When is Surgery Required for an Allergy Patient?

Asthma, sinus polyps, sleep apnea, deviated septum, chronic sinusitis, and more can be reasons for surgery

by Murray Grossan, MD

You may have heard some horror stories about ear, nose and throat doctors (ENT), but what you may not have heard is that they are trained specialists who are capable of performing many surgical techniques. In most cases there is a real indication for performing surgery. The benefit of surgery is to clear a chronic infection and open the airway, however, this will not cure the allergy itself.

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Asthma

Asthma patients suffer from heavy bacterial drainage into the chest and often breathe through their mouth. In Asthma, breathing through the mouth dries the chest. If the nose is blocked, it cannot moisten and warm the air that passes to the lungs. This aggravates the Asthma.

Is there pus dripping from the sinuses into the lungs? Normally, liquid from the Sinus can appear in the lungs in 16 hours. The infected material from the sinus into the lungs can then act as a trigger for the asthma sufferer. If such a chronic sinus condition cannot be cleared by pulsatile irrigation or other means, then a surgical approach may be necessary.

Nasal-Sinus Polyps

Here is one example where surgery might be the best choice.

If the nose and sinuses are filled with polyps and the patient has failed medical treatment such as a course of prednisone with antibiotic and cortisone sprays, surgery may be the best answer. Continuing to have too much sinus blockage due to nasal polyps is not a pleasant alternative.

Sleep Apnea

In sleep apnea, the content of oxygen in the body may fall to dangerous levels due to blocked airways. This means the patient is not breathing regularly during sleep. An example of this is when you get a fresh cold and cannot sleep due to nasal congestion.

The symptoms may include: fatigue, falling asleep in the daytime or while driving, and waking up in the morning feeling tired instead of rested. Sleep apnea is diagnosed by monitoring the patient's oxygen level and how often he or she stops breathing during sleep.

Various things can cause sleep apnea. A common reason is being overweight. Fat causes the palate to be so heavy that it blocks regular intake of air. Losing weight may take the excess weight off of the palate and uvula so that it no longer obstructs the breathing pattern.

Sleep Apnea may also be the result of the jaw falling back at night. A dental mouth guard may be a simple solution to clear the condition. If the nose is the cause, it can also be easily treated. Moisturizers such as Clear Ease used during sleep may prevent nasal dryness.

Another problem, (diagnosed by an ENT) could be that the uvula and soft palate are just too floppy or flaccid and a procedure called Uvulo Plasty may be necessary. This procedure called Somnoplasty may be done in the operating room or in the office.

Other doctors may use a suture to pull the tongue permanently forward.

Unfortunately the reason there are so many approaches is that results vary among doctors. However, most doctors agree that all sleep apnea patients should try a CPAP machine first. Here the patient uses a device that delivers air to him via a mask. The machine pushes pressurized air past the obstruction. The user must wear the mask all night. Wearing a mask during sleep can be objectionable and the noise associated with it maybe bothersome. Although drop out rate is high, when the mask is used the results of high energy in the morning and being wide-awake all day can be excellent.

Deviated Septum

Almost everyone has some irregularity of his or her septum. The septum is the part that divides the nose into two halves. If you place the index finger of each hand into each nostril, the hard part in between is the nasal septum.
One misconception is that straightening a deviated septum will cure an allergy. It won't. On the other hand we get many patients referred to ENT by allergists because despite clearing the dust allergy, there is still enough blockage of breathing from the septum being pushed over to where it blocks the passage.

Many deviated septum cases develop in childhood after a trauma. Surgical correction is up to the doctor looking at the nose and depends on if he thinks the deviated septum will grow straight as the child matures, or if it will get worse. If the deviated septum is so bad that little or no air can get through, then surgical correction may be the best course.

When the deviated septum is convex to the left and concave to the right, the septum is blocking the left side and there is room to breathe on the right (case can be vice versa). Because of the wide-open space on the right, the turbines on the right side of the nose may enlarge to fit that space. The patient is now blocked on both sides of the nose.

Hypertrophied Nasal Turbinates

Turbinates are like bookshelves, only much thicker. Air flows in the nostrils over the turbinates where it is warmed and moistened. Turbinates secrete the mucus to moisten air to the lungs. This is the same mucus in the mechanism that acts against bacteria.

