I Had Nasal Surgery: A Septoplasty and (Partial) Turbinectomy

When I saw ENT Dr Larry Kalish at the beginning of 2020 he said I had a deviated septum and enlarged turbinates, recommending a septoplasty and turbinate reduction. I declined because I was considering Vivos and had heard many users report improved nasal breathing which I thought may make surgery unnecessary.

However, I’d seen no improvement in nasal breathing so far after 14 months. Binge listening to Doctor Steven Park’s excellent Breathe Better, Sleep Better, Live Better podcast also convinced me that turbinate reduction is a routine procedure that often improves the lives of obstructive sleep apnea sufferers by improving the upper airway and making CPAP work better. I also learned that enlarged turbinates and a deviated septum could explain my post nasal drip. Nasal surgery is also my next step in the updated Stanford Obstructive Sleep Apnea Surgical Algorithm. Reducing my nasal congestion may improve my daytime energy levels and maintain my sanity while I work out what to do next about my obstructive sleep apnea.

One concern I had about proceeding was empty nose syndrome, a very rare side-effect of nasal surgery which I’d seen people express concern about online. There’s even an Empty Nose Syndrome Awareness Facebook group.

Fortunately, Dr Kalish is a co-author on a recent review paper Empty Nose Syndrome Pathophysiology: A Systematic Review, so he clearly knew about the condition and I asked him about it at my consultation. He said he’s done 6000+ surgeries and has only seen it twice: One patient made absurd claims about what happened during surgery and took him to the Healthcare Complaints Commission where the claim was dismissed, while the other was treated with cognitive behaviour therapy. Even when removing the entire turbinate to excise a tumour, his patients still don’t end up with ENS. He believes ENS results from somatization and doesn’t take any specific precautions to prevent it during surgery. He also expressed scepticism about surgeons who charge a lot of money to offer surgical corrections for the condition.

I wasn’t entirely convinced, and his attitude sounded reminiscent of the way chronic fatigue syndrome patients are often treated by doctors who don’t take the time to look deeper into the root cause of their illness. The situation there may have improved as graded exercise therapy is no longer recommended for treatment of ME/CFS in the UK, but CBT is still recommended “to support symptom management”. That’s not going to be effective if there’s an underlying condition causing the illness, like undiagnosed obstructive sleep apnea.

But back to ENS, the review paper found that the incidence of ENS when turbinates are removed completely is a disturbingly high 1-in-4, but it also suggests that there is no correlation between how much turbinate is removed and the likelihood of the patient getting ENS; which is a little contradictory. The paper also didn’t cite any incidence rate for ENS, which seemed odd to me. Surely if you’re writing a review paper about a rare and controversial illness, you’d want to give some idea exactly how rare it is.

It seems more likely to me that ENS is a real nervous system problem caused by the change to the nasal airflow, which just hasn’t been thoroughly studied yet. The prospect of ending up with ENS made me nervous but I had a 100% chance of nasal obstruction and debilitating daytime fatigue despite 20 months on CPAP, and only a remote chance that nasal surgery would leave me with ENS. If I did get it, my hope was that neural plasticity may be the way to deal with it, possibly as a side-effect of some other therapy.

I’ve also made an appointment to see Dr Narinder Singh to see what he could do for me surgically, but the first appointment I could get is August 2022 and I’m more interested in his take on soft palate surgery. His website says that empty nose syndrome only occurs when turbinates are completely removed and can be avoided by not removing the entire turbinate.

After an allergy test to ensure that allergies weren’t the cause of my enlarged turbinates, I took advantage of a last minute cancellation and had nasal surgery on 20^th December 2021. I wanted to get it over with as quickly as possible. Dr Kalish warned me it would ruin my Christmas though, and he was right.

I woke up from the surgery feeling like I’d been punched in the face by a Mack truck. It took a few hours before I felt well enough to stand up. I had swallowed a lot of blood during surgery, which came up rapidly just as I told the nurse I was going to be sick and she handed me the sick bag. Initially I thought I might be able to get a taxi home, but the information sheet from the surgeon and the hospital admission process both insisted that we must have someone pick us up and stay with us for 24 hours after surgery. This turned out to be good advice. I had arranged for my brother-in-law to pick me up from the hospital and I spent two nights at my sister’s place recovering.

