When to Choose Nasal Surgery

Sometimes You Need to Fix the Nose Before You Can Control the Allergies

by Murray Grossan, M.D.

Although I write of non- surgical approaches to Allergy, it is true that many persons with allergies can be helped by surgery. Actually, you want to recommend what is best for the patient.

If a patient has a 100% obstruction to breathing due to a deviated septum, and still has a dust and pollen allergy, no matter how effective the dust proofing and the desensitization treatment, he will still end up with 100% obstruction to breathing. Here it makes sense to fix the septum first, and then see if he can be relieved with simple medication.

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Where is gets difficult to decide, is when the deviated septum is just 50% obstructive plus a known allergy to dust and pollen. If you fix the septum, the person will still have an allergy. If you do the allergy Rx first, he or she still has the deviated septum. Regrettably you will find differences in recommendation here from different doctors. Each doctor tries to decide what is best for the patient, or the patient is given the facts and decides if he or she wants to try allergy desensitization or surgery first.

With surgery, we usually include reduction of blockage of turbinates in hopes that, with this reduction there will be less blockage even though the allergy persists. Many persons with allergies are comfortable with the newer allergy pills and cortisone sprays.

For a history of painful sinus blockage and infection, if the CT Scan shows blockage of sinus drainage, we recommend surgery to open the sinuses rather than wait for the allergy desensitization to accomplish this task. Likewise, if there is an anatomical blockage often it is best to clear this by endoscopic surgery. If the blockage is purely due to inflammation, medical and pulsatile irrigation treatment is tried first before we go to surgery.

If the nose is fully blocked by nasal polyps, first we try to shrink the polyps with medications such as cortisone and antibiotic combination. If this fails, then a CT scan can determine how much surgery is needed for relief of obstruction. Following polyp surgery, allergy treatment may help prevent re occurrence. Nasal polyps will re-occur with exposure to aspirin and aspirin related medications.

For asthmatics, a favorite surgery is Rhinoplasty. No, not to make the nose more beautiful, but to make it function better. For asthma, nasal breathing is essential and can be improved by moistening the air and reduce post nasal discharge.

However if the nose is crooked, this needed nasal function may not be possible. In addition, in aging, the skin of the top of the nose loses fat, and this causes the tip of the nose to hang down. This in turn creates a blockage by closing off a valve that can obstruct breathing. Fist we try taping the nose up at night to see is that helps. Then the patient can decide to continue using tape at night or to have the nose permanently fixed for better breathing.

Nasal/ sinus surgery for an allergy can fail. The number one reason for failure is not appreciating the degree of the allergy that the patient has. No matter how skilled the surgery, when you have completed it, he is still allergic to cats.

Another reason for surgery failure is not recognizing an immune deficiency problem. Treatment here is essential in order to avoid another surgery because of repeated infection.

Failure to restore cilia function after surgery, not dust proofing the bedroom, not doing irrigation to restore the cilia function, using medications that can harm the nose such as sprays with the preservative benzalkonium are other reasons for failure.

Nasal sinus surgery can also fail if the diagnosis is not correct – if sinus pain is due to Migraine or Histamine Cephalgia or referred pain from the neck. Failure can come with an overwhelming infection is present, especially a fungal one.

There is no simple yes or no answer to the question of doing surgery for an allergy and asthma and it requires all the skill and experience of the ENT and Allergy specialist to make the correct recommendation.

Murray Grossan, MD
www.grossan.com

First Published: May 2004
Updated: February 2007

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