When the turbinates become too large they become a major factor in blocking good breathing. If allergy and medication approaches have failed, a surgical solution called submucus resection of the turbinate can be performed. After an incision is made, mucosa is lifted off the turbinate bone. Then parts of the bone are removed and the flap is replaced. Before the turbinate stood out like a large shelf. Now with bone removed, it falls to the side where it won't obstruct any more. In addition, the procedure reduces the vascular supply, so there is less swelling. This procedure is safe for the mucosa and the cilia system. Another method doctor's use is a heat wave or microwave needle. The energy "cooks" the tissue but spares the surface cilia and reduces bacteria.

Chronic Sinusitis

Chronic sinusitis is when the infection hangs on despite the use of antibiotics or other treatments. The patient often has one episode every 3 months.Since most of these chronic infections are caused by failure of the cilia to do their job of sweeping out the bacteria, use of pulsatile irrigation such as Hydro Pulse® is often a good remedy. The sinus infection will heal if the cilia can get back to its normal motion. Adding the antibiotic to the Hydro Pulse may also help. But this may not be adequate. There may be an anatomical blockage to the sinus openings. The radiologist may report "obstruction to the osteomeatal complex" which means that the opening to the Maxillary sinus (The Sinus below the eye and above your teeth) is blocked.

In this situation, it best to do surgery called FESS, via the nose, to get the closure opened. At the same time as the closure is opened, diseased tissue is removed from the sinuses.

Chronic Sinusitis can also be found in the Frontal sinus. The Frontal sinus is the one above the eye. The drainage from this sinus is rather long and can cause the bone to build up, tissue to thicken or an overwhelming infection. The patient complains of pain above the eye or headache. If this sinus remains infected, it can push through behind into the brain. Surgery is required in such cases.

Other sinuses - the Sphenoid way in back, or the Ethmoids between the eyes, may also need surgical opening due to the loss in ability to drain or difficulty in getting medication to the infected area area.

Dependent Nasal Tip

As we age, fat leaves the skin of the nose. This causes the tip of the nose to droop. This in turn causes a valve near the opening of the nose to "close" and make breathing difficult. One can tape the tip of the nose up, thereby opening the valve, or have it done surgically. This will help the patient to avoid problems sleeping.

Reduced Complications of Sinus Surgery

In Sinus surgery the doctor is working near the brain and the eye. The doctor is working on the system that supplies mucus to the air we breathe and filters that air of bacteria and toxins. Some doctors reduce complications by using 3 D computerized imaging to visualize where their instruments are. One such system is called Insta Trak. The tip of the instrument is on three screens so the doctor will have a more accurate direction.

Allergies Do Not Cause Sinusitis

It is important to understand that allergies are not the cause of sinus disease. However, in the exhaustion stage of allergy, the exhausted cilia may slow or stop sweeping out bacteria. This causes the infection.

It is important to understand that before the sinus surgery you are allergic to cats. After sinus surgery that clears infection, opens your air passages, etc you will still be allergic to cats.

Before you are scheduled for surgery, your doctor will take a CAT scan, and then demonstrate to you that the sinus drainage is blocked, and his surgery is for the purpose of unblocking it. For example, headaches above your eye, in front of your head, may be due to the Frontal Sinus being blocked. This blockage of bacteria can multiply and put pressure on the sinus membrane with pain and fever. Sometimes in such blockage, surgery is the only answer.

Surgical correction of the blockage may be the only recourse when other treatments such as: allergy desensitization, dust proofing the bedroom, allergen avoidance and pulsatile irrigation with the Hydro Pulse do not cure the patient.

Surgery due to allergies is avoided when possible, however, sometimes the benefits of surgery are sufficient to warrant this approach.

Dr. Murray Grossan is a noted ENT specialist . He is one of the USA's leading medical experts on Sinusitis. Dr Grossan is the creator of the pulsatile nasal irrigator attachment to Waterpik, an award winning medical device and subject of numerous research studies over the past 20 years. Visit Dr. Grossan's web site.

First Published: late-April, 2003
Updated: September 2003

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