I couldn’t use my CPAP machine for the first two weeks during my recovery, and this reminded me of the hell of living with untreated sleep apnea: waking up every couple of hours, night sweats, having to get up to go to the toilet multiple times during the night, headaches, and generally feeling like crap all the time. I still wore my Vivos mRNA Appliance in the hope that the mandibular advancement function would help but I was still had bad symptoms. I’d been given antibiotics and painkillers to take so the pain wasn’t bad, and I kept doing saline rinses every couple of hours so my nose healed as quickly as possible because I couldn’t wait to get back on my CPAP machine. I never thought I’d say that.

After 10 days I returned to Dr Kalish to have the silicone sheets on each side of my newly straightened septum removed from my nose. He was happy and everything seemed to be going fine.

Then on day 13 I woke up choking at 4 am. “That’s a lot of phlegm”, I thought. “Oh shit… that’s not phlegm…”

I ran to the bathroom as blood poured out of my nose. There was blood everywhere: on the bedroom and hallway carpet, on the bathroom floor, in the sink. I’d never seen so much blood before; and it was coming out of me. I panicked. I’d been given me a sheet of post-operative instructions which included what to do if it started bleeding: squeeze the nose until it stops and get to hospital if necessary. I remember thinking “I hope I don’t need to do that” when I first read it. Now it was a different story though. My mind threw up the worst-case scenario of me passing out and bleeding to death with nobody around to find me. I live alone, don’t know my neighbours, my friends all live in different suburbs, and my mother isn’t going to call because she’s dead. I had to call an ambulance quickly before I passed out.

With so much blood on my hands, the touch ID on my iPhone wouldn’t work so I couldn’t unlock it to make the call. I couldn’t even manage to get the unlock code screen to appear. It didn’t occur to me that the iPhone has an emergency call feature because I’ve never had to use it before. Somehow, the more stressed I am the harder it is to unlock my phone.

“Do I go and bang on my neighbour’s doors?”, I thought. I didn’t want to disturb them, but this seemed like an emergency. Eventually I was able to activate Siri and started yelling “Siri, ring triple zero!!!”

The emergency line guy calmly asked what was going on while I yelled back the story that I’d had nasal surgery two weeks ago, and now blood was flowing out of my nose. A lot. Please help. Quick. After taking all the detail he said, “We’ll get an ambulance out to you but there is a long wait at the moment. Call us back if it gets any worse.”

“How am I going to do that??? If it gets worse, I’ll pass out!!!”, I replied.

“Just call us back if it gets worse.”

Oh great.

I went downstairs to chock the front security door to the building open, something I normally really hate other residents doing, and opened my front door so the ambulance crew could get into my apartment. Then I put my head down on the kitchen table so if I passed out I wouldn’t fall, held my nose, and waited for the ambulance to arrive.

Half an hour later, the ambulance crew came in and took me off to Prince of Wales public hospital. The emergency department nurses and doctors were great. When I told the nurse “I have so much respect for what you guys do”, he replied: “If only respect created more hospital beds. You saw all those ambulances out there? We’re treating the patients in the ambulances because we don’t have beds for them”.

There were 8 ambulances parked in the emergency bay because they couldn’t offload their patients: That’s why there was a long wait for the ambulance. I get the impression that the public hospital system is perpetually underfunded, but most people don’t notice because most people rarely go to hospital, so the government doesn’t have to worry about being voted out. They’d rather you pay to be in a private hospital anyway. I had my surgery in Prince of Wales private hospital but when there’s an emergency the ambulance takes you to a public hospital so it’s pretty important that they have a bed available for you.

The nurse gave me a bandage to hold on my nose, and a COVID test to confirm that I wasn’t infected before the hospital ENT would look in my nose. A nurse took the swab down my throat and remarked: “Oh look, there’s blood on it”.

