surgeries, I wish I could advise my daughter. Her (and my) allergist, who is brilliant, and semi-retired, said: "She's so young, don't go there yet." So, for now, that's where we stand. She's on low dose biaxin, but still gets infected--but mildly--almost every 8 weeks. Her asthma is much better. There's really no harm in waiting, but you reach this point, where you feel you have to act. I just have to realize it's her life and there's no emergency here. I've gotten her opinions from respected people, and got two more names at Mass Eye and Ear, and she's getting good immunotherapy--it will be a year in December. So, she's a lot better this year than last year (moved from a moldly dorm to a slightly musty apartment, but no carpets and far fewer people in the bathroom) and I have to accept there is no cure for her IgA deficiency and there's no one right answer about surgery. One surgeon told her he'd cure her, the next told her that there were really no guarantees--I believe the surgeon who wouldn't promise a cure. He also takes care of her infections, and calls back on the weekends, and thinks about how to approach her personally. If it were just simple... Judy > Judy, your words of wisdom are greatly appreciated. Thanks. judy--there are very serious consequenses of chronic sinus infections--like brain abscesses if the infections breaks thru bone principle to keep in mind infected sinuses are not draining properly and that has to be evaluated--there are very sohisticated imaging techniques available to at least document infection --once that it dofne then how to do it comes next. hth > Thanks Chris. After all my surgeries, I wish I could advise my > daughter. Her (and my) allergist, who is brilliant, and semi-retired, [quoted text clipped - 17 lines] > Judy >> Judy, your words of wisdom are greatly appreciated. Thanks. > judy--there are very serious consequenses of chronic sinus infections--like > brain abscesses if the infections breaks thru bone [quoted text clipped - 6 lines] > > hth Judy isn't just a sinusitis sufferer; she's a physician. Try to remember that others here have at *least* as much knowledge and intelligence as you seem to believe you do. Susan > x-no-archive: yes > [quoted text clipped - 15 lines] > > Susan I"m not trying to be mean here, but give him a braak. I think he is a physician's assistant and is just giving his input as well as all of the rest of us. We can take it or leave it, as we usually do, but I think he is really trying to be helpful. Kathyw > I"m not trying to be mean here, but give him a braak. I think he is a > physician's assistant and is just giving his input as well as all of > the rest of us. We can take it or leave it, as we usually do, but I > think he is really trying to be helpful. Perhaps, Kathy. I guess I think he showed up with no introduction and began handing down pronouncements as if from on high, and it rubs me the wrong way. Susan |
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