“Yes, that’s why I’m here.”, I thought.

Anyone who denies that COVID exists clearly hasn’t been to a hospital lately because they sure were taking it seriously there. I don’t know how much COVID delayed me seeing the ENT, but I waited about 8 hours all together, lying in a bed swapping the hand holding the bandage every minute of so as my hands kept cramping. Eating breakfast and lunch were a challenge, as was going to the toilet. Fortunately, I had taken my iPhone and charger in the ambulance and an online Zoom session with my musician friends from Songs On Stage helped keep me entertained and distracted while I waited nervously for the bleeding to stop.

By the time the ENT arrived, the bleeding had stopped. He checked my nose and put some dissolvable packing in it to put pressure on the bleeding site and gave me a vasoconstrictor spray to help stop it bleeding again. He rang Dr Kalish, who was on holiday as it was a public holiday, to update him and confirm how to treat me. He said to wait a further week before using my CPAP machine again and see him again in 6 weeks time. With the emergency over and the bleeding stopped, I took a taxi home and proceeded to clean up the crime scene in my bathroom.

For the next few days every time I did a saline rinse, I had a few drops of blood coming out of my nose. This freaked me out but fortunately it stopped of its own accord each time and after a few days the bleeding stopped altogether.

While I was recuperating, I dealt with some other health issues at the same time by getting cortisol injections in my still-partly-frozen shoulders, and a COVID booster vaccine shot. I really didn’t want to risk getting COVID straight after nasal surgery so I have been avoiding people but getting the booster meant an anxious wait in a poorly ventilated medical clinic. I told the doctor who screened me and took my medical history that I’d just had nasal surgery with Dr Kalish and she said: “He’s the best!”, which was reassuring. Then she asked: “You’re fit and healthy otherwise, right?”

“No, I have severe obstructive sleep apnea”, I replied.

She looked surprised and said: “Oh, I wouldn’t have thought that; you don’t fit the stereotype”.

“I hate that stereotype”, I said, “I wish it didn’t exist”.

I wish doctors diagnosed patients based more on symptoms and risk factors rather than stereotypes, but unfortunately some risk factors for obstructive sleep apnea like crowded teeth, a history of orthodontic extractions, bruxism and headaches aren’t included in commonly used diagnostic instruments like the STOP-BANG questionnaire.

I had a brief rant expressing my frustration at taking ten years to get a proper diagnosis for the condition causing my fatigue, including the doctor at the same clinic who had told me to “Stop fishing for answers, go get a hot personal trainer and start working out, because that will make you want to get out of bed”. What a moron.

The doctor described her process for diagnosing someone with fatigue, starting with blood tests, screening for depression and then sleep disorders. I suggested changing the order and screening for sleep disorders before depression, because 14% of people diagnosed with depression have undiagnosed obstructive sleep apnea and this doesn’t get tested for once they’ve been diagnosed with depression. She was clearly in a hurry to get me out of there and see the next patient in the flood of COVID booster seekers given 4-month eligibility had just been introduced that day, but her response was pretty positive, saying “We really need to listen to what patients are saying better.”

I still felt pretty terrible but it’s hard to say what proportion of that was due to recovery from nasal surgery, the COVID booster, cortisol injections, or not being able to use my CPAP machine. After the three weeks I was back on CPAP and I started to feel better again. I still feel somewhat crap during the day and have a headache all the time, but time will tell how complete a recovery I will make now I can nasal breathe properly.

My next step is to wait 6 months for the nasal swelling to heal and have another sleep study to see where I’m at. I’ve almost given up hope on my Vivos mRNA for curing my obstructive sleep apnea, which was always something of a long shot given mine is severe. I’ve booked appointments with two oral maxillofacial surgeons Dr Lydia Lim and Dr David Leinkram in six months’ time to get evaluated for MMA surgery if the sleep study shows I still have obstructive sleep apnea and I’m not feeling wonderful on CPAP.

In the meantime I’ll have another attempt at using the new facemask to see what forward growth I can get over the next 6 months, but I’m not holding my breath.